Lavine v. SAIF Corp.

Court of Appeals of Oregon

Lavine v. SAIF Corp.

718 P.2d 1391, 79 Or. App. 511

CourtCourt of Appeals of Oregon

DecidedMay 21, 1986

DocketWCB 84-03050; CA A35571

StatusPublished

This text of 718 P.2d 1391 (Lavine 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

Lavine v. SAIF Corp., 718 P.2d 1391, 79 Or. App. 511 (Or. Ct. App. 1986).

Pincite

Opinion

ROSSMAN, J.

Claimant seeks review of a Workers’ Compensation Board order which affirmed the referee’s determination that SAIF did not have to pay for certain medical services. At issue is the compensability of a thermogram, a diagnostic test which was performed on claimant in an effort to determine the cause of his chronic back pain.

In January, February and July, 1984, Dr. Wilson requested authorization for the thermogram, pursuant to OAR 436-69-201(13).¹ Wilson became aware on March 14, 1984, that SAIF had denied the request, even though no formal denial was issued. On August 1, 1984, the thermographic studies were performed and revealed abnormalities indicating to Wilson a need for chiropractic treatment.

SAIF questions the validity of a thermogram as a diagnostic tool. The dispositive issue, however, is whether SAIF is required to pay for the thermogram, in view of the fact that claimant did not obtain prior authorization for it, as required by OAR 436-69-201(13). Claimant asserts that the administrative rule is invalid, because it places the entire question of the compensability of a diagnostic procedure within the discretion of the insurer. We do not understand that to be the case. The rule merely requires “prior authorization”; it does not require prior authorization by the insurer. The insurer merely makes the first judgment, and, if it denies authorization, its decision is reviewable by the referee and the Board, either of which could have authorized the test. Because claimant failed to follow that procedure and obtain authorization before undergoing the thermogram, he is not entitled to be compensated for it.

Affirmed.

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ROSSMAN, J.

Claimant seeks review of a Workers’ Compensation Board order which affirmed the referee’s determination that SAIF did not have to pay for certain medical services. At issue is the compensability of a thermogram, a diagnostic test which was performed on claimant in an effort to determine the cause of his chronic back pain.

In January, February and July, 1984, Dr. Wilson requested authorization for the thermogram, pursuant to OAR 436-69-201(13).¹ Wilson became aware on March 14, 1984, that SAIF had denied the request, even though no formal denial was issued. On August 1, 1984, the thermographic studies were performed and revealed abnormalities indicating to Wilson a need for chiropractic treatment.

SAIF questions the validity of a thermogram as a diagnostic tool. The dispositive issue, however, is whether SAIF is required to pay for the thermogram, in view of the fact that claimant did not obtain prior authorization for it, as required by OAR 436-69-201(13). Claimant asserts that the administrative rule is invalid, because it places the entire question of the compensability of a diagnostic procedure within the discretion of the insurer. We do not understand that to be the case. The rule merely requires “prior authorization”; it does not require prior authorization by the insurer. The insurer merely makes the first judgment, and, if it denies authorization, its decision is reviewable by the referee and the Board, either of which could have authorized the test. Because claimant failed to follow that procedure and obtain authorization before undergoing the thermogram, he is not entitled to be compensated for it.

Affirmed.

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718 P.2d 1391, 79 Or. App. 511, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lavine-v-saif-corp-orctapp-1986.