Garcia-Solis v. Farmers Ins. Co. (In re Comp. of Garcia-Solis)

441 P.3d 573, 365 Or. 26
CourtOregon Supreme Court
DecidedMay 31, 2019
DocketWCB 12-03622 (SC S065956)
StatusPublished
Cited by7 cases

This text of 441 P.3d 573 (Garcia-Solis v. Farmers Ins. Co. (In re Comp. of Garcia-Solis)) is published on Counsel Stack Legal Research, covering Oregon Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Garcia-Solis v. Farmers Ins. Co. (In re Comp. of Garcia-Solis), 441 P.3d 573, 365 Or. 26 (Or. 2019).

Opinion

GARRETT, J.

*574**28Claimant Elvia Garcia-Solis (claimant) was injured in a work-related accident. Farmers Insurance Company and Yeaun Corporation (collectively referred to here as insurer) accepted a workers' compensation claim and certain specified medical conditions associated with the accident. Because claimant also showed psychological symptoms, her doctor recommended a psychological referral to diagnose her for possible post-traumatic stress disorder (PTSD). Insurer argued, and the Court of Appeals agreed, that the cost of the psychological referral was not covered by workers' compensation because claimant had failed to prove that it was related to any of the medical conditions that insurer had accepted. Garcia-Solis v. Farmers Ins. Co. , 288 Or. App. 1, 403 P.3d 803 (2017). We allowed review and now reverse.

I. FACTS

A. Legal Background

This case involves the state workers' compensation system. A brief overview will give context for the discussion that follows.

Oregon's workers' compensation law requires employers to provide compensation to workers who suffer "compensable injuries." ORS 656.017(1). The term "compensable injury" is defined in ORS 656.005(7)(a) as:

"an accidental injury *** arising out of and in the course of employment requiring medical services or resulting in disability or death[.]"

If there is an "accident resulting in an injury or death," the worker must give the employer notice "immediately" after the accident. ORS 656.265(1)(a) (discussing additional time limits). Within 60 days after the employer has notice or knowledge of a claim, the insurer (or self-insured employer1 ) must give the employee a written notice of acceptance or denial. ORS 656.262(6)(a). A written notice of acceptance must "[s]pecify what conditions are compensable." ORS 656.262(6)(b)(A) ; see also ORS 656.267(1) (employer's **29notice of acceptance is sufficient if it "reasonably apprises the claimant and the medical providers of the nature of the compensable conditions").

In general, the claimant has the burden to show that an "injury" is compensable. ORS 656.266(1). If a claimant believes that a written notice of acceptance incorrectly omits a compensable condition, he or she may object at any time and file a claim for the omitted condition. ORS 656.262(6)(d).

The issue in this case involves the medical services that the insurer must provide. Under ORS 656.245(1)(a), an insurer must provide services to the injured worker "[f]or every compensable injury." Specifically, the statute provides in part:

"For every compensable injury, the insurer *** shall cause to be provided medical services for conditions caused in material part by the injury for such period as the nature of the injury or the process of the recovery requires, *** including such medical services as may be required after a determination of permanent disability."

B. Facts

The facts, which are undisputed, are largely taken from the opinion of the administrative law judge (ALJ).

In 2009, high winds blew down a tent pole at an event where claimant was working as a *575food server. She was struck on the head and slammed against a wall. Claimant suffered multiple injuries and was hospitalized.

It is not disputed that claimant suffered an accidental injury that arose out of and in the course of her employment. See ORS 656.005(7)(a). Insurer initially accepted the following conditions:

• left midshaft clavicle fracture
• first through third left rib fractures
• C7-T3 spinous process fractures
• full thickness scalp laceration
• left elbow contusion
• T5-T8 compression fractures

**30In 2011, insurer also accepted the following conditions:

• concussion
• closed head injury
• chronic headache syndrome
• facial scarring
• right supraorbital nerve injury

The issue before us involves psychological symptoms. As early as January 2010, claimant had reported to her doctor, Dr. Erb, that she was having psychological problems when it was windy. The doctor's notes reported that claimant " 'becomes very tearful during a wind storm and quite frightened.' " In late 2011 and again in early 2012, claimant's son reported that claimant was still reacting fearfully to wind. In response, Erb recommended a "[p]sychology referral to address PTSD[ ]like symptoms."

Insurer refused to authorize the psychology referral on the ground that the referral was not causally related to any of the conditions that insurer had accepted.

Claimant then sent Erb the following question:

"Is [claimant's] need for medical services in the form of 'Psychology referral to address PTSD-like symptoms' caused in material part by her work injury of February 25, 2009 in which she sustained severe injuries ***?"

(Emphasis omitted.) Erb checked the following box:

"Yes, [claimant's] need for medical services in the form of 'Psychology referral to address PTSD-like symptoms' [was] caused in material part by her work injury of February 25, 2009."

(Emphasis omitted.)

The matter went to an ALJ, who ruled for insurer. The ALJ explained that the medical services required by ORS 656.245

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Cite This Page — Counsel Stack

Bluebook (online)
441 P.3d 573, 365 Or. 26, Counsel Stack Legal Research, https://law.counselstack.com/opinion/garcia-solis-v-farmers-ins-co-in-re-comp-of-garcia-solis-or-2019.