New/Deferred Claims

Question 1

New 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 time frames 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 siteis not considered medical servicesor treatment.Employers should document theincident. If the worker later seeks medical treatment or asks to submit a claim,the incident must bereported as work injury claim.

Question 3

How many days does an adjuster have to accept or deny a new claim.

Answer 3

60 days from date of injury.

Question 4

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

Answer 4

The worker generally has 90 days from the date of the injury or accident, but the injured worker has up to one year to report the claim if he can show good cause for not reporting it sooner.The worker has 90 days from the date a health benefit rejects a claim as being work related.

Question 5

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

Answer 5

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

Question 6

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

Answer 6

The employer has five days from the date the employer is informed of the claim (that is, the employer’s date of knowledge). (EDOK)

Question 7

What is the legal standard for determining the compensability of an Initial Injury?

Answer 7

material contributing cause of the need for treatment.

Question 8

What is the legal standard for determining the compensability of an OD claim?

Answer 8

major contributing cause of the condition.

Question 9

What is the legal standard for determining the compensability of a consequential condition?

Answer 9

compensable injury is the major contributing cause of the consequential condition.

Question 10

What is the legal standard for determining the compensability of a combined condition?

Answer 10

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

Question 11

n most instances, who has the burden of proof in the claim?

Answer 11

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

Question 12

What three situations typically make a claim NOT compensable?

Answer 12

▪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 13

How is an injury claim most often described?

Answer 13

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

Question 14

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

Answer 14

OD claims typically develop over a longer period of time.

Question 15

What does the phrase “course and scope” mean?

Answer 15

▪“Arising out of” means there is a causal relationship to work.
▪“In the course of”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

1. Is there a compensable injury?
2. Is there a qualified preexisting condition?
3. Did the injury combine with the qualified preexisting condition?
4. 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

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.

Question 18

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

Answer 18

The insurer.

Question 19

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

Answer 19

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

Question 20

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

Answer 20

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

Question 21

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

Answer 21

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 22

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

Answer 22

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 23

When is a designated paying agent requested?

Answer 23

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

Question 24

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

Answer 24

To work with claims adjuster to determine if a responsibility conflict exists.

Question 25

What information must be included on the acceptance?

Answer 25

▪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 26

Who receives a copy of the acceptance?

Answer 26

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

Question 27

What information must be included on the denial?

Answer 27

▪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 anindependent medical exam (IME),
▪Whether the attending physician agreed with the IME,
▪Information about the Expedited Claim Service,
▪Appeal rights.

Question 28

Who receives a copy of the denial?

Answer 28

▪The worker,
▪The employer,
▪The worker’s attorney, if
represented,
▪Each medical services provider,
▪Private health insurer, if any,
▪WCD

Question 29

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

Answer 29

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

Question 30

When a claim denial is appealed, what are the four levels of litigation(appeal) that can occur?

Answer 30

▪An in-person administrative hearing before an Administrative Law Judge (ALJ) at the WCB Hearings Division.
▪Board review of the ALJ’s opinion by the Workers’ Compensation Board.
▪Review by the Oregon Court of Appeals.
▪Review by the Oregon Supreme Court.

Question 31

What are some types of Third Party claims?

Answer 31

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