Daugherty v. SAIF Corp.

310 P.3d 713, 258 Or. App. 512
CourtCourt of Appeals of Oregon
DecidedSeptember 11, 2013
Docket1000114H; A148338
StatusPublished
Cited by3 cases

This text of 310 P.3d 713 (Daugherty v. SAIF Corp.) is published on Counsel Stack Legal Research, covering Court of Appeals of Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Daugherty v. SAIF Corp., 310 P.3d 713, 258 Or. App. 512 (Or. Ct. App. 2013).

Opinion

SERCOMBE, J.

Claimant seeks judicial review of a final order of the Director of the Department of Consumer and Business Services (the director) dismissing her request for administrative review of her medical services claim and refusing to transfer the matter to the Workers’ Compensation Board (the board) for a hearing. Although the parties advance a number of ancillary arguments, the central issue presented on review is whether, under ORS 656.704,1 the director had authority to determine that “there [was] no factual dispute” concerning the causal relationship between claimant’s requested medical services and her accepted lumbar strain and, on that basis, refuse to transfer the matter to the board. On review for errors of law, ORS 183.482(8), we conclude that he did not. Accordingly, we reverse and remand for transfer to the board.

Claimant was injured at work in November 2008, and employer2 subsequently accepted a compensable “lumbar strain.” In August 2009, employer enrolled claimant in a managed care organization (MCO), a state-certified organization designed to manage the provision of medical services to injured workers. See generally ORS 656.260; OAR 410-123-1600 (7/1/09). At that time, claimant had been experiencing ongoing low back pain and, as pertinent here, “tenderness at the right sacroiliac [(SI)] joint * * Dr. Kassube, a physician treating claimant, sought the MCO’s approval of medical services — namely, a right SI joint injection. However, in [515]*515June 2010, the MCO declined to review Kassube’s request because “[t]he requested procedure [was] not directed towards the accepted condition of lumbar strain.” Claimant subsequently requested that the director review the MCO’s denial of that medical service.

The propriety of Kassube’s requested right SI joint injection was consequently reviewed by the Medical Section Resolution Team (RT) under the director’s authority. In response to claimant’s request for review, employer asserted that the proposed injection “was excessive, inappropriate, or ineffectual” and that it was “for a new or omitted condition in [sic] which the worker had not asked for acceptance.” The RT issued an administrative order of dismissal on June 30, 2010, determining that “the requested treatment was directed towards a condition that had not been accepted” and dismissing the matter without prejudice “on the grounds [that] there was no dispute to review and the Workers’ Compensation Division therefore did not have jurisdiction.” Claimant then requested a contested case hearing regarding the RT’s order of dismissal, and, on October 20, 2010, the matter was heard by an administrative law judge (ALJ).

Before the ALJ, claimant requested that the matter be remanded back to the director for transfer to the board. In support of that request, she argued that, under ORS 656.704(3)(b)(C), “the Director did not have subject matter jurisdiction to dismiss [her] request for review because a causal relationship [was] at issue.” That is, claimant asserted that the director erred in retaining jurisdiction and dismissing her request for review because the dispute turned on the causal relationship between the requested medical services (i.e., the right SI joint injection) and claimant’s accepted lumbar condition — an issue that, according to claimant, only the board had authority to resolve under ORS 656.704(3)(b)(C). Employer responded by again noting that claimant had not made a claim “for a new and/or omitted medical condition involving the right SI joint” and arguing that, consequently, there was no causation or compensability issue to be transferred to the board. Although the ALJ expressly recognized that, under ORS 656.704(3)(b)(C), “[a]ny dispute that requires a determination of whether a [516]*516sufficient causal relationship exists between medical services and an accepted claim to establish compensability is a matter concerning a claim within the jurisdiction of the Board [,]” she ultimately affirmed the RT’s order of dismissal, reasoning:

“Here, at the time of the Order of Dismissal, claimant had not made a new and/or omitted condition claim for an SI joint condition. Nor does the evidence support a conclusion that the requested SI joint injection was directed at the accepted lumbar strain condition. Consequently, I conclude that there was no causal relationship issue to be referred to the [board’s] Hearings Division.”

Finally, claimant sought director review of the ALJ’s order, and, in the final order now under judicial review, the director affirmed the RT’s order of dismissal and the ALJ’s subsequent order. In so doing, the director focused on the evidence related to causation, noting that “ [a]n employer is only required to provide treatment for conditions caused in material part by the compensable injury” and stating:

“The accepted condition is a lumbar strain. The requested treatment is for an injection at the right SI joint. Claimant does not cite any evidence in the record suggesting [that] the proposed treatment is directed towards a condition caused in material part by the accepted condition. Claimant does not assert [that] she has filed a claim related to the right SI joint. The issue, then, is whether, under these facts, there is a dispute about the causal relationship between the proposed treatment and the accepted condition that must be transferred to the [board] to be resolved.”

(Citation omitted; emphasis added.) In turn, addressing that issue, the director reasoned:

“Claimant argues [that] RT should have transferred the matter to the [board], rather than dismissing. The [board] has jurisdiction to determine whether a proposed treatment is causally related to the accepted condition. ORS 656.704(3)(b)(C). Claimant’s position is that when an insurer denies treatment on the grounds [that] it is directed towards a condition that has not been accepted, this inherently raises a causal relation issue, because the insurer is impliedly asserting [that] the proposed treatment is not causally related to the accepted condition.
[517]*517“The difficulty with claimant’s position is that it is speculative. Claimant did not provide evidence to RT that the requested treatment was directed towards either the accepted condition or a condition caused in material part by the accepted condition. Absent such evidence, there is no factual dispute. RT had no evidentiary basis on which to issue a transfer order.
“* * * There can only be a dispute if there is some evidence [that] the condition being treated was caused in material part by the accepted condition. If there is no evidence of that causal relationship, there is a hypothetical dispute, but no actual, factual dispute.”

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Cite This Page — Counsel Stack

Bluebook (online)
310 P.3d 713, 258 Or. App. 512, Counsel Stack Legal Research, https://law.counselstack.com/opinion/daugherty-v-saif-corp-orctapp-2013.