Monday, December 19, 2011

OR Case Lesson - Don't Be Vague

The interplay between symptom and condition can be interesting, and tricky, once the law gets involved.

This is highlighted by an Oregon case reported in this morning's WorkCompCentral News.

In SAIF Corp. v. Stephens, No. A143526 (12/14/11) Sherrian Stephens, a caregiver, suffered an injury in 2007 when she fell at work and landed on her tailbone. On July 20, SAIF accepted the claim for a lumbar contusion and lumbar strain.  

Her physician diagnosed her with "coccydynia," which was defined as "pain in the coccyx." SAIF closed the claim in December 2007 with the accepted conditions of lumbar strain and a lumbar contusion, and no PPD award. 

Stephens continued to feel pain in her tailbone, and her physician referred her to a neurologist. A CT scan revealed a bone bruise of the coccyx. 

SAIF sent Stephens' physician questions about coccydynia, and received one-word responses. SAIF accepted the coccyx bone bruise, and the claim was reopened in March 2008 for the processing the newly accepted condition of coccyx bone bruise. However, there was no award for additional disability. SAIF determined that coccydynia was a symptom and not a "condition" as defined by Oregon law. The claim was then closed again.

After a hearing the administrative law judge and the Workers' Compensation Board determined that coccydynia was a new condition and that SAIF had to accept or deny the medical condition within 60 days after receiving notice of the claim, which is required by Oregon statutes. On reconsideration, the board determined that SAIF had failed to adequately and timely respond to the claim, and that the failure to respond was a de facto denial. 

As a result, the board assessed attorney fees against SAIF, along with other penalties. SAIF filed for judicial review. 

The appellate court ruled that SAIF still had an obligation to either accept or deny the claim. 

"Even if SAIF had correctly concluded that coccydynia was a symptom, it still had the obligation to either accept or deny the claim. As we recently explained in Crawford v. SAIF," the court opinion states, "if a claimant files a new or omitted medical condition claim pursuant to ORS 656.267 by clearly requesting formal written acceptance, the insurer's response must be by written notice of acceptance or denial within 60 days. In that circumstance, a mere letter of clarification or amendment of the notice of acceptance does not suffice."

But, the court also ruled that coccydynia is not a separate condition, but is rather a symptom. Therefore, SAIF did not have to accept coccydynia as a new or omitted medical condition. Consequently SAIF was not liable for attorney fees or penalty, reversing the Board.

The simple lesson in claims management: when in doubt, err on the side of some positive response within the stated time line.

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