Nearly every worker in Oregon is covered by workers’ compensation insurance. (Exception: If you work for the federal government or are engaged in maritime employment, you would not receive state workers’ compensation benefits. Other benefits would be available to you instead.) Oregon workers’ compensation insurance pays for medical expenses and provides compensation when you lose time from work or suffer a permanent disability from an accident or disease arising out of your employment. It may also provide vocational assistance. In the event of death resulting from a work related injury or disease, death benefits (including burial expenses) are available to your spouse and minor children including children who are attending college, in most cases.
If you have experienced a work-related injury or disability, you should give your employer written notice of your claim stating when, where and how your injury occurred as soon as possible. Your employer will send the notice to its workers’ compensation insurance company. Usually, your employer will have a special form that you can use, commonly referred to as an “801 form”). Once again, you should file your claim as soon as possible; if you delay too long you may be denied benefits.
Remember, there are certain deadlines for filing your claim. Your employer cannot refuse you the right to file a claim, and the law prohibits your employer from firing or discriminating against you for filing a claim.
You may choose your own Oregon doctor, or you may have to choose from a list of doctors provided by the insurer. More and more, your employer and/or the employer’s insurer will have an established Managed Care Organization. An “MCO” is a group of medical providers who have received certification from the Workers’ Compensation Division. The MCO enters into a contract with insurers. The MCO then is employed to manage and provide medical care to workers who have work-related injuries.
Reasonable and necessary medical expenses that are related to your injury will be paid by your workers’ compensation insurance. Your workers’ compensation carrier must either accept or deny your claim within 60 days from the day your employer had notice of your claim.
If you lose more than three days in a row from work or are hospitalized, you are entitled to receive money to compensate for your lost wages within 14 days of the day your employer had notice of your claim. The amount of money you receive will depend on your average weekly wage — including regularly worked overtime, commissions, room and board, and so on. (Also, if you have a second job, you might be entitled to supplementary wage loss/time loss payments). The amount you receive will probably be close to two-thirds of your gross salary tax-free, up to a maximum amount set by the legislature. Your wage reimbursement checks will continue to be paid to you every two weeks, until your doctor releases you to return to work. If you return to regular work without a doctor’s release, if your claim is denied or if you receive an order from the workers’ compensation department or your insurer closing your claim, your checks for time loss also will stop.
If your claim is denied, you may appeal this denial by asking for a hearing. You must ask for a hearing within 60 days or you risk losing all of your rights under the Workers’ Compensation Act.
If you ask a lawyer to help you contest the denial, in the vast majority of cases, you will not have to pay for the lawyer’s professional services out of your own pocket, because if the denial is overturned the insurer almost always has to pay your attorney fees. However, you might possibly be responsible for out-of-pocket costs. The law does provide that you might be able to get reimbursed for costs, which can include primarily medical and legal costs for specific written reports from your doctor that address certain aspects of your claim for benefits as well as conferences that your attorney might have with your doctors. Your attorney will ask the judge or board or court to reimburse reasonable and necessary costs (although the costs can be limited to $1,500 depending upon the facts and complexity of your case).
The lawyer cannot charge a fee that is not approved by the Workers’ Compensation Board or the court. Once again, if you win your case on the insurance company’s denial, the insurance carrier will have to pay your lawyer. If you lose and the denial is upheld, you will not owe the lawyer for professional/attorney fees.
If your claim is accepted, it will remain open until you are medically stationary. When you are medically stationary, your claim will then be closed. If you have suffered any permanent disability, you will be entitled to receive additional compensation called permanent partial disability, or “PPD.” The amount of compensation depends on the date of your injury and the body part injured. If you are not happy with the amount of your PPD, you may appeal within 60 days from the date your claim is closed by asking for reconsideration. If you ask a lawyer to help you get increased compensation, the lawyer will charge you 10 to 25 percent of any increase you actually receive. If you do not receive any increased compensation, you will owe your lawyer nothing except for out-of-pocket costs that he or she has paid on your behalf.
After your claim is closed, you may receive medical care. However, some medical services may not be covered. If your condition becomes worse within five years after your claim is first closed, resulting in increased disability, you may have your claim reopened for additional compensation including time loss if you miss work. Any request to reopen your claim should be in writing and sent to the insurance carrier with a report from your doctor. After five years, your rights are much more limited.
While your rights under the Workers’ Compensation Act are generally your only remedy against your employer for a work-related injury, you may have additional remedies against other persons who are responsible for your injury. These types of remedies and claims are referred to generally as “third party claims,” which means that a third party (someone else who is not your employer or a co-worker) arguably caused or contributed to your injury through their negligence or by reason of, for instance, a defective product.
Legal editor: Robert J. Guarrasi, January 2016