Employees face different risks as part of their work. In the unfortunate situation where someone falls ill or incurs an injury, they can obtain benefits in the form of workers’ compensation.
The importance of such benefits should not be overstated in light of the state’s employment statistics. Most workers in Oregon are employed in the food services, healthcare, administrative, specialty trade, and social assistance sectors. These comprise employees like servers, nurses, plumbers, and electricians. The types of injuries associated with their work — trips, burns, and falls — require a robust workers’ compensation system.
In 2022, the same system accepted about 25,000 disabling claims. Around 10% of these were initially rejected by insurance companies. This figure is the lowest on record, as the claim denial rates in 2020 and 2021 were 12.8% and 11%, respectively.
Despite this decreasing trend, workplace accidents and denials are still possible. In such cases, one must understand how to pursue workers’ compensation benefits.
This article provides an overview of how to do so in Oregon. It also delivers information on how workers whose claims were denied can file an appeal. The article additionally lists helpful resources that assist employees in their recovery process.
Oregon Workers’ Compensation Insurance Requirements
Most employers need workers’ compensation insurance under state law. If they have one or more individuals working for them, whether full-time or part-time, they will need to purchase coverage. Subject workers — or those bound by Oregon labor regulations — qualify for compensation in cases of workplace-related injuries.
They are different from non-subject workers, who are not required to be covered by their employer’s insurance policies. These may include domestic servants and those performing services for religious or charitable organizations in exchange for board and lodging. State law also specifies that casual employees whose labor costs are less than $3,000 within 30 days are non-subject workers.
In addition, businesses that hire independent contractors are not obligated to insure them. State law defines these workers as those free from control and direction over how they deliver their services. Nevertheless, companies that employ independent contractors have the right to specify their desired output.
Those employed in the federal government are likewise exempt from workers’ compensation, although they can access other benefits.
Meanwhile, individuals temporarily employed in different states can still obtain workers’ compensation benefits. The accessibility of these, though, depends on the state. Some maintain reciprocal agreements with Oregon, which means businesses do not need additional coverage for their out-of-state employees. Some of these reciprocal states consist of nearby states like California, Idaho, and Washington.
Unlike in neighboring Washington, however, businesses in Oregon can purchase insurance from private companies. There are over 300 insurers approved to sell such policies. There is also the State Accident Insurance Fund, a nonprofit responsible for more than half of the premiums provided to injured or sick workers throughout the state. Another way for businesses to comply is to get self-insured.
There are other regulations that companies must keep in mind. For example, their central gathering areas need a Notice of Compliance poster.
Penalties are also present for businesses without workers’ compensation insurance. Uninsured companies caught for the first time have to pay twice the premium amount they were supposed to if they had insurance. The minimum fine imposed on first-time offenders is $1,000.
Meanwhile, uninsured employers whose workers were injured are still on the hook for their benefits. They also need to hire a certified claims agent to process the claim, which comes with fees. In addition, if the business goes into debt to finance workers’ compensation benefits, this liability remains even if they declare bankruptcy.
Oregon Workers’ Compensation Benefits
Through workers’ compensation benefits, injured or sick workers can manage a variety of costs. These can consist of:
Continuing care expenses.
Insurance policies also cover disability payments. These vary depending on whether a worker incurs a temporary or permanent disability. The distinction between the two is that the former refers to medical conditions that affect individuals for a limited time. Examples of these conditions include concussions and sprains. On the other hand, permanent disabilities cannot improve despite medical treatment. Some forms of these are blindness, deafness, arthritis, and lung damage.
Temporary and permanent disability benefits can be further classified into four groups, which are:
Temporary partial disability: This applies to those who can return to work with modified duties.
Temporary total disability: This applies to those who cannot be released for alternative work.
Permanent partial disability: This is given to those who have lost a bodily function.
Permanent total disability: This is provided to those who can no longer return to work.
Note that insurers may not cover injuries caused by certain circumstances. For example, if horseplay was involved, an injured worker could not obtain benefits. Employees under the influence of drugs and alcohol also do not have the right to workers’ compensation. However, in these circumstances, it is the employer's responsibility to demonstrate that the injury was a result of intoxication. This information is crucial since Oregon is the first state to decriminalize marijuana and legalize it for medical use.
Another thing that employees must keep in mind is that they cannot sue their employers for damages. Under the state’s exclusive remedy laws, workers' compensation benefits solely address any work-related injury claim. In 2016, the Oregon Supreme Court overturned a ruling from 2001 that permitted employees to sue their employers for some damages.
How to File a Workers’ Compensation Claim in Oregon
Employers, workers, insurance companies, and healthcare providers each have responsibilities in the filing process. Injured employees, for instance, must keep in mind deadlines when submitting their claims to avoid losing their rights to benefits. On the other hand, employers need to coordinate with insurers and state agencies to steer clear of penalties.
When is the Deadline for Workers’ Compensation Claims in Oregon?
Employees who sustain a workplace injury should report it immediately to their employer. This must be made within 90 days after the incident. When an employee passes away due to a job-related accident, their loved one also has 90 days to report it to their employer.
However, there are some cases where the immediate physical impact of a job-related accident is not apparent. These may involve occupational diseases, like asthma, due to dust exposure. Some medical conditions, on the other hand, come from repetitive motions. These include carpal tunnel syndrome and hernias.
In such cases, injured workers have a year to file a claim. This one-year period starts from the date of the injury discovery. It may also begin on the day the employee develops a disability. Additionally, surviving family members of deceased employees have one year from when their illness was discovered to submit a claim.
If a worker’s claim is denied because they cannot prove that their job-related accident caused their injuries, they may file a civil negligence claim. This action needs to commence within one of these timeframes, whichever comes later:
Within 180 days from the date when the worker receives the decision that their claim is not valid.
Within two years from the injury date.
A Step-By-Step Guide on Filing a Workers’ Compensation Claim in Oregon
1. Report Illness or Injury to Employer or Physician
The first step involves submitting Form 801 (Report of Job Injury or Illness) to one’s employer. If properly filled out, it can provide multiple details, including the affected body part and the cause of the accident.
An individual seeking medical treatment from a doctor needs to disclose that their injury is work-related. In turn, their doctor needs to fill out Form 827 with them. This document allows them to provide a range of information to the insurer, from the type of treatment to impairment findings.
Within eight hours of the incident or after becoming aware of it, employers must report work-related fatalities and catastrophes to the Oregon Occupational Safety and Health Division or OSHA. In situations where a worker is hospitalized, undergoes an amputation, or loses an eye, their employer needs to submit a report within 24 hours.
Informing OSHA is done either through a telephone call or in person. The agency’s office locations are scattered throughout Oregon, in places like Tigard, Salem, and Bend.
2. Employer and Physician Submit Claim to Insurer
Note that businesses cannot withhold their workers from starting the claims process. But in case the employer refuses to submit the form, the injured worker should still continue with the process and look up the right insurance carrier through the Proof of Coverage Search webpage.
One can also call the Ombuds Office for Oregon Workers at 800-927-1271 to receive assistance in the claims process. Additionally, a worker may reach out to the Oregon Workers’ Compensation Division via 800-452-0288 if their employer does not possess job-related injury insurance.
Sometimes, an injury arises from workplace safety violations, which should be reported to the right authorities. In such cases, the employer might fire the hurt worker as retaliation. One can then submit a retaliation complaint to the Oregon Bureau of Labor & Industries. Workers may also contact the bureau for help at 971-673-0764.
3. Receive Wage-Loss Benefits, if Applicable
Within 14 days of claim submission, the injured worker may receive lost wages from their employer’s insurer. But keep in mind that there’s a three-day waiting period, which refers to the first three consecutive days an employee misses work. Insurers will not cover this period if the worker is released by their doctor for work within 14 days of the accident.
However, if an individual is not authorized by their healthcare provider to perform work tasks during the two-week period, the first three days are included in the lost wages payment. Another situation where the three-day period is incorporated is if the worker is hospitalized overnight.
Reimbursement for missed wages is impossible if the insurer denies the workers’ compensation claim 14 days after the accident.
4. Insurer Investigates Claim
Workers’ compensation insurance carriers look at various pieces of evidence to determine whether to accept or deny claims. These range from past healthcare records to statements from supervisors.
Sometimes, the insurer may request that the worker undergo an independent medical examination. Here, the presiding physician is different from the workers’ attending doctor. At least 10 days prior to the exam, the insurer needs to send written notice to the employee. Note that the costs for the worker to attend the exam are borne by the carrier.
<h4>5. Receive Notice of Acceptance from Insurer</h4>
Within 60 days of the employer’s knowledge of the claim, the insurer must decide whether to accept or deny it. If it is approved, the insurer needs to provide a Notice of Acceptance. This document lists the medical conditions that the insurer agrees to cover.
They also need to classify the claim as either disabling or non-disabling. Non-disabling claims, as the name implies, mean that the injury or illness does not lead to a permanent loss of bodily function or the ability to work. In such cases, insurers only pay the medical bills required to treat the compensable injury.
Disabling claims, meanwhile, are categorized as such since the worker’s injury will likely lead to permanent loss of bodily function or their capacity to work. If the worker’s doctor deems them to be medically stationary, insurers may issue a Notice of Closure indicating that the claim is closed. An individual who is medically stationary is someone whose condition will not improve over time despite further treatment. Within 30 days of mailing the Notice of Closure, the insurer must pay permanent disability benefits to the worker.
In situations involving workplace-related fatalities, insurers are required to submit monthly payments to the eligible beneficiaries. The compensation that carriers pay includes coverage for costs like funeral expenses.
6. Notify Insurer About Aggravation of Illness or Injury, if Necessary
In some cases, conditions may worsen. Individuals can file Form 827 to reopen their claims and report that their injury or illness has deteriorated. They have five years to do so, with the timeframe depending on how the claim is classified. In non-disabling claims, for instance, the five-year period starts from the injury date. Meanwhile, in cases involving disabling claims, it begins on the date the claim was initially closed.
What Should One Do If a Workers’ Compensation Claim in Oregon Has Been Denied?
There are multiple reasons why insurers deny claims. One is the absence of witnesses; a carrier can deny benefits because no third parties back up a worker’s claim. Other reasons include the lack of proper medical records and the misrepresentation of medical symptoms.
In cases of denial, one can submit an appeal. Workers may file a Request for Reconsideration with the Oregon Workers’ Compensation Division within 60 days of receiving the Notice of Closure. The division has 18 working days to file a response. This timeframe may be extended to 60 calendar days if the division requires more time to gather evidence. The 60-day period also applies if the worker or the division requests a medical arbiter exam.
The division’s response after the 18- or 60-day period is known as the Order on Reconsideration. Note that the response may lead to reduced benefits as the division assesses information, which can include new records. Workers who disagree with this decision may file an appeal through a request for a hearing with the Oregon Workers’ Compensation Board. They must submit this appeal within 30 days after the order is given.
Under state law, the board needs to schedule a hearing within a 90-day period starting from the date the appeal was filed. The hearing is presided over by an administrative law judge. They have 30 days after the hearing to issue their decision, which is known as the Opinion and Order.
If the judge’s decision is not favorable, the worker may submit an appeal through a Request for Board Review. The deadline for this appeal is 30 days from the date when the Opinion and Order is issued. It can take anywhere between six months and one year for the board to decide on the matter. This judgment is referred to as an Order on Review.
After the Order on Review is given, the worker may file an appeal with the Oregon Court of Appeals within 30 days if they are still not satisfied with the decision. The case can end up before the Oregon Supreme Court, but this is highly unlikely. If it does ultimately arrive at the state’s highest court, the decision on the matter will be final.
Legal Resources for Injured Workers in Oregon
The resources below allow injured and sick workers to access programs that can help them return to work or obtain benefits as part of the process of transitioning careers or industries. Besides issues like workplace discrimination and unemployment insurance, Oregon state agencies also assist in a variety of matters. These include housing, job training, and career coaching. There is also a link that aids Oregonians aiming to enter the hospitality industry.
Oregon Bureau of Labor & Industries</h3>
The bureau seeks to protect workers, empower them through apprenticeship programs, and educate employers about their need to comply with civil rights laws. It has experience guiding employees about their rights at work in areas like minimum wage, overtime pay, sexual harassment, and workplace safety. Those who are looking to file a complaint for a violation of their rights may do so by calling 971-245-3844 or sending an email to firstname.lastname@example.org.
One can also take an online quiz to determine whether they are on the receiving end of common workplace violations. The bureau also provides financial assistance to apprentices in the highway construction trade. Contact 503-205-4769 for more information.
Oregon Employment Department
The department assists workers who are eligible for unemployment insurance benefits. Individuals can send an application online. They may also submit an initial claim by calling 1-877-345-3484. Another way to apply is by faxing or mailing Form 115, which is available in English, Russian, Vietnamese, and Spanish, to the department.
A program that the agency also oversees is Training Unemployment Insurance. Those who lost their jobs and are attending school can obtain unemployment insurance benefits. One may send an application through fax at 503-974-1335 or by email at OED_TUI@oregon.gov. Note that any failure to fill out the application completely can lead to a denial or delay of benefits from the department.
Oregon Housing and Community Services
The agency provides resources that help Oregonians, including injured workers, access stable housing and avoid poverty. It oversees multiple programs, such as the Utility Bill Payment Assistance project. It assists low-income households looking to manage their energy-related costs and aids them in avoiding the loss of their home energy service.
Another solution that the agency offers is Emergency Housing Assistance. Injured workers at risk of becoming homeless or already out on the streets may obtain help through their local community action agency.
Oregon Restaurant & Lodging Association
Oregon Restaurant & Lodging Association represents the interests of the lodging and food service industries in Oregon. The association counts the National Restaurant Association and the American Hotel and Lodging Association as its affiliate partners. It helps workers seeking to transition into hospitality jobs through training programs. Some of these include education for those looking to become food handlers and alcohol servers.
The association also oversees the Oregon Tourism Leadership Academy, which delivers training for hospitality professionals aiming to level up their professional skills. Interested individuals may submit an application online. Note that eligible applicants can obtain scholarships to attend the academy.
WorkSource matches businesses with job seekers. The agency helps those seeking to return to work through training and career coaching. It also educates individuals on how they can access GED programs, college classes, and paid internships. Those who have a disability may contact WorkSource online to receive assistance in obtaining a job that matches their interests, skills, and abilities. Moreover, the agency helps veterans qualify for priority job referrals. Those aiming to get in touch with WorkSource through other means may do so with a call at 503-947-1680 or an email to EmployerServices@oregon.gov.
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