(1)
General. The
director may
suspend compensation by order when the worker commits insanitary or injurious
acts that imperil or delay recovery; refuses to submit to medical or surgical
treatment reasonably required to promote recovery; or fails or refuses to
participate in a
physical rehabilitation program.
(a) The worker must have the opportunity to
dispute the suspension of compensation before the director will issue an
order.
(b) The worker is not
entitled to compensation during or for the period of suspension.
(2)
Notice to worker.
The
insurer must demand in writing the worker either immediately cease all
actions which imperil or delay recovery or immediately begin to change the
inappropriate behavior, and participate in activities needed to help the worker
recover from the injury. Each time the
insurer sends such a notice to the
worker, the
written demand must contain the following information, and a copy
must be sent simultaneously to the worker's attorney and attending physician:
(a) A description of the unacceptable
actions;
(b) Why such conduct is
inappropriate, including the fact that the conduct is harmful or delays the
worker's recovery, as appropriate;
(c) The date by which the inappropriate
actions must stop, or the date by which compliance is expected, including what
the worker must specifically do to comply; and
(d) The following notice of the consequences
should the worker fail to correct the problem:
(A) In prominent or bold text:
"If you continue to do insanitary or injurious acts
beyond the date in this letter, or fail to consent to the medical or surgical
treatment which is needed to help you recover from your injury, or fail to
participate in physical rehabilitation needed to help you recover as much as
possible from your injury, then we will request the suspension of your workers'
compensation benefits. In addition, you may also have any permanent disability
award reduced in accordance with ORS
656.325 and OAR
436-060."
(B)
Effective no later than Oct. 1, 2024, the text in (d)(A) of this section must
be replaced with the following language in bold and formatted as follows:
If you continue this inappropriate conduct after the
above date:
- We will ask that your workers' compensation benefits be
suspended, and
- Your permanent disability award, if any, may be reduced
under ORS 656.325 and OAR
436-060.
(3)
Failure or refusal to accept
medical treatment. For the purposes of this rule, failure or refusal to
accept medical treatment means the worker fails or refuses to remain under a
physician's or authorized nurse practitioner's care or abide by a treatment
regimen. A treatment regimen includes, but is not limited to a prescribed diet,
exercise program, medication or other activity prescribed by the physician or
authorized nurse practitioner that is designed to help the worker reach maximum
recovery and become medically stationary.
(4)
Request for suspension of
benefits. The
insurer must verify whether the worker complied with the
request for cooperation on the date specified in subsection (2)(c) of this
rule. If the worker initially agrees to comply, or complies and then refuses or
fails to continue doing so, the
insurer is not required to send further notice
before requesting
suspension of compensation.
(a) The request for suspension must be sent
to the division. A copy of the request, including all attachments, must be sent
simultaneously to the worker and the worker's attorney, if any, by registered
or certified mail or by personal service as for a summons.
(b) The request must include the following
information:
(A) That the request for
suspension is made in accordance with ORS
656.325 and OAR
436-060-0105;
(B) A description of the actions of the
worker that prompted the request, including whether such actions
continue;
(C) Any reasons offered
by the worker to explain the behavior, or a statement that the worker has not
provided any reasons, whichever is appropriate;
(D) How, when, and with whom the worker's
failure to comply or refusal to comply was verified;
(E) A copy of the notice required in section
(2) of this rule;
(F) Any other
relevant information including, but not limited to; chart notes, surgical or
physical therapy recommendations/prescriptions, and all recommendations from
the attending physician or authorized nurse practitioner; and
(G) The following notice:
(i) In prominent or bold text:
"Notice to worker: If you think this request to suspend
your compensation is wrong, you should immediately write to the Workers'
Compensation Division, 350 Winter Street NE, PO Box 14480, Salem, Oregon
97309-0405. Your letter must be mailed within 10 days of the date this request
was mailed or personally served on you. If the division authorizes suspension
of your compensation and you do not correct your unacceptable actions or show
us a good reason why they should be considered acceptable, we will close your
claim."
(ii)
Effective no later than Oct. 1, 2024, the text in (G)(i) of this subsection
must be replaced with the following language in bold and formatted as follows:
Notice to worker:
If the Workers' Compensation Division decides to suspend
your benefits and you do not correct your unacceptable actions, or show us a
good reason why they are acceptable, we will close your claim.
If you think this request to suspend your benefits is
wrong, write to the Workers' Compensation Division immediately.
- Your letter must be mailed within 10 days of the date
this request was mailed or personally served on you.
- Address your letter to:
Workers' Compensation Division
350 Winter Street NE
PO Box 14480
Salem OR 97309-0405
If you have any questions, you may call the Workers'
Compensation Division at 800-452-0288 (toll-free) or
503-947-7585.
(c) Any delay in obtaining confirmation or in
requesting the suspension of compensation may result in authorization being
denied or the date of authorization being modified by the date of actual
confirmation or the date the request is received by the division.
(d) If the
director approves authorization of
suspension of compensation:
(A) An order will
be issued suspending compensation from a date established under subsection
(2)(c) of this rule until the worker complies with the insurer's request for
cooperation. Where the worker is suspended for a pattern of noncooperation, the
director may require the worker to demonstrate cooperation before reinstating
compensation;
(B) The insurer must
make all reasonable efforts to assist the worker to reinstate benefits when the
worker demonstrates the willingness to make such efforts;
(C) The
insurer must monitor the claim to
determine if and when the worker complies with the
insurer's requests;
(i) When cooperation resumes, payment of
compensation must resume effective the date cooperation was resumed;
(ii) If the worker makes no effort to
reinstate benefits within 60 days of the
mailing date of the suspension order,
the
insurer must close the claim under OAR
436-030-0034;
(D) The director may modify or set aside the
suspension order before or after filing of a request for hearing;
(E) The director may order payment of
compensation previously suspended where the director finds the suspension to
have been made in error;
(F) The
director may re-evaluate the necessity of continuing a suspension;
and
(G) The order will become final
unless, within 60 days after the date of mailing of the order, a party files a
request for hearing on the order with the board.
(e) If the director denies the insurer's
request for suspension of compensation, the insurer will be notified of the
reason for denial. The insurer's failure to comply with one or more of the
requirements addressed in this rule may be grounds for denial of the insurer's
request.
(5)
Requests to reduce benefits. The
director may reduce any benefits
awarded the worker under ORS
656.268 when the worker has
unreasonably failed to follow medical advice, or failed to participate in a
physical rehabilitation program or vocational assistance program prescribed for
the worker under ORS chapter 656 and OAR chapter 436. Such benefits must be
reduced by the amount of the increased disability reasonably attributable to
the worker's failure to cooperate.
(a) When an
insurer submits a request to reduce benefits under this section, the
insurer
must:
(A) Specify the basis for the
request;
(B) Include all supporting
documentation;
(C) Send a copy of
the request, including the supporting documentation, to the worker and the
worker's attorney, if any, by certified mail; and
(D) Include the following notice:
(i) In prominent or bold text:
"Notice to worker: If you think this request to reduce
your compensation is wrong, you should immediately write to the Workers'
Compensation Division, 350 Winter Street NE, PO Box 14480, Salem, Oregon
97309-0405. Your letter must be mailed within 10 days of the mailing date of
this request. If the division grants this request, you may lose all or part of
your benefits."
(ii)
Effective no later than Oct. 1, 2024, the text in (D)(i) of this subsection
must be replaced with the following language in bold and formatted as follows:
Notice to worker:
If the Workers' Compensation Division grants this
request, you may lose all or part of your benefits.
If you think this request to reduce your benefits is
wrong, write to the Workers' Compensation Division immediately.
- Your letter must be mailed within 10 days of the date
this request was mailed or personally served on you.
- Address your letter to:
Workers' Compensation Division
350 Winter Street NE
PO Box 14480
Salem OR 97309-0405
If you have any questions, you may call the Workers'
Compensation Division at 800-452-0288 (toll-free) or
503-947-7585.
(b) The director will make a decision on a
request to reduce benefits and notify the parties of the decision. The
insurer's failure to comply with one or more of the requirements addressed in
this rule may be grounds for denial of the request to reduce
benefits.
Notes
Or. Admin. Code §
436-060-0105
WCD 6-1989, f.
12-22-89, cert. ef. 1-1-90; WCD 29-1990, f. 11-30-90, cert. ef. 12-26-90; WCD
7-1994, f. 8-11-94, cert. ef. 8-28-94, Renumbered from
436-060-0085(1),(2),(4),(5); WCD 5-1996, f. 2-6-96, cert. ef. 2-12-96; WCD
11-2000, f. 12-22-00, cert. ef. 1-1-01; WCD 11-2001, f. 11-30-01, cert. ef.
1-1-02; WCD 13-2003(Temp), f. 12-15-03, cert. ef. 1-1-04 thru 2-28-04; WCD
2-2004, f. 2-19-04 cert. ef. 2-29-04; WCD 9-2004, f. 10-26-04, cert. ef.
1-1-05; WCD 8-2005, f. 12-6-05, cert. ef. 1-1-06; 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 3/13/2020,
effective 4/1/2020;
WCD
13-2022, amend filed 12/19/2022, effective
1/1/2023;
WCD
14-2024, amend filed 06/07/2024, effective
7/1/2024
Statutory/Other Authority: ORS
656.325, ORS
656.704 & ORS
656.726(4)
Statutes/Other Implemented: ORS
656.325, ORS
656.704 & ORS
656.726(4)
