Claims Management - Deferred Claims

Question 1

New/deferred claims management

Answer 1

During the deferred status, the adjuster determines whether a claimed work injury or occupational disease can be covered under workers’ compensation insurance. There are tight timeframes and adjusters need to ensure decisions are made accurately and timely.

Question 2

If the injury only requires first aid treatment, does a claim need to be filed?

Answer 2

No. First aid rendered at the job site is not considered medical services or treatment. Employers should document the incident. If the worker later seeks medical treatment or asks to submit a claim, the incident must be reported as work injury claim.

Question 3

How many days does the worker have to report an injury to the employer?

Answer 3

• 90 days from the date of the injury or accident,

- the injured worker has up to one year to report the claim if he can show good cause for not reporting it sooner

Question 4

How long does the worker have to report an occupational disease (OD) to the employer?

Answer 4

• One year from the date the worker first discovered the OD
• One year from the date the worker became disabled because of the OD
• One year from the date the worker is informed by a doctor of the OD
• One year from the date of death or when it was discovered the OD was the cause of death

Question 5

How many days does the employer have to send the Form 801 to the insurer?

Answer 5

• five days from the date the employer is informed of the claim - EDOK

Question 6

Legal standards for determining the compensability of a claim or condition? – Initial Injury Claim
*What we base our decision on

Answer 6

Material Contributing cause of the need for treatment

Question 7

Legal standards for determining the compensability of a claim or condition? – OD claim
*What we base our decision on

Answer 7

Major contributing cause of the condition.

Question 8

Legal standards for determining the compensability of a claim or condition? –Consequential condition
*What we base our decision on

Answer 8

compensable injury is the major contributing cause of the consequential condition

Question 9

Legal standards for determining the compensability of a claim or condition? –Combined Condition
*What we base our decision on

Answer 9

major contributing cause of the combined condition’s need for treatment

Question 10

Who has the burden of proof in the claim?

Answer 10

The injured worker has the burden of proof to show a claim is compensable.

Question 11

What three situations typically make a claim NOT compensable?

Answer 11

• Injury occurs to any active participant in assaults or combats that are not connect to the job assignment and are a deviation for customary duties.
• Injury occurs while engaging in or performing any social or recreational activity primarily for the worker’s pleasure.
• Major contributing cause of the injury is caused by the worker’s consumption of drugs or alcohol. Major cause must be demonstrated by a preponderance of the medical evidence.

Question 12

How is an injury claim most often described?

Answer 12

An injury claim usually occurs within a discreet period of time. An injury has a sudden and acute onset.

Question 13

How is an occupational disease (OD) most often described?

Answer 13

OD claims typically develop over a longer period of time.

Question 14

What does the phrase “course and scope” mean when it comes to “arising out of”

Answer 14

means there is a causal relationship to work.

Question 15

What does the phrase “course and scope” mean when it comes to “In the course of”:

Answer 15

refers to the time, place, and circumstances surrounding the accident.

Question 16

What four questions should you ask yourself to help determine if you are dealing with a compensable combined condition?

Answer 16

• Is there a compensable injury?
• Is there a qualified preexisting condition? (See the General Definitions section.)
• Did the injury combine with the qualified preexisting condition?
• Is the combined condition compensable?

Question 17

In what situations could you revoke the notice of acceptance (also known as a back-up denial) once a claim has been accepted?

Answer 17

When the denial is for fraud, misrepresentation, or other illegal activity by the worker, or
The insurer later obtains evidence that the claim is not compensable or that the insurer or employer is not responsible (within two years after the date of the initial acceptance).

Question 18

Who has the burden of proof when a back-up denial is issued?

Answer 18

The insurer.

Question 19

Is everyone hurt in Oregon covered by Oregon Workers’ Compensation Insurance?

Answer 19

No. Not all employees hurt in Oregon work for an Oregon subject employer; and not all workers are Oregon subject workers (see definitions).

Question 20

In addition to overall compensability, what other issue must an adjuster consider before making a decision on the claim?

Answer 20

– Responsibility: Only one employer can be responsible for the compensable injury or OD.
and
– Compensability is determined first, then responsibility: If the claim is compensable, is the employer responsible?

Question 21

In context of a responsibility case, what is the Last Injurious Exposure Rule (LIER)

Answer 21

Used in occupational disease claims, the employer upon whom the rule “triggers” is presumptively responsible for the claim.

Question 22

In context of a responsibility case, what is the Last Injury Rule (LIR)?

Answer 22

The last injury that made an independent contribution to the underlying pathology of the condition, even though it is slight, is responsible. A contribution to the symptoms, but not the pathology, is not sufficient.

Question 23

What is the purpose of a designated paying agent order (also known as a .307 Order)?

Answer 23

The claim is compensable, but there is a dispute as to which insurer or employer is responsible. A designated paying agent order (.307 Order) allows the worker to receive benefits until the responsibility issue is resolved.

Question 24

When is a designated paying agent requested?

Answer 24

It is requested when responsibility is the sole issue in the claim.

Question 25

What is the role of SAIF’s Conflict Resolution Committee (CRC)?

Answer 25

The CRC’s role is to work with claims adjusters to determine if a responsibility conflict exists. If so, they advise the legal department of the need for outside counsel.

Question 26

Under what circumstances must an insurer request suspension of benefits from WCD?

Answer 26

• Worker fails to attend an IME. OAR 436-060-0095(1)
• Worker commits insanitary or injurious acts. OAR 436-060-0105
• Worker fails or refuses to accept medical treatment. OAR 436-060-105
• Worker fails or refuses to cooperate with investigation. OAR 436-060-0135(2)

Question 27

What is the timeframe within which the injured worker must cooperate with the investigation of the claim to avoid suspension of benefits?

Answer 27

14 days from written notice being sent

Question 28

What information must be included on the acceptance?

Answer 28

• Compensable conditions,
• Disabling or nondisabling status,
• Information about the Expedited Claim Service, hearing, and aggravation rights related to nondisabling injuries,
• Employment reinstatement rights,
• Assistance available from the Reemployment Assistance Program,
• Reimbursement to the worker for out of pocket expenses for meals, lodging, transportation, and prescriptions,
• What to do if the worker believes a condition has been omitted,
• What to do if the worker wants the insurer to accept a new condition.

Question 29

Who receives a copy of the acceptance?

Answer 29

• The worker,
• The employer (ORS),
• The worker’s attorney, if represented,
• The worker’s attending physician,
• The MCO, if enrolled,
• WCD (on disabling claims only).

Question 30

What information must be included on the denial?

Answer 30

• The factual and legal reasons for the denial,
• The worker’s right to request a Worker Requested Medical Exam (WRME),
• Whether the denial was based in whole or in part on an independent medical exam (IME),
• Whether the attending physician agreed with the IME,
• Information about the Expedited Claim Service,
• Appeal rights.

Question 31

Who receives a copy of the denial?

Answer 31

• The worker,
• The employer (ORS),
• The worker’s attorney, if represented,
• Each medical services provider,
• Private health insurer, if any,
• WCD.

Question 32

How many days does a worker have to appeal a denial?

Answer 32

The worker has 60 days from the mailing date of the denial.

Question 33

What are some types of Third Party claims?

Answer 33

Motor vehicle accidents (MVAs), Subsequent intervening causes, Negligence, Product liability, Premises liability, Assaults, Dog bites

Question 34

Examples of potential Third-Party claims

Answer 34

• A sheet metal worker was injured when a new arc welder exploded due to a problem in the production of the welder.
• An employee was injured when he was knocked off the back of a flatbed truck by an employee of a neighboring employer who had volunteered to help unload the cargo.
• A property appraiser was bitten by a dog while inspecting a private residence.
• A sales representative was injured in an auto accident when she was hit head-on by another driver.
• An employee is exposed to toxic fumes while mixing two industrial solvents that were mislabeled by the manufacturer.

Question 35

Examples of situations that are likely not a Third-Party claim

Answer 35

• A traveling salesman was injured when he hit a patch of black ice and lost control of his car and ran into a ditch, resulting in neck, back and ankle injuries.
• A delicatessen worker was injured when a coworker spilled hot soup on her arm.
• A custodian was injured when an aerosol can exploded after he mistakenly threw the can in with burning debris.
• An employee was injured when she was grabbed from behind in a bear hug by a co-worker.