State workers’ compensation insurance covers almost all workers in Oregon. You are not covered if you work for the federal government or in maritime employment, but other benefits may be available to you.
Workers’ compensation insurance pays benefits if you suffer from an injury or disease in your employment. It pays for medical expenses for your accepted conditions. It provides compensation when you lose time from work. It provides compensation if you suffer a permanent disability. It may provide vocational help if your permanent disability prevents you from returning to your regular job. It pays death benefits to your spouse and minor children if you die from a work-related injury or disease. This includes children who are attending college.
Tell your employer immediately if you suffer a work-related injury or disease. Usually, your employer will have a special form you can use to file the claim, called an “801 form.” Your employer must notify its workers’ compensation insurer, which will then contact you about the claim. You can also file a claim through your doctor (with an “827 form”).
Your employer cannot refuse to let you file a claim. It is unlawful for your employer to fire you or discriminate against you for filing a claim. Contact the Workers’ Compensation Division for help if your employer refuses to let you file a claim or tells you it does not have workers’ compensation insurance. (800-452-0288). If the employer fires you or you believe it is discriminating against you because you filed a claim, you can contact the Bureau of Labor and Industries for help. (971-673-0764).
You may choose your own doctor, in any state. But not all doctors accept Oregon workers’ compensation claims. Or, if the insurer enrolls you in a Managed Care Organization (“MCO”), you may have to choose from a list of doctors provided by the insurer. The MCO has a contract with insurers to manage and approve medical care. You still choose your doctor, but the doctor and all other medical providers must be part of the MCO to provide you treatment and work restrictions.
The workers’ compensation insurer must accept or deny your claim within 60 days from the day the insurer had notice of your claim. You will receive a letter of acceptance or notice of denial in the mail. If the insurer does not send an acceptance or denial within 60 days, you can file a request for hearing with the Workers’ Compensation Board. (503-378-3308).
If the workers’ compensation insurer accepts your claim, it will pay benefits. If the workers’ compensation insurer denies your claim, you should appeal the denial. You must send your appeal to the Workers’ Compensation Board. You have only 60 days from the date of the denial letter to send your appeal, or you risk losing all your rights on the claim.
If accepted, the insurer accepts specific conditions. If you or your doctor believe you have other conditions too, you must send a written request to the insurer to accept the other conditions. Then the insurer has another 60 days to accept or deny the other conditions. If accepted, those conditions become part of your claim. If denied, you need to request a hearing on the denial. But you will still receive benefits for the accepted conditions to the claim.
On an accepted claim, the insurer has to pay you lost wages if you lose more than three days of work. These payments are called time loss or temporary disability. You must have a doctor’s note taking you off of work. If you have work restrictions, take them to your employer. Then the employer has a choice. It can provide you with light duty work you are capable of performing. Or, if it does not have light duty work, you stay home and the insurer will pay you. You need a medical doctor (called an “attending physician”). There are time limitations for treatment with an emergency room doctor, chiropractor, or nurse practitioner.
Your attending physician can refer you to other treatment. You should always follow your attending physician’s written instructions. You will not receive time loss if you miss work without a doctor’s authorization. This could also jeopardize your employment. If you quit your job while receiving time loss benefits, or are fired for reasons unrelated to your injury, the insurer may stop paying you.
The insurer must mail your first time loss check within 14 days of its notice that you are missing work with a doctor’s note. The amount of your time loss will depend on your average weekly wage. This is an average of all the wages, overtime, commissions, room and board, and other monetary compensation you received during the last 52 weeks of employment. Once the insurer calculates your average weekly wage, it will pay you 2/3rds of that amount in time loss. Time loss is paid every two weeks. You do not pay taxes on these payments.
If you have more than one job when you are injured, you must tell the insurer within 30 days of filing your claim. The insurer will give you forms to complete. Then you may receive supplementary time loss from the state if you miss work at your other jobs because of your injury.
An accepted claim remains open until you are “medically stationary.” This means that no more treatment or time will improve your condition. Your attending physician makes this decision. It may not mean you are 100% recovered. When you are medically stationary, the insurer closes your claim. Time loss payments stop. You will receive in the mail a document called a Notice of Closure. The insurer may have to pay you compensation when it closes your claim if your doctor believes you have permanent problems because of the accepted conditions. This is called permanent partial disability (“PPD”). The amount of compensation depends on the date of your injury and the body parts injured. If you disagree with the amount of the PPD, you may appeal within 60 days from the date of the Notice of Closure. You appeal to the Workers’ Compensation Division. This is called "Reconsideration." You should ask for a “medical arbiter exam.” This means a new doctor chosen by the state will examine you. That doctor will tell the Workers’ Compensation Division if you should get more, less, or the same PPD.
If your PPD prevents you from returning to your regular job, you may get vocational help. The insurer will send a vocational counselor to interview you. It will then decide if you are eligible for vocational retraining. This benefit is available if there does not exist a job you can do with your limitations and still earn 80% of your regular wage. If eligible, the insurer will pay to send you to school to learn a new profession. The insurer pays you time loss while you are in school.
You may receive more benefits even after your claim is closed. Your doctor can request the insurer pre-authorize more treatment. This is available if you need treatment to help with your permanent symptoms so that you can keep working. This is called “palliative care." The doctor can also request the insurer reopen your claim if the doctor believes your condition is actually worse. This is called “aggravation rights.” If reopened within five years of when your claim was first closed, all the same benefits are available to you. After five years, the monetary benefits are more limited, but the medical rights stay the same.
There are some limitations to workers’ compensation benefits. You do not receive money for “pain and suffering.” You do not get time loss for regular medical appointments, even if they are because of the claim. But you can use sick leave for these appointments. If your employer has workers’ compensation insurance, you cannot sue it or co-workers for negligence. But you can sue other persons who are responsible for your injury. These are called “third party claims." Examples are a car accident while you are on the job, a defective product, or a worker of another employer. You can sue your employer or co-workers only for intentional acts. An example is if a co-worker assaults you. The workers’ compensation insurer has a lien against your third party claim for compensation it paid to you through the claim.
If there is any dispute on your claim, you need attorney to represent you. Some examples of disputes are:
If you think there is a dispute on your claim, you should contact an attorney. The attorney cannot charge a fee that is not approved by the Workers’ Compensation Board or the court. If there is no dispute, the attorney will not receive any part of your benefits. The attorney only gets paid if he or she wins a dispute for you. In most disputes, the insurer pays the attorney separate from the benefit to you. If the dispute in about your PPD benefits, the fee is a percentage of the increased benefits, but never more than 25%. If you do not win in a dispute, there is no attorney fee. But you may owe the attorney for out-of-pocket costs that he or she has paid on your behalf.
You can sometimes settle all or part of your claim. On an accepted claim, you can settle your right to all benefits except medical treatment. This is called a Claim Disposition Agreement (“CDA”). On a denied claim, you can settle all your rights so you receive nothing more from the insurer. This is called a Disputed Claim Settlement (“DCS”). If you have an attorney, the attorney will receive no more than 25% of your settlement.
If you do not know an attorney, you can contact the Oregon State Bar Lawyer Referral Service. (800-452-7636). If you have questions about the claim process but you do not have an attorney, you can contact the Ombudsman for Injured Workers. (800-927-1271). That office helps unrepresented workers understand the claim process.
Legal editor: Jovanna L. Patrick, March 2019