Case Lesson: When is a Denial Based on an IME in Oregon?

Salem, OR (WorkersCompensation.com) -- For readers fortunate enough to have access to Simply Research, a case popped up on that site last week that has important information on how IMEs work in Oregon.

The case, In the Matter of the Compensation of Cardoza, No. 238 (Or. Ct. App. 04/17/22) involved a worker's challenge to an ALJ's denial of benefits, which was upheld by the Workers' Compensation Board.

The worker, and then eventually his personally representative, posited that the worker was eligible for a worker requested medical examination because his denial of benefits was "based" on an IME. The ALJ and the board disagreed because the IME occurred after the initial denial of the worker's claim.

The law itself reads that a worker is eligible for a WRME if the "denial is based on one or more independent medical examination reports."

According to the appeals court, nothing in the statute's or rule's text or context required that an IME be performed before the denial of a compensation claim for a worker to be eligible for a WRME.

"The purpose of allowing a worker to request a WRME is to obtain an additional professional opinion where there are at least two competing reports, or, as in this case, the first two medical examinations are not in concurrence," the court wrote. "That purpose would be frustrated where a worker submits to two competing professional examinations and timely requests that the division make a determination on the claim based on those examinations."

The court emphasized that what happened in the worker's case was that the insurer submitted an IME report as evidence supporting the denial of his claim, and the reviewing authority considered that report as evidence in deciding whether to affirm or reverse the denial.

Thus the denial was based on an IME and the worker should have been granted his request for a WRME.

What's the lesson? In Oregon, when an insurer submits an IME report as evidence to support its denial of a worker’s claim, the denial is “based” on an IME such that the worker is eligible for a WRME under the terms of Oregon law.

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