Insurer's de facto denial of symptom doesn't trigger penalties, fees
Case name: SAIF Corp. v. Stephens, No. A143526 (Or. Ct. App. 12/14/11).
Ruling: The Oregon Court of Appeals held that a caregiver was not entitled to attorney's fees or penalties for the insurer's failure to accept or deny her claim.
What it means: In Oregon, if an injured worker expressly requests acceptance of a condition that the insurer believes is actually a symptom, the insurer has an obligation to process the claim by accepting or denying it.
Summary: A caregiver sustained an injury when she fell at work and landed on her tailbone. The employer's insurer accepted a claim for lumbar contusion and lumbar strain. The caregiver received treatment from a doctor, who identified "coccydynia," which she defined as pain in the coccyx. The insurer closed the claim. The caregiver continued to experience pain, and a CT scan revealed a bone bruise of the coccyx. The insurer reopened the claim to accept a coccyx bone bruise. The caregiver sought attorney's fees and a penalty for an alleged de facto denial of coccydynia. The Oregon Court of Appeals held that the caregiver was not entitled to attorney's fees or penalties.
The insurer argued that coccydynia was a symptom and not a condition, so it had no obligation to accept or deny the claim. The court said that even if coccydynia was a symptom, it still had the obligation to process the claim by either accepting or denying it. The insurer's failure to do so was a de facto denial.
The insurer asserted that the doctor's definition of coccydynia appeared to describe a symptom, rather than a separate condition. The court agreed and found the caregiver's condition was a coccyx bone bruise. The court noted that the doctor stated that a bone bruise could be considered the underlying condition causing the coccydynia. Therefore, the insurer was not required to accept the coccydynia as a new or omitted medical condition.
Since the insurer was not required to separately accept coccydynia, the caregiver was not entitled to attorney's fees. Also, despite the insurer's de facto denial, the court said the insurer's failure to respond by accepting or denying the new or omitted medical condition claim was not unreasonable.
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February 6, 2012
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