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Filing/subjectivity Course and scope Injury Combined Condition OD Processing PPD Agg/OM Start Finish Chance  TTD/ Medical         

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Presentation on theme: "Filing/subjectivity Course and scope Injury Combined Condition OD Processing PPD Agg/OM Start Finish Chance  TTD/ Medical         "— Presentation transcript:


2 Filing/subjectivity Course and scope Injury Combined Condition OD Processing PPD Agg/OM Start Finish Chance  TTD/ Medical                                                                                     

3 “Independent contractor” takes job delivering phone books. Compensable injury to “subject worker” nonetheless. Jeannette Jensen, 63 Van Natta 1542 (2011). Pay up.

4 Delay filing knee claim because you think pain is from prior MVA. Late filing excused, but lose on the merits. John Smith, 64 Van Natta 340 (2012). Do not pay.

5 Good cause for filing late hearing request when denial was sent to address from which the employer evicted the claimant. Martin Granados, 63 Van Natta 2364 (2011). Pay up.

6 Claim filing not untimely when doctor tells claimant it’s “very possible” cancer was due to work exposure, but waits 3 years to file. Glenn Severns, DCD, 63 Van Natta 991. Pay up.

7 Snap achilles tendon during pre- employment physical exam. Claim denied – not yet a subject worker. Stanley Burch, 63 Van Natta 1732 (2011). Do not pay.

8 MVA while hauling potatoes in Washington. Collect Oregon benefits - employer is based in Oregon. Gustavo Bustamante, 63 Van Natta 996 (2011). Pay up.

9 Trip over your dog in your own home – home workplace, that is. Mary Sandberg, 64 Van Natta 238 (2012). Pay up.

10 Security camera proves claimant didn’t actually fall in a pothole. Back-up denial upheld. David Hetrick, 64 Van Natta 43 (2012). Do not pay.

11 Employer unable to prove that claimant intentionally lunged in front of a moving fork lift to get injured. Nathaniel Hardy, 63 Van Natta 1977 (2011). Pay up.

12 Claimant enters a motocross race during sales promotion at an event. Compensable injury. Matthew Barrall, 63 Van Natta 2218 (2011). Pay up.

13 Inner ear problems and neuropathy potential causes of a fall at work. Not truly “unexplained.” Lily Blank, 63 Van Natta 1515. Do not collect.

14 Bus driver fights with passenger at a bus stop. Not in the course and scope. Victor Alicea, 63 Van Natta 1964 (2011). Do not pay.

15 Struck by a car while walking across the street to get coffee. Compensable part of police officer’s work duties. City of Eugene v. McDermed (2012). Pay up.

16 Fall in employer parking lot while depositing a personal check. Did not “arise out of” work. Legacy Health Systems v. Noble (2012). Do not pay.

17 Injury from idiopathic faint and fall on a brick floor did not “arise” out of employment. Pamela Hamilton, 63 Van Natta 736 (2011).

18 Fracture arm while arm wrestling at work. Did not arise out of employment. Christopher Fitzpatrick, 64 Van Natta 174 (2012). Do not collect.

19 Slip in lobby while on coffee break, using gift card provided by employer. Compensable injury. Diane Pohrman, 64 Van Natta 752 (2012). Pay up.

20 Psychological pain disorder a greater cause than work activities in CTS claim. Washington County v. Jansen, 248 Or App 335 (2012). Do not pay.

21 Foot fracture and avascular necrosis were “otherwise compensable injuries,” not pre-existing conditions. Randi Ayres, 63 Van Natta 1821 (2011). Pay up.

22 “Otherwise compensable injury” does not extend to unclaimed, unaccepted conditions. Gary Sather, 63 Van Natta 1727 (2011). Do not pay.

23 Burn to wrist directly caused MSSA in artificial knee – not combined nor consequential. William Merrill, 63 Van Natta 2498 (2011). Pay up.

24 Identification of combined condition is not an acceptance. Procedurally invalid denial. Lillian Wilkinson, 63 Van Natta 1839 (2011). Pay up.

25 Pain in hamstring while playing golf was a back injury (pre-existing condition). Kenneth Dukek, 64 Van Natta 575 (2012). Do not pay.

26 Can’t file hearing loss claim for just the “pre-1994” hearing loss. David Brumage, 63 Van Natta 27 (2011). Do not pay.

27 Autonomic heart dysfunction is not “cardiovascular disease” for firefighter presumption statute. City of Eugene v. McCann, 248 Or App 527 (2012). Do not pay.

28 Minor or slight contribution is enough to shift responsibility under LIER. JH Kelly, LLC v. Smith, 244 Or App 223 (2011). Pay up.

29 Son moving back home was not a stressor, and termination of co-worker a “relief. ” Work stress more causative. David Meier, 63 Van Natta 2312 (2011). Pay up.

30 Responsibility-only denial is not a concession that claim is compensable. Hearing loss denial affirmed. David Hatt, 64 Van Natta 459 (2012). Do not pay.

31 Failure to insure self- employment as property manager dooms your LIER claim. Lewis Vanover, 64 Van Natta 206 (2012). Do not pay.

32 Symptoms were not the disease. Work activities causing “treatment” insufficient for an OD claim. Kenneth Pierce, 61 Van Natta 888 (2009). Do not pay.

33 Acceptance of bone bruise not a proper response to claim for coccydynia. But de facto denial affirmed anyway. SAIF v. Stephens, 247 Or App 107 (2011). Do not pay.

34 First acceptance of the claim was called “updated” instead of “initial” acceptance. Attorney fee awarded. Carol Groleau, 63 Van Natta 1313 (2011). Pay up.

35 “Current condition” denial invalid, in the absence of a combined condition, claim for medical services, or claim for new/omitted condition. Barbara Ferguson, 63 Van Natta 2253 (2011). Pay up.

36 Claimant attorney’s mileage to depo and hearing are not a reimbursable “cost” from the employer. Shirley Smith, 63 Van Natta 2354 (2011). Do not pay.

37 Clarification letter is not a legally- proper acceptance or denial of a new/omitted condition. Penalties and fees awarded. Patsy Sanborn, 63 Van Natta 2214 (2011). Pay up.

38 New/omitted claim for “low back conditions” denied because they were not new or separate from prior accepted conditions. Michael Long, 63 Van Natta 2134 (2011). Do not pay.

39 Board’s inference that MA followed ARU instructions was improper when MA didn’t follow other instructions. Multnomah County v. Shults, 243 OR App 354 (2011). Do not pay.

40 Restriction from working overtime leads to “work disability” award when overtime was part of “regular” work. Thrifty Payless, Inc. v. Cole, 247 Or App 232 (2011). Pay up.

41 Medical Arbiter’s critique of the claim acceptance and critique of claimant’s attorney made him unpersuasive. AP’s PPD award granted. Shanna Macpherson, 63 Van Natta 763 (2011). Pay up.

42 AP’s concurrence with IME on “resolved, no impairment” did not retract earlier opinion on no “regular work.” Heidi Galla, 63 Van Natta 1488 (2011). Pay up.

43 Arbiter’s failure to explain “what, how and why” findings were invalid allows rating for ROM loss. SAIF v. Miguez, 249 Or App 388 (2012). Pay up.

44 Teacher/coach awarded work disability because he could not longer demonstrate how to throw a discus. Gregory Ketner, 63 Van Natta 1904 (2012). Pay up.

45 Diagnostic facet injections not directed to accepted condition of lumbar contusion. SAIF v. Swartz, 247 Or App 515 (2012). Do not pay.

46 Supplemental TTD processor had no obligation to investigate eligibility for those benefits. Burden is on worker. Valencia v. GET BTL, LLC, 247 Or App 115 (2011). Do not pay.

47 Unreasonable failure to pay TTD, and failure to award it in the NOC, were two separate acts of misconduct. Double penalties. Kerry Hagen, 64 Van Natta 316 (2012). Open the checkbook.

48 Unilateral termination of TTD improper when the record lacked evidence from AP that he could not verify worker’s disability status. Alvin Devi, 64 Van Natta 400 (2012). Pay up.

49 Diagnostic neuro evaluation was not for the accepted concussion, but for an unaccepted possible seizure disorder. Sandra Freeman, 64 Van Natta 176 (2012). Do not pay.

50 No evidence that insurer contacted the employer to determine if claimant’s 48- hour work week included overtime pay. Case remanded. Scott Plummer, 63 Van Natta 2031 (2011).

51 Vocational benefits terminated before end of 10- day warning letter time period. Remanded. Dubray v. SAIF, ___ Or App ____ (2012).

52 Although AP did not check “aggravation” box on 827 form, the claimant did. Denial was not premature nor invalid. Francisco Carlos- Macias, 63 Van Natta 2184 (2011). Do not pay.

53 Filing of aggravation claim, not date of worsening, controls in dispute over whether the one- year period has passed in prior non-disabling claim. Beth Wilson-Atagabe, 63 Van Natta 2621 (2011). Pay up.

54 When worker signs CDA, and then tries to file aggravation claim (within first 5 years), claim not subject to Own Motion benefits. Donald Hamilton, 63 Van Natta 1271 (2011). Do not pay.

55 Insurer may recover third party lien on medical malpractice suit arising frm compensable injury. Sandra Campbell, 64 Van Natta 445 (2012). Collect!

56 Board would not approve a third party settlement in which claimant attempted to assign 42 percent to wife’s loss of consortium claim. David Hanson, 63 Van Natta 1108 (2011). Collect!

57 Promoted from claims assistant to claims examiner. Collect.

58 Your TPA is purchased. Commute to new location increases. Pay up.

59 Take account executive position with IME company. Collect.

60 Losses in California bankrupt your insurance company. Pay up.

61 Join OSIA committee. Honor and prestige follows. Collect.

62 Spend your weekend preparing claims review reports for Home Office. Pay up.

63 Orthopedic surgeon retires. You are first to sign him up to your IME company. Collect bonus.

64 MRI films don’t get to IME in time. Pay for supplemental report.

65 Largest client wants to “flat rate” your litigation defense bills. Do not collect.

66 Home Office demands greater expense control. Do not collect.

67 Client’s late reporting of injuries generates civil penalties. Pay up.

68 WCD comes in with full compliance audit. Pay up.

69 Injured workers on TTD get a bigger raise than you do. No collect.

70 Inherit old claims from prior TPA. Data conversion is difficult. Pay up.

71 IME’s in remote locations are cancelled. Pay for ortho’s vacation instead.

72 Bill Cross slips you an extra drink ticket. Collect!

73 Good Job

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