Workers Comp Claim Denied in Portland
You were injured at work. There’s no question it happened while you were on the job, and there is no question you were seriously hurt. There are witnesses, and you even reported it to your supervisor right away. Now you are being told that your claim is denied. You’ve missed work, maybe you’ve even lost your job.
Can a Portland Employer Deny a Workers Comp Claim?
This is a very common scenario sick from occupation hazards and for injured workers in Oregon. If you’ve been hurt at work, it may seem fairly clear and straightforward that you should receive compensation for your injuries. In theory, it should be a very simple process.
Unfortunately, Oregon workers’ compensation claims can be quite complex. If you are denied benefits, your very first step should be to contact an experienced Portland workers’ compensation lawyer, because you will likely have to appeal your claim denial.
What if My Workers Comp Claim is Denied: Steps for Appealing a Denied Workers Compensation Claim
Once an initial decision is reached in your case, you will receive either an initial notice of acceptance or a denial. If you receive a denial letter, you don’t have a lot of time to act. What you do next may make or break your appeal.
Step 1: Request a Hearing (60 days)
If you disagree with the denial of your claim, you can request a hearing. You can either send a letter to the Workers’ Compensation Board (Board) and the Insurer requesting a hearing, or use the Request for Hearing Form, which can be downloaded from the Board’s website. You must make this request for a hearing in writing within 60 days of receiving the denial.
The Board must set a hearing within 90 days of your request for a hearing. Your hearing will be assigned to an Administrative Law Judge (ALJ) who specializes in Oregon Workers’ Compensation Law and only resolves claims like yours. (https://www.oregon.gov/wcb/Documents/employee/hearingrequestflowchart.pdf).
Step 2: The Hearing
This is a formal process and similar to a formal lawsuit in traditional court, and the Board strongly encourages workers to be represented by an attorney at their hearing (https://www.oregon.gov/wcb/Documents/employee/hearingdescription.pdf). Your attorney may submit additional evidence, records, expert opinions, written arguments or witness testimony necessary to win your claim. An attorney may also issue subpoenas to get witnesses to appear.
The ALJ assigned to your case must issue their decision, called an Opinion and Order, within 30 days of the hearing or 30 days after all the evidence has been submitted in your case. The ALJ can either agree with the insurer that your claim should stay denied by affirming the denial or find in your favor by setting aside the insurer’s denial. If you lose, you have the right to appeal the ALJ’s Opinion and Order to the Board.
Step 3: Request for Board Review (30 days)
If you disagree with the ALJ’s decision, you must appeal the Opinion and Order within 30 days of receiving this decision. If you do not, the ALJ’s Opinion and Order will become final, which means nothing more can be done to challenge the denial of your claim. There are three additional levels of appeal after a hearing. The first level of appeal is to the Board.
If you timely appeal the ALJ’s Opinion and Order, the Board has de novo review, which means the Board can re-evaluate all the evidence presented to the Administrative Law Judge. Appeals to the Board are submitted in writing. The appellate process is challenging to successfully manage on your own and is really designed for attorneys.
The Board consists of 5 board members who are appointed by the Governor. Your case will be decided by at least 2 board members. The Board can issue an Order on Review either agreeing with the ALJ by affirming the Opinion and Order or disagreeing with the ALJ by modifying or reversing the Opinion and Order. Typically, the review process before the Board takes from 6-9 months depending on the complexity of the issues in your case, as well as the time necessary to provide the Board with the necessary written arguments.
Once the Board issues its Order on Review, you have 30 days to file for judicial review to the Oregon Court of Appeals.
Step 4: Judicial Review (30 days)
The first level of appeal after the Board is to the Oregon Court of Appeals. If you still disagree with the decision regarding your claim, you can file an appeal of the Order on Review to the Court of Appeals within 30 days. This level of judicial review is much more limited and requires payment of a filing fee plus additional mailing charges. The Court of Appeals reviews the Board’s Order on Review primarily for legal error. An appeal at the Court of Appeals can take 2-3 years.
The final level of appeal is to the Oregon Supreme Court. Very few cases progress to this level of review because it is up to the justices on the court to determine whether they will consider the merits of your case by granting a petition for review. No further appeals are available under Oregon law for a workers’ compensation claim. The Oregon Supreme Court is the final authority.
Common Reasons Workers’ Comp Claims Are Denied in Portland
There are plenty of reasons why claims get denied. Here are just seven of the most common reasons:
- Course and Scope of Employment – One of the most fundamental principles of workers’ compensation is that you must be on the job at the time you are injured. In a factory, this may be pretty clear. But there are lots of jobs where this can become a tricky question. This can be especially problematic for traveling employees or those who must drive from one work location to another. A lot of workers are denied their benefits because the employer argues that they were not acting in the course and scope of employment at the time of the injury.
- Failure to Notify Employer – The law requires you to timely notify your employer. In other words, you have to report the injury. The sooner the better. If possible, you should report it immediately, while still at work. It is best if you do it in writing. If your employer has a safety log, you should make sure you enter your injury into this log or fill-out an employer incident report. If you need medical care because of your injury, you should file your claim using an 801 claim form. If you do not report your injury timely, you may not be able to continue with your claim.
- Lack of Medical Care – Some people get badly injured but try to “tough it out.” This is usually a mistake, because conditions can get worse with time or lead to complications you may not have anticipated. If you disregard the injury and don’t get care, then it gives the employer and their insurance company a strong argument that you were not truly injured.
- Wrong Medical Care – Many people find it odd that an employer can legally require you to select a treating provider from their approved list of physicians and other health professionals. And many of these “approved” providers make their living trying to diminish the value of work injuries. Still, by working with a skilled workers’ compensation lawyer, you increase your chances of being treated fairly during this process and making sure that you receive the appropriate and necessary care.
- Disqualifying Conduct (drug or alcohol impairment, for example) – Although Oregon is a no-fault state, an employer may argue that certain worker conduct caused the injury and that this conduct disqualifies the worker from workers’ compensation benefits. This can mean anything from roughhousing to being under the influence of drugs or alcohol at work could be used as an argument for denying your claim.
- Paperwork or Technical Defects – As you can probably imagine, there is a lot of paperwork involved in workers’ compensation claims. As you will notice from the steps to appealing your workers’ compensation claim, there are also a lot of very strict deadlines. Miss one, and you could lose your claim entirely.
- Prior Injuries and Medical Conditions – A lot of workers may have pre-existing health conditions or prior injuries from years ago. A worker may even have a preexisting health condition that they did not know about, or have symptoms from, such as arthritis, which may impact their claim. If the injuries or body parts affected are similar, an employer may argue your current condition is due to those old injuries instead.
It’s important to remember that many of these reasons for a denial may not hold up on appeal. In other words, with the help of a workers’ compensation attorney, you may be able to show that the denial was invalid, and you are, in fact, entitled to benefits. Don’t give up just because your employer or its insurer has cited one of the reasons listed here or another ground for trying to avoid paying you what you are due for the harm that occurred while working.
How a Portland Workers’ Compensation Attorney Can Help Your Workers’ Compensation Claim Denial
If you’ve been hurt on the job, you shouldn’t be forced to defer to your employer or be at the mercy of their insurance company. You have rights. If your workers’ compensation claim was denied, you need to get an attorney involved who understands the process and knows how to navigate the system to maximize your benefits and settlement.