Oregon Court Affirms Denial of Claim Due to Claimant’s Failure to Cooperate

On Wednesday, an Oregon appellate court affirmed the denial of an injured worker’s claim for workers’ compensation benefits on the grounds that she had, without an appropriate reason, failed to cooperate with the claims process, as required under ORS 656.262(15) [see Hopper v. SAIF Corp., 2014 Ore. App. LEXIS 1230 (Sept. 10, 2014)]. In doing so, the court agreed with the state’s Workers’ Compensation Board which had upheld an earlier denial on the basis that claimant failed to prove that her failure to cooperate was “for reasons beyond [her] control.”

Background

Claimant injured her lower back at work in September 2011 and filed a claim for workers’ compensation for the injury. SAIF, the workers’ compensation insurer, contacted her and requested that she make a statement to an investigator. She did not reply. The insurer set up an appointment for her, but she did not attend. Multiple additional communications were sent to claimant, but she failed to respond. In several of the later communications, the insurer advised claimant that her benefits would be suspended if she continued to be uncooperative and that her claim could be denied on the basis of her failure to cooperate.

Benefits were eventually suspended and one week later the SAIF investigator left a voice mail message with claimant indicating her benefits had been suspended and they would remain so until she contacted a SAIF investigator. Still she did not reply. One month later, SAIF denied her claim for failure to cooperate with the claims process. More than a month later, claimant requested, and was granted, an expedited.

Claimant contended her failure to cooperate was “for reasons beyond her control,” as defined in ORS 656.262(15). Claimant testified that her brother died unexpectedly, that she had been depressed as a result of his death, and that she had not opened the letter advising her of the requested interview until after the date had passed. While she acknowledged receiving the other communications from SAIF regarding the need for an interview, she admitted that she had not followed up. Claimant also reported that she had been injured in a motor vehicle accident during the period in question.

The ALJ set aside SAIF’s noncooperation denial, finding that while claimant had failed to cooperate, claimant’s brother’s death and claimant’s motor vehicle accident, which the ALJ found were both beyond claimant’s control, were the reasons for claimant’s failure to comply with SAIF’s interview request. On de novo review, the board determined that claimant’s brother’s death and claimant’s motor vehicle accident were circumstances beyond her control that could, in theory, excuse her noncooperation if they were, in fact, the reasons for her noncooperation. The board found, however, that it was “not persuaded” that those circumstances were the reasons for claimant’s noncooperation. Instead, the board found that claimant’s “lack of diligence” was the reason that she failed to comply with SAIF’s interview request. Based on that finding, the board reversed the ALJ’s order and reinstated SAIF’s denial of claimant’s claim.

Appellate Court’s Decision

The appellate court agreed. Claimant’s testimony had tended to undercut her position. While she claimed she had been debilitated at times, based on her brother’s death and the car accident, she had not missed any work because of the accident and she had missed only a single day of work in connection with her brother’s death. Nor did the claimant apparently have any difficulty contacting the insurance company following her motor vehicle accident. Her failure to contact SAIF was, therefore, apparently due to neglect and not to circumstances beyond her control.

The court concluded that while a reasonable fact finder could infer on this record, as the ALJ and dissenting board member did, that claimant’s failure to cooperate stemmed from the traumatic events that she confronted and, thus, was for reasons beyond her control, the record also permitted the contrary inference reached by the board: that claimant’s lack of diligence, rather than those events beyond her control, caused her failure to cooperate.

This entry was posted in Case comment and tagged , , . Bookmark the permalink.