(1)
General. If the
insurer changes the classification of an accepted
claim, the
insurer must:
(b) Send the worker and the worker's
attorney, if any, a "Modified Notice of Acceptance" explaining the change in
status; and
(c) Close the claim
under ORS 656.268(5), if
the claim qualifies for closure.
(2)
Reclassification of a nondisabling
claim. The
insurer must reclassify a nondisabling claim to disabling:
(a) Within 14 days of receiving information
that:
(A) Temporary disability is due and
payable;
(B) The worker is
medically stationary within one year of the date of injury and the worker will
be entitled to an award of permanent disability; or
(C) The worker is not medically stationary,
but there is a reasonable expectation that the worker will be entitled to an
award of permanent disability when the worker does become medically stationary;
or
(b) Upon acceptance of
a new or omitted condition that meets the disabling criteria in this
section.
(3)
Worker
request for reclassification. A worker may request the
insurer review
the classification of a nondisabling claim under ORS
656.277 if the claim has been
classified as nondisabling for one year or less after the date of acceptance
and the worker believes the claim was or has become disabling.
(a) The request for classification status
review must be first made to the insurer in writing.
(b) Within 14 days of receipt of the worker's
request, the
insurer must review the claim and:
(A) If the classification is changed to
disabling, provide notice under this rule; or
(B) If the
insurer believes evidence supports
denying the worker's request to reclassify the claim, the
insurer must mail a
"Notice of Refusal to Reclassify" to the worker and the worker's attorney, if
any. The notice must include:
(i) The
following statement, in bold text:
"If you disagree with this Notice of Refusal to
Reclassify, you may appeal by contacting the Workers' Compensation Division
within sixty (60) days of the mailing date of this notice. You may
appeal by using Form 2943, "Worker Request for Claim Classification Review,"
available on the division's website at wcd.oregon.gov.
Send written appeals to the Workers' Compensation
Division, Appellate Review Unit, PO Box 14480, Salem OR
97309-0405
Or fax to: 503-947-7794
Or hand-deliver to: Workers' Compensation Division,
Appellate Review Unit, 350 Winter Street NE, 2nd Floor, Salem OR
97301
You may appeal by phone by calling the Appellate Review
Unit at 503-947-7816. A member of the Appellate Review Unit will complete and
sign Form 2943 as the worker's designee and they will send a copy of the
completed form to you, the insurer, and any attorneys involved in the
claim.
If you do not appeal to the Workers' Compensation
Division within 60 days of the mailing date of this notice, you will lose all
rights to review of this decision. For assistance, you may call the Workers'
Compensation Division at 503-947-7816, or the Ombuds Office for Oregon Workers
at 503-378-3351 or 800-927-1271 (toll-free)."
(ii) Effective no later than Oct. 1, 2024,
the statement in (B)(i) of this subsection must be replaced with the following
language in bold and formatted as follows:
If you disagree with this Notice of Refusal to
Reclassify, you may appeal by contacting the Workers' Compensation Division. To
appeal:
- Contact the division within 60 days of the mailing date
of this notice.
- You may use Form 2943, "Worker Request for Claim
Classification Review," available on the division's website at
wcd.oregon.gov.
- Request review in writing or by phone.
Send, hand deliver, or fax written requests
to:
Workers' Compensation Division
Appellate Review Unit
350 Winter Street NE, 2nd Floor
PO Box 14480
Salem OR 97309-0405
Fax: 503-947-7794
Or, call the Workers' Compensation Division at
503-947-7816. The division will complete and sign Form 2943 on your behalf, and
will send copies of the completed form to you, the insurer, and any attorneys
involved in the claim.
If you do not appeal to the Workers' Compensation
Division within 60 days of the mailing date of this notice, you will lose all
rights to appeal this decision.
For help, call:
- Workers' Compensation Division at
503-947-7816
- Ombuds Office for Oregon Workers at 503-378-3351 or
800-927-1271 (toll-free)
(c) If the worker disagrees with the
insurer's decision in the Notice of Refusal to Reclassify, the worker may
appeal to the
director under section (7) of this rule:
(A) The appeal must be made no later than the
60th day after the mailing date of the Notice of Refusal to Reclassify;
and
(B) A copy of the insurer's
Notice of Refusal to Reclassify must be provided to the director.
(d) If the
insurer does not
respond to the worker's request for reclassification within 14 days of receipt
of the worker's request:
(A) The worker may
request review by the director under section (7) of this rule as if the insurer
issued a Notice of Refusal to Reclassify;
(B) The
director may assess civil penalties
under OAR
436-060-0200; and
(C) The director may assess an attorney fee
under ORS 656.386(3).
(e) If the worker is represented by an
attorney, and the attorney is instrumental in obtaining an order from the
director that reclassifies the claim from nondisabling to disabling, the
director may order a reasonable assessed attorney fee under ORS
656.277 and OAR
436-001-0435.
(4)
Time frame for aggravation
rights. A claim for
aggravation under ORS
656.273 must be filed within
five years after:
(a) The first valid closure
of a claim that is reclassified from nondisabling to disabling within one year
from the date of acceptance; or
(b)
The date of injury of a claim that is not reclassified from nondisabling to
disabling within one year from the date of acceptance.
(5)
Claims for aggravation on
nondisabling claims. When a claim has been classified as nondisabling
for at least one year after the date of acceptance, a worker who believes the
claim was or has become disabling may submit a claim for aggravation under ORS
656.273.
(6)
Reclassification of a disabling
claim. If a claim has been accepted and classified as disabling:
(a) All aspects of the claim are classified
as disabling and may not be reclassified, unless:
(A) The claim has been classified as
disabling for less than one year from date of acceptance;
(B) The insurer determines the criteria for a
disabling claim were never satisfied; and
(C) The
insurer has notified the worker and
the worker's attorney, if any, by issuing a Modified Notice of Acceptance. The
Modified Notice of Acceptance must include:
(i) The following statement in bold text:
"Notice to Worker: Your claim has been reclassified to
nondisabling. Generally, this means your insurer concluded no disability
payments are due and all of the following are true:
You were able to return to work at full wages on or
before the fourth calendar day after leaving work or losing wages as a result
of your injury.
You did not lose time or wages from work as a result of
your injury on or after that fourth calendar day.
It appears you will not have any permanent disability as
a result of your injury.
If you think there is a mistake in the classification of
your claim as nondisabling, contact the insurer within one year of the date the
insurer first accepted your claim and request reclassification.
If you request reclassification, the insurer must
complete its review and send you its decision within 14 days of receiving your
request. If you disagree with the insurer's decision, you have the right,
within 60 days of the date of the insurer's notice, to request that the
Workers' Compensation Division review your claim to determine if it was
correctly classified. If the insurer does not respond to your request for
reclassification within 14 days of receiving your request, you may ask the
Workers' Compensation Division to review your claim as though the insurer
refused to reclassify your claim. For assistance, you may call the Workers'
Compensation Division at 503-947-7816, or the Ombuds Office for Oregon Workers
at 503-378-3351 or 800-927-1271 (toll-free)."
(ii) Effective no later than Oct. 1, 2024,
the statement in (C)(i) of this subsection must be replaced with the following
language in bold and formatted as follows:
Notice to worker:
We have changed your claim to nondisabling. Generally,
this means no disability payments are due and all of the following are
true:
- You were able to return to work with full wages by the
fourth calendar day after leaving work or losing wages because of your
injury.
- You did not lose time or wages from work because of
your injury on or after that fourth calendar day.
- It appears you will not have any permanent disability
because of your injury.
If you disagree that your claim is nondisabling, you may
request that we change your claim to disabling.
- You must send us your request in writing within one
year of the date we first accepted your claim.
- We must review and send you our decision within 14 days
of receiving your request.
If you disagree with our decision, or we do not respond
to your request, you have the right to appeal to the Workers' Compensation
Division. To appeal:
- You must ask the division to review your claim within
60 days of the date we mailed you our decision.
- If we did not respond within 14 days of receiving your
request, ask the division to review your claim as if we refused to change your
claim.
For help, call:
- Workers' Compensation Division at
503-947-7816
- Ombuds Office for Oregon Workers at 503-378-3351 or
800-927-1271 (toll-free)
(b) Any subsequently accepted conditions or
aggravations must be processed as disabling claims; and
(c) Claim closure must be processed under ORS
656.268.
(7)
Appeal of insurer's classification
decision. If a worker disagrees with an
insurer's decision to not
reclassify the worker's claim from nondisabling to disabling, the worker may
appeal the decision by requesting review by the
director:
(a) The request must be submitted to the
division by mail, hand-delivery, fax, or phone within 60 days from the date of
the insurer's notice;
(b) The
worker may use Form 2943, "Worker Request for Claim Classification Review," for
requesting review of the insurer's claim classification decision; and
(c) The worker does not need to be
represented by an attorney to appeal the
insurer's reclassification decision
under section (3) or (6) of this rule. If a worker appeals an
insurer's
reclassification decision:
(A) The worker's
appeal must be copied to the insurer;
(B) The director will acknowledge receipt of
the appeal in writing to the worker, the worker's attorney, if any, and the
insurer, and initiate the review;
(C) Within 14 days of the
director's
acknowledgement:
(i) The
insurer must provide
the
director and all other parties with the complete medical record and all
official actions and notices on the claim. The
director may impose penalties
against an
insurer under OAR
436-060-0200 if the
insurer
fails to provide claim documents in a timely manner; and
(ii) The worker may submit any additional
evidence for the director to consider. Copies must be provided to all other
parties at the same time; and
(D) After receipt and review of the required
documents, the
director will issue an order:
(i) The worker and the insurer have 30 days
from the mailing date of the order to appeal the director's decision to the
board; and
(ii) The director may
reconsider, abate, or withdraw any order before the order becomes final by
operation of law.
Notes
Or. Admin. Code §
436-060-0018
Renumbered to
436-060-0018 by WCD 2-2004, f. 2-19-04 cert. ef. 2-29-04; WCD 10-2001, f.
11-16-01, cert. ef. 1-1-02; WCD 9-2000, f. 11-13-00, cert. ef. 1-1-01; WCD
17-1997, f. 12-22-97, cert. ef. 1-15-98; WCD 8-1996, f. 2-14-96, cert. ef.
2-18-96; WCD 12-1994, f. 11-18-94, cert. ef. 1-1-95; WCD 5-1992, f. 1-17-92,
cert. ef. 2-20-92; WCD 31-1990, f. 12-10-90, cert. ef. 12-26-90; WCD
5-1990(Temp), f. 6-18-90, cert. ef. 7-1-90; Sunset on 09-28-2017; WCD 2-2004,
f. 2-19-04, cert. ef. 2-29-04, Renumbered from 436-030-0045; WCD 9-2004, f.
10-26-04, cert. ef. 1-1-05; WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD
5-2008, f. 12-15-08, cert. ef. 1-1-09; WCD 3-2009, f. 12-1-09, cert. ef.
1-1-10;
WCD
6-2016, f. 11-28-16, cert. ef.
1/1/2017; WCD 7-2020, amend filed 03/13/2020,
effective 04/01/2020;
WCD
6-2022, amend filed 07/05/2022, effective
9/1/2022;
WCD
14-2022, amend filed 12/20/2022, effective
1/1/2024;
WCD
14-2024, amend filed 06/07/2024, effective
7/1/2024
Statutory/Other Authority: ORS
656.268, ORS
656.277, ORS
656.386, ORS
656.726(4)
& ORS 656.745
Statutes/Other Implemented: ORS
656.268, ORS
656.277, ORS
656.386, ORS
656.745, ORS
656.210, ORS
656.212, ORS
656.214, ORS
656.262 & ORS
656.273
