Oregon Regulations 436-030-0020
§ 436-030-0020 Requirements for Claim Closure.
|(1) Provided the worker is not enrolled and actively engaged in training,the insurer must issue a Notice of Closure on an accepted disabling claim within 14 days when:
(a) Medical information establishes there is sufficient information to determine the extent of permanent disability under ORS 656.245(2)(b)(B),and indicates the worker's compensable condition is medically stationary;
(b) The accepted injury/condition is no longer the major contributing cause of the worker's combined or consequential condition(s),a major contributing cause denial has been issued,and there is sufficient information to determine the extent of permanent disability;
(c) The worker fails to seek medical treatment for 30 days for reasons within the worker's control and the worker has been notified of pending actions in accordance with these rules; or
(d) The worker fails to attend a mandatory closing examination for reasons within the worker's control and the worker has been notified of pending action(s) in accordance with these rules.
(e) A worker receiving permanent total disability benefits has materially improved and is capable of regularly performing work at a gainful and suitable occupation.
(2) For purposes of determining the extent of disability,"sufficient information" requires the following:
(a) An authorized nurse practitioner's,podiatrist's,chiropractor's,naturopathic physician's,physician assistant's or attending physician's written statement that clearly indicates there is no permanent impairment,residuals,or limitations attributable to the accepted condition(s),and there is no reasonable expectation,based on evidence in the record,of loss of use or function,changes in the worker's physical abilities,or permanent impairment attributable to the accepted condition(s). If the physician,nurse practitioner,podiatrist,chiropractor,naturopathic physician,or physician assistant indicates there is no impairment,but the record reveals otherwise,a closing examination and reports specified under (b) of this section are required; or
(b) A closing medical examination and report when there is a reasonable expectation of loss of use or function,changes in the worker's physical abilities,or permanent impairment attributable to the accepted condition(s) based on evidence in the record or the physician's opinion. The closing medical examination report must describe in detail all measurements and findings regarding any permanent impairment,residuals,or limitations attributable to the accepted condition(s) under OAR 436-010-0280 and OAR 436-035; and,if there is not clear and convincing evidence that the worker has been released to regular work (for dates of injury on or after January 1,2006) or returned to regular work at the job held at the time of injury and ORS 656.726(4)(f) does not apply,all of the following:
(A) An accurate description of the physical requirements of the worker's job held at the time of injury,which has been provided by certified mail to the worker and the worker's legal representative,if any,either before closing the claim or at the time the claim is closed;
(B) The worker's wage established consistent with OAR 436-060;
(C) The worker's date of birth;
(D) Except as provided in OAR 436-030-0015(3)(d),the worker's work history for the period beginning five years before the date of injury to the mailing date of the Notice of Closure,including tasks performed or level of SVP,and physical demands; and
(E) The worker's level of formal education .
(3) When determining disability and issuing the Notice of Closure,the insurer must apply all statutes and rules consistent with their provisions,particularly as they relate to major contributing cause denials,worker's failure to seek treatment,worker's failure to attend a mandatory examination,medically stationary status,temporary disability,permanent partial and total disability,review of permanent partial and total disability.
(4) When issuing a Notice of Closure,the insurer must prepare a summary worksheet,"Notice of Closure Worksheet",Form 440-2807 (Form 2807),as described by bulletin of the director.
(5) The "Notice of Closure",Form 440-1644 (Form 1644),is effective the date it is mailed to the worker and to the worker's attorney if the worker is represented,regardless of the date on the Notice itself.
(6) The notice must be in the form and format prescribed by the director in these rules and include only the following:
(a) The worker's name,address,and claim identification information;
(b) The appropriate dollar value of any individual scheduled or unscheduled permanent disability based on the value per degree for injuries occurring before January 1,2005 or,for injuries occurring on or after January 1,2005,the appropriate dollar value of any "whole person" permanent disability,including impairment and work disability as determined appropriate under OAR 436-035;
(c) The body part(s) awarded disability,coded to the table of body part codes as prescribed by the director;
(d) The percentage of loss of the specific body part(s),including either the number of degrees that loss represents as appropriate for injuries occurring before January 1,2005,or the percentage of the whole person the worker's loss represents as appropriate for injuries occurring on or after January 1,2005;
(e) If there is no permanent disability award for this Notice of Closure,a statement to that effect;
(f) The duration of temporary total and temporary partial disability compensation;
(g) The date the Notice of Closure was mailed;
(i) The date the worker's aggravation rights end;
(j) The worker's appeal rights;
(k) The right of the worker to consult with the Ombudsman for Injured Workers;
(l) For claims with dates of injury before January 1,2005,the rate in dollars per degree at which permanent disability,if any,will be paid based on date of injury as identified in Bulletin 111;
(m) For claims with dates of injury on or after January 1,2005,the state's average weekly wage applicable to the worker's date of injury is to be shown on the Notice of Closure;
(n) The worker's return to work status; and
(o) A general statement that the insurer has the authority to recover an overpayment.
(7) The Notice of Closure (Form 440-1644) must be accompanied by the following:
(a) The brochure "Understanding Claim Closure and Your Rights";
(b) A copy of summary worksheet Form 2807 containing information and findings which result in the data appearing on the Notice of Closure;
(c) An accurate description of the physical requirements of the worker's job held at the time of injury unless it is not required under section (2)(a) of this rule or it was previously provided under section (2)(b)(A) of this rule;
(d) The Updated Notice of Acceptance at Closure which clearly identifies all accepted conditions in the claim and specifies those which have been denied and are on appeal or which were the basis for this opening of the claim; and
(e) A cover letter that:
(A) Specifically explains why the claim has been closed (e.g.,expiration of a period of suspension without the worker resolving the problems identified,an attending physician stating the worker is medically stationary,worker failure to treat without attending physician authorization or establishing good cause for not treating,etc.);
(B) Lists and describes enclosed documents; and
(C) Notifies the worker about the end of temporary disability benefits,if any,and the anticipated start of permanent disability benefits,if any.
(8) A copy of the Notice of Closure must be mailed to each of the following persons at the same time,with each copy clearly identifying the intended recipient:
(a) The worker;
(b) The employer;
(c) The director; and
(d) The worker's attorney,if the worker is represented.
(9) The worker's copy of the Notice of Closure must be mailed by both regular mail and certified mail return receipt requested.
(10) An insurer may use electronically produced Notice of Closure forms if consistent with the form and format prescribed by the director.
(11) Insurers may allow adjustments of benefits awarded to the worker under the documentation requirements of OAR~ 436-060-0170~ for the following purposes:
(a) To recover payments for permanent disability which were made prematurely;
(b) To recover overpayments for temporary disability; and
(c) To recover overpayments for other than temporary disability such as prepaid travel expenses where travel was not completed,prescription reimbursements,or other benefits payable under ORS 656.001 to 656.794.
(12) The insurer may allow overpayments made on a claim with the same insurer to be deducted from compensation to which the worker is entitled but has not yet been paid.
(13) If after claim closure,the worker became enrolled and actively engaged in an approved training program under OAR 436-120,a new Notice of Closure must be issued consistent with the following:
(a) In claims with dates of injury on or after January 1,2005,the insurer must redetermine work disability when:
(A) The worker has ended training; and either
(B) The worker's condition is medically stationary; or
(C) The claim otherwise qualifies for closure in accordance with these rules.
(b) For claims with dates of injury before January 1,2005,permanent disability must be redetermined by the insurer when:
(A) The worker has ended training; and either
(B) The worker's condition is medically stationary; or
(C) The claim otherwise qualifies for closure in accordance with these rules.,except
(D) When the worker became medically stationary after June 7,1995 for a scheduled disability. Then the scheduled disability must remain unchanged from the last award of compensation in that claim unless the condition did not remain medically stationary through training.
(c) For claims with dates of injury before January 1,2005,if the worker has remained medically stationary throughout training and the closing examination is six months old or older,a current medical examination will be required for redetermination unless the worker's attending physician provides a written statement that there has been no change in the worker's accepted condition since the previous closing examination.
(14) When,after a claim is closed,the insurer changes or is ordered to change the worker's weekly wage upon which calculation of the work disability portion of a permanent disability award may be based,the insurer must notify the parties and the division of the change and the effect of the change on any permanent disability award. For purposes of this rule,the insurer must complete Form 440-1502 consistent with the instructions of the director and disperse it within 14 days of the change.
Hist: Amended 11/1/07 as WCD Admin. Order 07-059,eff. 1/2/08