Accepted - The status a claim is placed in once the insurer has determined that there is a compensable injury or disease according to workers’ comp statutes and case law.
Active - The status a claim is placed in once the insurer has determined that there is a compensable injury or disease according to workers’ comp statutes and case law.
Aggravation - After the last award or arrangement of compensation, an injured worker is entitled to additional compensation for worsened conditions resulting from the original injury. Such a condition is established by medical evidence of an actual worsening of the compensable condition supported by objective findings. However, if the major contributing cause of the worsened condition is an injury not occurring within the course and scope of employment, the worsening is not compensable. A worsened condition is not presumed to have been established by either or both of the following:
- The worker's absence from work for any given amount of time as a result of the worker's condition from the original injury;
- Inpatient treatment of the worker at a hospital for the worker's condition from the original injury.
Appeals - The process begins with a Request for Hearing filed by the worker or representative of the worker (usually an attorney) with the Workers' Compensation Board (WCB). The appeal is assigned to an administrative law judge, whose decision is appealable to the Board. Any action the Board takes is then appealable to the state appellate court system.
Attending physician (AP) - A doctor or physician who is primarily responsible for the treatment of a worker's compensable injury and who is:
- A medical doctor or doctor of osteopathy licensed under ORS 677.100 to 677.228 by the Board of Medical Examiners for the State of Oregon or an oral and maxillofacial surgeon licensed by the Oregon Board of Dentistry or a doctor similarly licensed to practice one or more of the healing arts in any country or in any state, territory or possession of the United States within the limits of the license of the licentiate.
- A doctor or physician licensed by the State Board of Chiropractic Examiners for the State of Oregon or a doctor similarly licensed in another jurisdiction. These medical providers may be attending physicians for a period of 60 days from the date of the first visit on the initial claim or for 18 visits whichever occurs first. Medical services provided after the 60 day/18 visit requirement are not compensable without the written authorization of an attending physician, or unless the chiropractor qualifies as an attending physician as part of a managed care contract.
Authorized nurse practitioners - Were eligible to treat injured workers for up to 90 days as of January 1, 2004. They can only authorize the workers disability for 60 days and must refer to another qualified attending physician for claim closure.
Average weekly wage - The Oregon average weekly wage in covered employment, as determined by the Employment Department for the last quarter of the calendar year preceding the fiscal year in which compensation is paid and as computed by the Employment Department as of May 15 of each year. This term is also used when an averaging method is used to calculate the worker’s temporary total disability rate.
Claim - A written request for compensation from a subject worker or someone on the worker's behalf, or any compensable injury of which a subject employer has notice or knowledge.
Closed claim - This term is used to a describe a point in time that the worker is medically stationary for establishing when time-loss payments should terminate and any permanent disability should be determined.
Compensable injury - An accidental injury, or accidental injury to prosthetic appliances, arising out of and in the course of employment requiring medical services or resulting in disability or death; an injury is accidental if the result is an accident, whether or not due to accidental means, if it is established by medical evidence supported by objective findings, subject to the following limitations:
- No injury or disease is compensable as a consequence of a compensable injury unless the compensable injury is the major contributing cause of the consequential condition.
- If an otherwise compensable injury combines at any time with a pre-existing condition to cause or prolong disability or a need for treatment, the combined condition is compensable only if, so long as and to the extent that the otherwise compensable injury is the major contributing cause of the disability of the combined condition or the major contributing cause of the need for treatment of the combined condition.
Compensable injury does not include:
- Injury to any active participant in assaults or combats which are not connected to the job assignment and which amount to a deviation from customary duties;
- Injury incurred while or as a result of engaging in or performing any recreational or social activities primarily for the worker's personal pleasure; or
- Injury where the major contributing cause is demonstrated to be, by a preponderance of the evidence, due to the injured worker’s consumption of alcoholic beverages or the unlawful consumption of any controlled substance; unless the employer permitted, encouraged or had actual knowledge of such consumption.
Compensable medical services - Medical, surgical, hospital, nursing, ambulances and other related services, and drugs, medicine, crutches and prosthetic appliances, braces and supports and where necessary, physical restorative services. A pharmacist or dispensing physician shall dispense generic drugs to the worker in accordance with ORS 689.515.
Compensation – All benefits including medical services, provided for a compensable injury to a subject worker or the worker's beneficiaries by an insurer or self-insured employer.
Claims disposition agreement (CDA) - A process that permits an insurance company and any injured worker or the worker's representative to negotiate a lump-sum settlement on a compensable injury. A settlement of this type may include any future entitlement to time loss, vocational, permanent partial and/or permanent total disability benefits. Generally, CDAs include all of these benefits. Medical benefits can not be negotiated as part of a CDA.
Closed - This term is used to a describe a point in time that the worker is medically stationary for establishing when time-loss payments should terminate and any permanent disability should be determined.
Consulting physician - A doctor or physician who examines a worker or the worker's medical record to advise the attending physician regarding treatment of a worker's compensable injury.
Course and scope - Oregon’s Workers' Compensation system uses a "unitary" approach to determining compensability of a claim. Thus, a claim occurs in "course of employment" when the worker is actually performing activities associated or incidental to work responsibilities. A claim must also "arise out of employment", meaning that the injury or disease must be attributable to the hazards of the employment. In Oregon, these two concepts are merged to form one of the tests for claim acceptance or denial.
DCBS - Abbreviation for the Department of Consumer and Business Services, which administers the Workers' Compensation Division (WCD), the Oregon Occupational Safety and Health Division (OR-OSHA), and the Workers' Compensation Board (WCB).
Deferred - The status a claim is placed in while it is being evaluated for acceptance or denial. During this time the insurer gathers information regarding the claim’s compensability. The law allows an insurer up to 60 days from the date the worker’s employer knew about the injury or disease to make this determination.
Denial - The status a claim is placed in once an insurer has decided the claim for benefits is not compensable according to workers’ comp statutes and case law.
Disputed claim settlement (DCS) - An agreement, subject to approval by a Workers' Compensation Board administrative law judge, between an insurance carrier or self-insured employer and the injured worker, when the compensability of the claim is in dispute. This agreement is used only when facts support the contentions, thus making it difficult to determine who is correct or should prevail in the dispute.
Elective surgery - Surgery which may be required in the process of recovery from an injury or illness but need not be done as an emergency to preserve life, function, or health. Pain, of itself, does not constitute a surgical emergency.
Federal claims - Workers' compensation claims processed under federal (rather than state) law. Major federal laws are the Longshore and Harbor Workers' Compensation Act, the Federal Employers' Liability Act and the Jones Act.
Federal Longshore and Harbor Workers' Compensation Act (USL&HW) - Federal coverage laws which apply to all longshoremen, ship repairmen, ship builders, ship breakers and harbor workers whose employer is engaged in maritime employment. The act covers work on the navigable waters of the U.S.; also any pier, wharf, dry dock, terminal, building way, marine railway or other adjoining area customarily used by an employer in loading, unloading, repairing or building a vessel.
Inactive - This term is used to a describe a point in time that a worker is medically stationary, to establish when time-loss payments should end and any permanent disability should be determined.
Impairment - A permanent loss of use or function of a body part or system as measured by a physician.
Loss of earning capacity - The difference between the earning capacity of the worker at the time of the injury and the earning capacity available from any kind of work approved by the attending physician prior to claim determination.
Lump sum payment - Payment of the full amount of a permanent partial disability award in one installment. Small awards are paid to injured workers in one installment (under $6,000). Larger awards are paid to injured workers in monthly installments which equal their monthly compensation rate. However, the worker can petition the insurer to pay the entire award in one payment. In doing so the worker gives up their right to appeal the adequacy of the award.
Managed care organization (MCO) - A group of medical care providers which obtains certification from the Department of Consumer and Business Services and contracts with an insurance carrier(s) to provide medical care to the injured workers of the carrier's policyholders.
Medical only - A claim without time-loss or permanent disability that requires medical treatment only. Also called a "non-disabling injury."
Medically stationary - The status of an injured worker when no further improvement is expected from additional medical treatment or the passage of time.
New claim - The status a claim is placed in while it is being evaluated for acceptance or denial. During this time the insurer gathers information regarding the claim’s compensability. The law allows an insurer up to 60 days from the date the worker’s employer knew about the injury or disease to make this determination.
Nondisabling compensable injury - Any injury which requires medical services only. Disability did not exceed the three-day waiting period.
Objective findings - Objective findings in support of medical evidence include, but are not limited to, range of motion, atrophy, muscle strength and palpable muscle spasm. "Objective findings" does not include physical findings or subjective responses to physical examinations that are not reproducible, measurable or observable.
Occupational disease - Any disease or infection arising out of and in the course of employment caused by substances or activities to which an employee is not ordinarily subjected or exposed other than during a period of regular actual employment therein, and which requires medical services or results in disability or death, including:
- Any disease or infection caused by ingestion of, absorption of, inhalation of or contact with dust, fumes, vapors, gases, radiation or other substances.
- Any mental disorder which requires medical services or results in physical or mental disability or death.
- Any series of traumatic events or occurrences which require medical services or results in physical disability or death.
Open claim - The status a claim is placed in once the insurer has determined that there is a compensable injury or disease according to workers’ comp statutes and case law.
Own motion - After aggravation rights have expired (five years from the date of the first valid closure on disabling claims or five years from the date of injury in non-disabling claims) the Workers’ Compensation Board may, upon its own motion, from time to time modify, change or terminate former findings, orders or awards if, in its opinion, such action is justified in those cases in which:
- There is a worsening of a compensable injury that requires either inpatient or outpatient surgery or other treatment in lieu of hospitalization that would render worker capable of return to work. In such cases, the board may authorize the payment of temporary disability compensation. Or,
- The date of injury is earlier than January 1, 1966. In such cases, in addition to the payment of temporary disability compensation, the board may authorize payment of medical benefits.
Palliative treatment - Medical services rendered to temporarily reduce or moderate the intensity of an otherwise stable medical condition as compared to those medical services rendered to diagnose, heal, or permanently alleviate or eliminate a medical condition. (Makes you feel good, but doesn't heal you). Insurance companies are not required to pay the cost of palliative care unless it is prescribed by the attending physician to enable the workers to continue current employment or a vocational training program. Occasionally, acute flare-ups which require a short term of curative treatment is allowed.
Permanent partial disability (PPD) - Permanent loss of use or function
Permanent total disability (PTD) - The permanent loss of use or function of portion of the body which permanently incapacitates the worker from being gainfully employed in a suitable occupation. A suitable occupation is one that the worker has the ability, training or experience to perform. A PTD results in a lifetime pension. Each PTD claim is re-examined by the insurer or self-insurer at least every two years from the date of PTD order.
Physical capacities evaluation - An objective, directly observed, measurement of a worker's ability to perform a variety of physical tasks (For example: Physical tolerance screening, Blankinship's Functional Evaluation and Functional Capacity Evaluation).
Preferred Worker - A worker who, because of a permanent disability resulting from a compensable injury or occupational disease, is unable to return to the worker's regular employment without substantial work or work-site modification.
Preferred Worker Program - A program designed to encourage employers to employ injured workers that have a permanent disability which may be a substantial obstacle to employment. Self-insured employers or the insurance carrier of employers who hire "preferred workers" receive reimbursement from the Workers’ Benefit Fund for claim costs of injuries incurred by these workers for three years from date of hire. In addition, the employer does not pay insurance premiums or premium assessments on the payroll of the preferred worker during the three-year period.
Residual functional capacities - An individual's remaining ability to perform work-related activities despite medically determinable impairment resulting from the accepted compensable condition. A residual functional capacity evaluation includes, but is not limited to; capability for lifting, carrying, pushing, pulling, standing, walking, sitting, climbing, balancing, stooping, kneeling, crouching, crawling and reaching.
Temporary partial disability (TPD) - Pro-rated time-loss payment that is paid to an injured worker who has returned to a modified job at a modified salary or modified hours that is less than the wage at time of injury.
Temporary total disability (TTD) - A disability which is temporary, but severe enough that the worker's treating doctor removes him/her from all work activities. Time-loss payments, subject to minimum and Average Weekly Wage maximum, are based on 66 2/3 percent of the worker's wages at time of injury.
Third party claim - When someone other than the injured worker's employer or co-worker is responsible for an accident, a third party claim may be filed. Third party cases involve three major areas: product liability, motor vehicle accidents and personal liability. Recoveries from third party claims may be applied retroactively against claim costs, which help reduce premiums.
Three-day wait - Three consecutive calendar days beginning with the day the worker first loses time from work or loses wages as a result of an injury and does not return. If the worker leaves work and returns to the same shift, this day only counts towards the three-day wait if the worker loses remuneration for the time missed. No temporary total disability suffered during the three-day wait is due unless the total disability is continuous for a period of 14 calendar days or the worker is an inpatient in a hospital within 14 days.
Time-loss compensation - Term used to describe payments made to workers to replace 66 2/3 percent of their wages at time of injury while they are off work due to a work-related injury or disease. Payments are made to injured workers who are unable to perform all or part of their job functions as result of their injuries. Compensation is due 14 days from date of employer notice or knowledge or date of disability, whichever is later, for new claims. For aggravation claims, payments are due 14 days from receipt of medical verification of inability to work as result of a worsened condition via 827 form. Subsequent payments after the initial payment are due every 14 days from the date of the first payment.
Treatment plan - Attending physician plan of treatment which must include: objectives, modalities, frequency of treatment and duration.
Wages - The money rate at which the service tendered is compensated under the hiring contract in force at the time of the accident. This includes the reasonable value of board, rent, housing, lodging or similar advantage received. It also includes the amount of tips required to be reported by the employer to the Internal Revenue Service, or the amount of actual tips reported, whichever amount is greater.
Work capacity evaluation (WCE) - A physical capacity evaluation with special emphasis on the ability to perform a variety of vocationally-oriented tasks based on specific job demands. Work tolerance screening is considered to have the same meaning as WCE.
Work hardening – An individualized, medically ordered and monitored, work-oriented treatment process. The worker is involved in simulated or actual work tasks that are structured and graded to progressively increase physical tolerances, stamina, endurance and productivity to return-to-work goals.
Workers' Compensation Board (WCB) - A forum within the Department of Consumer and Business Services for resolving claim disputes between injured workers and insurance carriers who represent employers. This board of five permanent members administers the Workers' Compensation Board Hearings Division and reviews appealed orders of administrative law judges. It also exercises "own motion" jurisdiction. The Governor appoints Board members who represent labor, employers and the public. The Board has its own budget and rule-making authority.
Workers’ Compensation Division (WCD) - A part of the Department of Consumer and Business Services that is responsible for enforcing and regulating Oregon's workers’ compensation law. This also includes making evaluations on claims involving disability. The WCD is funded through an employer premium assessment collected by insurers.