SAIF Corp. v. Dubose

74 P.3d 1072, 335 Or. 579, 2003 Ore. LEXIS 567
CourtOregon Supreme Court
DecidedAugust 7, 2003
DocketWCB 97-01993; CA A103853; SC S47731
StatusPublished
Cited by5 cases

This text of 74 P.3d 1072 (SAIF Corp. v. Dubose) 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
SAIF Corp. v. Dubose, 74 P.3d 1072, 335 Or. 579, 2003 Ore. LEXIS 567 (Or. 2003).

Opinion

*581 RIGGS, J.

In this workers’ compensation case, SAIF Corporation (SAIF), the insurer, denied a claim for benefits because claimant had failed to cooperate with SAIF’s investigation. Claimant requested a hearing, using the standardized form that the Workers’ Compensation Board (board) provides for such requests, but she did not check a box on the hearing request form to indicate that SAIF had denied her claim for “worker noncooperation.” Instead, claimant checked the box to indicate that SAIF had denied her claim on “compensability complete claim denial” grounds. At the hearing, SAIF argued that claimant was not entitled to a hearing on the denial of her claim because she had failed to request an “expedited hearing” on the denial of her claim on noncooperation grounds. The administrative law judge (ALJ) and, later, the board held that claimant had failed to attend an insurer medical examination (IME), 1 but that her failure to attend was for reasons beyond her control. The Court of Appeals reversed, holding that claimant had been required to request an “expedited hearing” and that, by checking the incorrect box on the hearing request form, she had failed to do so. SAIF v. Dubose, 166 Or App 642, 999 P2d 529 (2000). For the reasons that follow, we reverse the decision of the Court of Appeals and remand to that court for further proceedings.

We take the following undisputed facts from the opinion of the Court of Appeals and the record:

“Claimant filed a claim for workers’ compensation benefits based on a diagnosis of carpal tunnel syndrome and situational anxiety, the cause of which she attributed to her work as an assistant manager of a McDonald’s restaurant. SAIF scheduled claimant for an independent medical examination (IME), notified her of the date, time, and place of the IME, and reminded claimant of her obligation to *582 cooperate and assist in the investigation of her claim. See ORS 656.262(14). Claimant did not attend the IME. On January 24, 1997, the Department of Consumer and Business Services (DCBS) notified claimant that it would be suspending her compensation benefits for ‘noncooperation’ based on her failure to attend the IME. DCBS later issued an order suspending benefits and allowing SAIF to deny the claim unless claimant cooperated within 30 days of the January 24 notice. Claimant did not appeal that order. Nor did she communicate with DCBS or SAIF during the 30-day period. SAIF denied the claim on February 25, 1997, citing claimant’s failure to cooperate as the sole reason for the denial.
“On March 5, 1997, claimant requested a hearing on SAIF’s denial by filling out a standardized form provided by the Board. That form stated: ‘A hearing is requested for the reason(s) checked below.’ Claimant checked ‘DENIAL’ and, as the reason for the denial, marked ‘Compensability — complete claim denial.’ Claimant did not check the box identifying a denial based on “Worker noncooperation.’
“A hearing was scheduled for June 2,1997, almost three months after claimant’s hearing request. At the beginning of the hearing, the ALJ identified the issues before it as ‘compensability of the claim and a carrier-paid fee if claimant prevails.’ SAIF clarified that its denial was not based on noncompensability but was based, instead, on claimant’s noncooperation. SAIF argued that claimant should not be allowed to proceed because she had failed to request an expedited hearing as required by ORS 656.262(15), which provides, in part:
“ ‘[T]he insurer * * * may deny the claim because of the worker’s failure to cooperate. * * * After such a denial, the worker shall not be granted a hearing or other proceeding under this chapter on the merits of the claim unless the worker first requests and establishes at an expedited hearing under ORS 656.291 that the worker fully and completely cooperated with the investigation, that the worker failed to cooperate for reasons beyond the worker’s control or that the investigative demands were unreasonable.’
“(Emphasis added.) The ALJ did not consider claimant’s failure to request an expedited hearing to ‘be of significance’ and determined that claimant should be allowed to present *583 evidence establishing the reasonableness of her failure to attend the IME. Claimant put on evidence that she was unable to attend the IME due to hazardous weather conditions, and the ALJ concluded that claimant’s failure to cooperate was beyond her control. Accordingly, the AU set aside SAIF’s denial and ordered that SAIF process the claim.
“On review of the ALJ’s order, the Board agreed with SAIF that a worker first must challenge a noncooperation denial before he or she is entitled to a hearing on the merits of the claim for compensation. The Board determined, however, that ORS 656.262(15) does not provide that an expedited hearing is the ‘only avenue for challenging a noncooperation denial. Specifically, the Board said:
“ ‘For instance, the statute does not provide that “the worker first requests and establishes only at an expedited hearing * * In the absence of such limiting language, we find that the statute shows that an expedited hearing is an option, not a requirement.
"'*** Under ORS 656.291 and OAR 438-013-0010(1)(c), the Board assigns certain cases to the Expedited Claims Service. In other words, there is no statutory procedure for the worker to request an expedited hearing.’
“(Emphasis in original.) Thus, the Board concluded that a worker need only make a generic request for a hearing and that the Board has the option, but not a mandatory duty, to provide a hearing on an expedited basis. The Board therefore affirmed the ALJ’s order.”

Dubose, 166 Or App at 644-46 (footnote omitted). SAIF sought judicial review.

The Court of Appeals reversed. The court first rejected the board’s conclusion that ORS 656.262(15) did not mandate an expedited hearing. The court also rejected the board’s conclusion that a claimant has no duty to request an expedited hearing if the insurer denied the claim for worker noncooperation. The court noted that the statutory text “plainly places a burden on the worker to make an effective request for the necessary hearing.” 166 Or App at 647. The court concluded that the board provided a reasonable means *584

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Lewis v. CIGNA Insurance
121 P.3d 1128 (Oregon Supreme Court, 2005)
SAIF Corp. v. Dubose
88 P.3d 933 (Court of Appeals of Oregon, 2004)
Lewis v. CIGNA Insurance
87 P.3d 698 (Court of Appeals of Oregon, 2004)
SAIF Corp. v. Wart
87 P.3d 1138 (Court of Appeals of Oregon, 2004)

Cite This Page — Counsel Stack

Bluebook (online)
74 P.3d 1072, 335 Or. 579, 2003 Ore. LEXIS 567, Counsel Stack Legal Research, https://law.counselstack.com/opinion/saif-corp-v-dubose-or-2003.