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Workers’ compensation disputes

Highlights:

  • In 2018, the WCD Appellate Review Unit issued more than 2,500 orders.
  • WCD also issued more than 2,000 medical dispute orders and 138 vocational assistance dispute orders.
  • In 2018, the Workers’ Compensation Board issued almost 6,000 hearings orders.
  • WCB also issued 269 board orders and completed 295 mediations.
  • In 2018, the Oregon Court of Appeals issued 37 orders involving workers’ compensation cases.
  • In 2018, there were more than 2,800 claim disposition agreements and more than 3,500 disputed claim settlements.

The purpose of the Oregon workers’ compensation system is to provide fair and timely benefits to injured workers. Impartial dispute resolution is a vital part of the workers’ compensation system.

During dispute resolution, workers, employers, insurers, and, in some instances, medical service providers have legal rights. Workers may contest claim denials and benefits, insurers and employers may defend against claims and benefits believed to be unwarranted, and medical providers may raise concerns about medical services and fees.

The Oregon workers’ compensation system has a two-part dispute resolution system:

  • The Workers’ Compensation Division (WCD) provides administrative review for many types of disputes. Within the Resolution Section, the Appellate Review Unit resolves disputes involving claim closures and classifications, and the Employment Services Team resolves vocational assistance disputes. The Medical Resolution Unit resolves medical disputes.
  • The Workers’ Compensation Board (WCB) is an independent agency that receives administrative support from the Department of Consumer and Business Services (DCBS). It has original jurisdiction on insurer claim denials and certain claims-processing issues, such as time-loss and time-loss rates when the claim is open. It also hears appeals of cases decided by WCD’s administrative review – primarily the reconsideration of claims closures, medical services and vocational assistance disputes, and nonsubjectivity and noncomplying employer determinations. Hearings decisions can be appealed to board review, and then to the Court of Appeals. Court of Appeals decisions can be appealed to the Oregon Supreme Court, whose review is discretionary.

The system can be more complex than this description suggests. Workers may have disputes in different venues at the same time. For instance, they may be disputing vocational assistance decisions while appealing a permanent partial disability award. In other cases, medical disputes may have two issues: whether the proposed treatment is related to the accepted conditions and whether the proposed treatment is reasonable and necessary. In these cases, after WCB decides treatment is related to the accepted condition, the WCD Medical Resolution Unit decides on the necessity or propriety of the treatment. Finally, the issue of insurer penalty for unreasonable conduct, and related attorney fees, may be heard by either WCD or WCB; WCD has original jurisdiction in proceedings involving solely these issues.

Reforming the dispute-resolution system

In 1990, SB 1197 created new administrative review processes and provided for claim disposition agreements (CDAs). Before 1990, there were voluntary administrative review processes to resolve disputes over claim closure and disability classification (disabling or nondisabling), but these processes were used infrequently. SB 1197 made the reconsideration and medical dispute processes mandatory. CDAs reduced litigation by allowing workers to take a settlement and release rights to workers’ compensation benefits other than medical services and the Preferred Worker Program.


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