The complicated part of workers’ compensation is making sure the insurance companies pay you your benefits. Getting compensation often requires developing expert medical opinion evidence to prove your case, and dealing with insurance company claims adjusters and lawyers to make sure they pay you your full benefits. Your benefits under workers’ compensation law may include 1) time loss, 2) medical, 3) permanent disability, 4) vocational assistance, 5) benefits for spouses and children of deceased workers.
If you have been injured at work, the first question is “is my claim compensable?” In Oregon, there are two basic kinds of claims: injuries and occupational diseases. An injury is a sudden, one-time event that causes disability or the need for medical treatment. Most claims happen like this. Examples include falling off a ladder or lifting something heavy that causes you to be injured. The other kind of claim, an occupational disease, occurs due to gradual exposure to harmful conditions at work over time. Examples include repetitive motion injuries, chemical exposure, or long-term hearing loss. Some medical conditions can occur as a result of either an injury or an occupational disease. The difference is how long it takes for the condition to develop.
The distinction between injuries and occupational diseases is important because the standard of proving medical cause is different in each. In injury cases, the worker must prove the injury was a “material cause,” meaning a substantial or important cause, but not necessarily the only cause. In occupational disease claims, the worker must prove the work exposure is the “major contributing cause, or 51% or more of the cause, of his condition. Proving an occupational disease is more difficult because the medical cause standard is higher.
Insurance companies will often argue your condition was caused by an occupational disease rather than an injury to subject you to the higher standard of medical cause. It is important to make clear when and how your condition developed so there is no confusion about whether it is an injury or an occupational disease. Then it is critical to have your doctor explain why the evidence meets the appropriate medical cause standard.
The most common medical defense insurance companies use is the pre-existing condition. Most people have some form of arthritis in their joints once they reach a certain age. Or, some people have injured the same body part before. Insurance companies are expert at using this as an excuse to deny a claim or defend a denial at hearing. Only workers’ compensation attorneys know all the rules for when and how preexisting conditions can be used as an excuse for a denied claim. Most of the time, preexisting conditions should not preclude you from receiving workers’ compensation benefits. If your claim has been denied because you have a preexisting condition, consult a lawyer immediately.