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Claim closure

The steps to closing a claim:

Medically stationary

The process of closing a claim starts when the worker is deemed medically stationary.

"Medically stationary" means that no further material improvement would reasonably be expected from medical treatment or the passage of time.

All conditions related to, or resulting from, the workplace injury need to be medically stationary for closure to begin.

A worker may still qualify for medical treatment after the claim is closed, but only under certain circumstances, and there are limitations. Please contact the claims adjuster if you have questions.


Impairment

Part of the process of closing a claim is determining if the worker has a physical impairment, and if he or she is entitled to work disability benefits. Impairment is determined by the attending physician (AP).

Examples of physical impairment are loss of range of motion, loss of sensation, and loss of strength.

The worker is entitled to both an award for physical impairment and compensation for work disability. Work disability is only awarded when the worker is not capable of performing the job he or she was doing at the time of injury.

Workers' Compensation Division (WCD) bulletin 239 explains how to rate impairment.

Work release

If the worker is able to return to work, the attending physician must sign a "Release to Return to Work."

Types of closing exams

  • Attending physician closing exam | If impairment is established, only a Type A attending physician can close. A Type B attending physician or nurse practitioner can close only if there is no impairment.
  • Independent medical evaluation (IME) is done by an independent, third-party physician and can provide impairment findings. An IME can be used to close the claim if the insurer gets concurrence from the AP.
  • Physical capacity evaluation (PCE1) is a measurement of impairment only. The AP must concur with this evaluation.
  • Physical capacity evaluation 2 (PCE2) is a two-hour evaluation to test the worker's abilities--such as whether she is able to lift a certain amount of weight--and identify her impairment finding.
  • Work capacity evaluation (WCE) describes what the job-at-injury requirements are and lists specific duties, stating that the worker can do each of those duties. See the OAR Division 9 rules for more on WCE.
  • Concurrence explanation | If the providers involved in the claim don't concur, they need to provide documentation for concurrence. If the AP doesn't concur, she needs to provide a closing exam with its own impairment findings.

Important: Not including all necessary impairment findings can delay the compensation that the worker is entitled to.


Reconsideration

When the insurance company closes the claim, it issues a "Notice of Closure," which is a legal order.

Once the claim is closed, the worker or insurer may request that the closure be reconsidered. The worker has 60 days to request an appeal (also called reconsideration); the insurer has seven days.

WCD reviews the written documentation of the claim. But it also may ask for more information or schedule a medical arbiter exam. Learn more about how WCD reviews the information that the insurer used to close the claim.

From saif.com

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