If you are applying for Workers’ Compensation in Oregon, you might get confused with the terminology and legal red tape involved in the process. The FAQ section below can help you navigate the complicated system. For more information, contact our Workers’ Compensation attorneys to discuss your case, free of charge.
The role of Ombudsman is to inform you of your rights and help you solve problems and to educate and advise regarding claim disposition agreements, disputed claim settlements, hearings and appeals. The Ombudsman acts as your advocate in all claim-related problems. You may contact an Ombudsman Worker Advocate at (503) 378-3351 or toll free 800-927-1271. TTY access at (503) 378-4100.
WCD’s staff can explain your rights and answer your questions about medical benefits, disability benefits, vocational assistance, and re-employment assistance.
The Workers’ Compensation Board is the state agency responsible for conducting hearings and appeals and reviewing legal decisions and agreements affecting injured workers’ benefits.
Your insurer must accept or deny your Workers’ Compensation claim within 90 days from the day you tell your employer about the injury or illness. If your claim is denied, the insurer will tell you about your appeal rights in the denial letter they send to you. Denials have a 60-day time limit to file the necessary appeal with the Oregon Workers’ Compensation Board.
If your claim is accepted, your insurer will send you a Notice of Acceptance. The Notice of Acceptance will name the medical conditions accepted for coverage by your insurer. If you believe that a condition has been omitted from the notice, or the notice is otherwise incomplete or incorrect, you must notify your insurer of the error in writing.
If you develop a new medical condition after your claim is accepted, write to your insurer, identify the condition as being a new condition, and request formal written acceptance of the condition. Your insurer has 90 days to accept or deny the new condition claim.
If your injury or illness is non-disabling and your non-disabling claim (also called medical-only claim) is accepted, your medical bills will be paid, but you won’t receive disability (time-loss) payments.
Contact your insurer if you believe your claim was mistakenly classified as non-disabling. You have one year from the date of injury to appeal this issue. Your appeal must first be in writing to the insurer. Within 14 days of receipt of your request, the insurer must issue a Modified Notice of Acceptance reclassifying your claim to disabling status.
A claim is non-disabling if all the following are true: You are able to return to work at full wages on or before the fourth calendar day after leaving work or losing wages as a result of your injury; You don’t lose work time or wages later as a result of your injury; You won’t have any permanent disability as a result of your injury.
When there is a disagreement between you and your insurer about whether you have a valid workers’ compensation claim, you and your insurer may agree to a cash settlement for the claim. If you agree to a cash settlement, your claim will be denied, and you give up all rights to future benefits for the denied medical conditions of the claim. If you have questions regarding disputed claim settlements, call the Workers’ Compensation Division or the Ombudsman for Injured Workers.
On an accepted claim, you may agree to accept money instead of present and future workers’ compensation benefits (with the exception of medical benefits, which cannot be given up). Accepting money instead of benefits from your insurer is called “compromise and release.” The agreement you sign that tells you what benefits you’ve given up is called a “claim disposition agreement.” Claim disposition agreements are reviewed by the Workers’ Compensation Board. The Board will notify you of its decision, usually after a 30-day waiting period. If you are represented by an attorney, the claim disposition agreement may include a provision to waive this 30-day “cooling-off” period; if so, you may expect approval within about 14 days after the Board receives the agreement. If you have questions regarding compromise and release or claims disposition agreements, call the Ombudsman for Injured Workers. Monies payable from a Claim Disposition Agreement are due within 14 days from the date approved by the Workers’ Compensation Board.
Many disagreements may be resolved informally. Some of the decisions made by your insurer, the WCD, or others may be appealed if you disagree with them. The documents you receive will have instructions on how to appeal the decisions. There are time limits for most appeals, and you will lose your appeal rights if you don’t appeal within those limits. If you need more information about hearings or special appeal rights under the workers’ compensation law, call the WCD or the Ombudsman for Injured Workers. The Workers’ Compensation Board Hearings Division also provides mediation services.
The claim your insurer has filed with the WCD isn’t open to the public under Oregon law; however, your insurer can get information about your past claims, including relevant medical information, in order to make decisions about your current claim. Government agencies also may use claim information as needed. You and your attorney have access to WCD claim information. Release of information about your claim for any other reason requires your written permission.
Your attending physician is in charge of your medical treatment. Only your attending physician can authorize your time-loss benefits. (In some rural areas, a nurse practitioner or physician’s assistant may authorize time-loss for a period not to exceed 30 days from the first visit.)
Tell the doctor on your first visit that your injury or illness is job-related. The doctor must tell you if there are limits to the medical services he or she can provide under the Oregon workers’ compensation system.
You may select as your attending physician: a physician at the hospital or clinic treating you, your regular doctor, or another provider. In any case, the person you select must be qualified as an attending physician and must agree to direct your treatment. (If your employer is enrolled in a Managed Care Organization, see Managed Care Organizations, below.)
Ask the doctor for Form 827, First Medical Report for Workers’ Compensation Claims. You and the doctor complete the form together and your doctor sends it to your insurer.
You may choose to change your attending physician two times. Generally, changes outside your control do not count toward your limit of three attending physicians. Additional changes require permission from your insurer or the WCD. If you are enrolled in a Managed Care Organization (MCO), you may choose and change attending physicians as allowed by the MCO contract. (See Managed Care Organizations below.)
An MCO is health care provider (or group of medical service providers) who contracts to provide medical care to injured employees.
If your employer is covered by an MCO contract, the insurer may enroll you with the MCO at any time after your injury, and you may be required to select a MCO physician. Your insurer will send you a notice of enrollment and give you a list of providers. Your regular doctor may or may not be authorized to treat you after you are enrolled with the MCO. However, until you receive a notice of enrollment, you may continue treatment with your regular doctor and your doctor is licensed in family practice, general practice, or internal medicine, your doctor may continue to treat you if he or she agrees to treat you according to the terms and conditions of the MCO.
If you have questions about your medical care, call your insurer.
The insurer will refund some of your out-of-pocket expenses, including prescriptions and reasonable transportation costs, meals, lodging, and other charges for claim-related treatment. There are maximum amounts the insurer will refund. You must ask for this money in writing and provide receipts or other proof of expenses. If your claim has been accepted, your insurer is required to pay you within 30 days of receipt of your bill. In most cases, your request for reimbursement must be sent to your insurer within two years of the service.
Your insurer will pay for all necessary medical services during your recovery; however: Medical bills are not required to be paid until your claim is accepted. Medical bills are usually not paid if your claim is denied, treatments are not related to your accepted condition, or treatments aren’t prescribed by your attending physician.
See above for information about medical benefits after claim closure.
Workers’ compensation reference websites:
Ombudsman for injured workers: http://www.cbs.state.or.us/external/wco/
State of Oregon: http://www.state.or.us/
Oregon Employment Division: http://www.emp.state.or.us/