If your claim or a medical condition
is denied
The
insurer must accept or deny your claim within 60 days from the day you
tell your employer about the injury. If your claim is denied, the insurer
will tell you about your appeal rights in the denial letter they send
to you. An “appeal” is a request by you, an insurer or someone
else for a review of a decision made about your claim. If you receive
a notice that your claim or benefits are denied or ended, the document
you receive will have instructions on how to appeal if you disagree with
the decision. There are time limits for most appeals, and you’ll
lose your appeal rights if you don’t appeal within those limits.
Benefits that are the subject of the appeal are usually not paid until
the review of the decision is completed and there is no further appeal.
If you want legal advice, check the yellow pages of your phone directory
under “Attorneys” or contact the Oregon State Bar, 800-452-7636,
to find a lawyer who handles workers’ compensation in your area.
The insurer will pay time-loss authorized by your doctor up until the
time your claim is denied. You won’t have to repay time-loss benefits
if your claim is denied. However, if your claim is denied within two weeks
of the date you reported the claim to your employer, you will not receive
time-loss payments.
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Worker
requested medical examination
If your claim has been denied by the insurer based on an insurer medical
examination (IME), and your doctor (attending physician) disagrees with
the IME results, you may be eligible to request a medical examination
by a doctor chosen by the Workers’ Compensation Division. In order
to be eligible for this exam, you must appeal your denied claim in writing
within 60 days of the denial. After you have requested an appeal on the
denial, you may send a written request for an exam to WCD. A copy of your
request should be sent simultaneously to the insurer or self-insured employer.
The request must include:
Claim disposition agreement
(CDA)
On an accepted claim, you may enter into a CDA. This
is a legal agreement where in return for an agreed-upon amount of money,
you give up your right to the following: Present and future time-loss
benefits, present and future permanent partial disability awards, monthly
payments for permanent total disability, vocational assistance benefits,
and aggravation rights to reopen your claim. However, you cannot release
your right to medical benefits or eligibility for the Preferred Worker
Program. All claim disposition agreements are reviewed by the Workers’
Compensation Board, which approves or disapproves the agreement. If you
have questions about claim disposition agreements, contact the Ombudsman
for Injured Workers 1-800-927-1271.
Disputed
claim settlement (DCS)
When you disagree with the insurer about whether you
have a valid workers’ compensation claim, you and the insurer may
agree to a cash settlement for the claim. If you agree, your claim will
be denied, and you give up all rights to future benefits for the denied
medical conditions of the claim. Medical providers may bill you for unpaid
services, so find out what your obligations will be before you agree to
a settlement.
When
your claim is closed
You will receive a Notice of Closure from the
insurer. This is a legal document that closes your claim. It lists the
periods for which time-loss was authorized and tells you how much permanent
disability has been determined. This document also tells you what to do
if you want to appeal the closure.
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What
does “closure” mean?
Disabling claims are “open” while you are
recovering from your injury and must be “closed” when you are
medically stationary. Your claim will also be closed if your work injury
is no longer the major cause of your disability or if you fail to keep
medical appointments. The following important documents will be mailed
to you when your claim is closed:
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A Notice
of Closure from the insurer. This is the legal document that
closes your claim. It lists the periods for which time-loss was
authorized and tells you how much permanent disability you may have.
This document also tells you what to do if you want to appeal the
closure.
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An
Updated Notice of Acceptance at closure, which lists all
of the conditions the insurer has accepted. If the updated notice
is incomplete or incorrect, notify the insurer in writing.
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Claim
closure reconsideration process Appeal
Rights:
If you disagree with the Notice of Closure, you have the right
to appeal the closure of your claim by asking the Workers' Compensation
Division for a “Reconsideration” within 60 days from the mailing
date printed in box 1 on the front of the form. If you do not appeal within
60 days, you will lose all rights to appeal your claim closure. Your appeal
rights and the address to which to send your appeal are printed on the
back of the Notice of Closure.
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Ways
to request reconsideration of your claim closure:
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Fill
out and mail a Request
for Reconsideration form
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Send
form by electronic transmission (by facsimile or FAX)
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Hand
deliver form to a Workers' Compensation Division office
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Request
by phone or in-person — Ask to speak to a worker liaison
or appellate reviewer
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Who
are worker liaisons?
Worker liaisons help workers understand the reconsideration
process. They will send you the Request for Reconsideration form. They
explain options, help you complete Requests for Reconsideration, and answer
questions.
When the Appellate Review Unit of the Workers’ Compensation Division
receives your request for reconsideration, an acknowledgment letter is
mailed to the insurer, the injured worker, and attorneys, if any are involved.
This letter tells you that the reconsideration process has begun.
Reconsideration is an informal review process, not a hearing. You may
talk to your reviewer or the worker liaison and you may submit a written
statement explaining your condition and your disagreement with the claim
closure. You may also submit statements from others to support your position.
This will be your last opportunity to provide new information about your
claim.
You may make a statement for the record or ask anyone else to make a statement
for you. If you need help filing your statement, contact the Appellate
Review Unit worker liaison. A statement gives you a chance to tell us
your story.
An Order on Reconsideration may either be issued by the Workers’
Compensation Division on the 18th working day from the date of the initial
request by the injured worker, or it may be postponed for 18 working days
(plus an additional 60 days) if more information is needed or a medical
arbiter exam is requested. If the process is postponed, you will receive
a postponement letter, which will tell you we are postponing our decision
because we are requesting additional information or scheduling a medical
arbiter exam.
Brochures and forms
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Medical
arbiter examinations
The medical arbiter exam is scheduled by WCD's Appellate
Unit staff to settle disputes over your impairment findings and is based
on your accepted condition(s) at the time of your claim's closure.
Your reviewer will ask the medical arbiter physician questions about your
accepted condition(s) and review the Disability Rating Standards. Because
the focus of the exam is determining your impairment, the medical arbiter
is not authorized to offer you any medical treatment. For more detailed
information about the medical arbiter process, refer to What
is a medical arbiter examination? | Espanol
A medical arbiter is a physician appointed by the Workers’ Compensation
Division to perform an impartial examination and review your records.
The physician is randomly chosen from our list of medical arbiters within
the medical specialty that reflects your claim. The medical arbiter will
be a physician you have not seen as a patient.
The medical arbiter must be a medical doctor as defined by Oregon statute
and must be in good standing with the Oregon Medical Board Examiners.
All physicians must undergo medical arbiter training prior to their first
arbiter exam. Medical arbiter reports are monitored by WCD to ensure quality
and impartiality.
If a medical arbiter exam is scheduled, you will receive an appointment
letter with a date, time and location. If you do not keep your exam appointment
and do not have a good reason for missing it, your disability benefits
may be suspended. You must contact the Appellate Unit staff within 24
hours after the missed appointment.
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When
there is a medical treatment dispute
Treatment disputes may be initiated by any party using
Form
2842. The insurer can request administrative review if they think
treatment is excessive, inappropriate, unnecessary, or in violation of
a medical services rules. The physician can request administrative review
if the insurer does not approve a palliative care, elective surgery, or
experimental treatment request.
For additional information on requests for administrative review of medical
issues, refer to Bulletin
293.
