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Oregon Law sets a process
that an injured worker can follow to disagree with the terms of a claim closure the
insurer or self-insured employer issues. The worker can ask the director to review
specific issues on the closure. The name of this review process is Reconsideration.
A worker must make their request for reconsideration within 60 days of the mailing
date of the closure. A reviewer in the Appellate Review Unit of the Benefit Services
Section does the review. Issues the worker can dispute include (at least):
- When the worker's
condition was medically stationary,
- Whether the claim
was closed incorrectly or before it should have been,
- How long temporary
disability benefits were authorized,
- Whether permanent
disability was awarded and, if it was, the amount of that award, and
- Eligibility for
death benefits.
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An insurer or self-insured
employer may also request reconsideration of the closure. However, they must make their
request within 7 days of the mailing date of the closure. The insurer or self-insured
employer can only disagree with the impairment findings used as the basis for a permanent
disability award.
Because reconsideration is the last chance to add new information to the official claim
closure record, both parties in the dispute must provide all their documents during
the reconsideration process. The worker or insurer/self-insured employer may:
- Correct information
in the record,
- Submit additional
materials, including evidence that should have been-but was not-submitted by
the attending physician at the time the claim was closed.
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The injured worker may
also submit written statements:
- Explaining their
condition at the time the claim was closed,
- Giving the reasons
for their disagreement with the claim closure,
- From other people
who support their position.
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The department must either:
- Complete the
reconsideration process by the 18th working day after the reconsideration proceeding
begins, or
- Postpone issuing
an order for an additional 60 days if they need more information or a medical
arbiter examination (see below).
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An
appellate reviewer will study all information received from the injured worker and
the insurer. After reviewing the information (including any report from a medical arbiter),
the reviewer will issue an Order on Reconsideration.
Reference: ORS 656.268, OAR 436-030-0165
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When there is a dispute
over impairment findings for an injured worker's accepted condition at the time the
insurer closes the claim, the department may need to have the worker examined by a
medical arbiter. The medical arbiter:
- Must be a medical
doctor as defined by Oregon law,
- Must be in good
standing with the Oregon Board of Medical Examiners,
- Is chosen at
random from the department's list of qualified doctors,
- Has not seen
or treated the worker during the time the claim was open,
- Reviews the medical
records and examines the worker's accepted condition, and
- Provides the
appellate reviewer with a written report describing the objective findings
of impairment.
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Reference: ORS 656.268, OAR 436-030-0165
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