SAIF Corp. v. Traner

346 P.3d 1248, 270 Or. App. 67
CourtCourt of Appeals of Oregon
DecidedMarch 25, 2015
Docket1104729; A152085
StatusPublished
Cited by2 cases

This text of 346 P.3d 1248 (SAIF Corp. v. Traner) 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
SAIF Corp. v. Traner, 346 P.3d 1248, 270 Or. App. 67 (Or. Ct. App. 2015).

Opinion

DEVORE, J.

In this workers’ compensation case, SAIF petitions for judicial review of an order of the Workers’ Compensation Board (board), which concluded that, after claimant initiated a claim for a new or omitted medical condition under ORS 656.267(1), SAIF failed to formally accept or deny that request within 60 days as required by ORS 656.262(7)(a). Although the board ultimately determined that the claim actually involved only a symptom of previously accepted conditions, the board awarded attorney fees under ORS 656.262(ll)(a) based on SAIF’s unreasonable delay in accepting or denying what was claimed to be a new or omitted condition. On review, SAIF contends (1) that it was not required to respond to a claim later found to involve only a symptom; (2) that no attorney fees were permitted when no penalty was assessed; and (3) that SAIF’s failure to respond timely or properly was not “unreasonable,” given an uncertain state of the law. For the reasons that follow, we affirm.

The dispositive facts are not in dispute. Claimant compensably injured her right shoulder in 2007 while operating a floor-buffing machine. SAIF initially accepted a right shoulder strain, and later added right-shoulder tendonitis and a partial rotator cuff tear. The claim was closed in December 2008 but was reopened in July 2009 to address worsening tendonitis, which required two shoulder surgeries. In a post-surgery follow-up report, the attending physician, Dr. Yoshinaga, described worsening right-shoulder “arthralgia.”

On March 9, 2011, claimant sent a letter to SAIF requesting acceptance of “right-shoulder chronic arthralgia.” SAIF asked Yoshinaga about the arthralgia. He responded that arthralgia meant “pain,” was “merely a descriptor of symptoms, and [was] not an objective diagnosis.”

On April 12, SAIF sent claimant a letter responding that the request for acceptance of arthralgia “does not qualify as a claim under ORS 656.267 because [the] request seeks the acceptance of a body part, procedure, and/or symptom, which is not a new or omitted medical condition.” The letter added that claimant could clarify her request in [69]*69writing and that it would then be processed. SAIF included a notice of hearing rights.

Claimant requested a hearing before an administrative law judge (ALJ). The ALJ deemed SAIF’s April 12 letter to be a “denial” of a claim, and the ALJ determined that the denial was justified. Based on Yoshinaga’s explanation of arthralgia, the ALJ found that arthralgia was a symptom of claimant’s other accepted shoulder conditions and the resulting two surgeries. Therefore, arthalgia was not itself a new or omitted condition.

Claimant appealed to the board. The board affirmed the ALJ’s finding that arthralgia was a symptom, not a new or omitted condition. Nonetheless, the board determined that SAIF had unreasonably delayed responding to the claim for arthralgia. The board observed that, under ORS 656.267(1), claimant was required to “clearly request formal written acceptance of a new [or] omitted medical condition ***.” Whether or not ultimately successful, she had done so, and, in response, SAIF was obligated under ORS 656.262(7)(a) to give written notice of acceptance or denial of the requested medical condition within 60 days.1 The board disagreed with the ALJ’s characterization that SAIF’s April 12 letter to claimant was a “denial.” The board opined that the letter more closely resembled a “clarification letter” or a “no perfected claim letter,” which is not a statutorily authorized response to a request for acceptance of a new or omitted medical condition. Because SAIF failed to formally accept or deny claimant’s request within 60 days, the board concluded that the procedural failure represented a de facto denial.2

With that determination, the board reached the question whether claimant was entitled to a penalty or attorney fees under ORS 656.262(ll)(a). The statute provides, in pertinent part:

[70]*70“If the insurer *** unreasonably delays or unreasonably refuses to pay compensation, or unreasonably delays acceptance or denial of a claim, the insurer * * * shall be liable for an additional amount up to 25 percent of the amounts then due plus any attorney fees assessed under this section.”

The board concluded that SAIF’s letter, “without any legal support for such a document, and in direct contravention of case law requiring the carrier to either accept or deny such a claim, constitute [d] an unreasonable lapse in its claim [-] processing responsibilities.” Because the board upheld SAIF’s de facto denial of claimant’s claim for arthralgia, there were no “amounts then due” and, consequently, no amounts upon which to base the 25 percent penalty. Even so, the board determined that a penalty was not a prerequisite to an award of attorney fees under ORS 656.262(11)(a). The board relied on its decision, Nancy Ochs, 59 Van Natta 1785, 1793 (2007), holding to that effect. The board recognized that attorney fees are to be awarded in a reasonable amount that is “proportionate to the benefit to the injured worker” and gives “primary consideration to the results achieved and to the time devoted to the case.” ORS 656.262(ll)(a). The board considered that the efforts of claimant’s attorney “were of significant benefit to claimant” by obtaining a hearing and soliciting an express position from SAIF regarding claimant’s arthralgia. The board awarded attorney fees of $1,500 for claimant’s attorney’s efforts.

As the first of three issues on appeal, SAIF contends that claimant did not initiate a claim for acceptance of a new or omitted medical condition within the meaning of ORS 656.267(1), inasmuch as the purported condition was ultimately determined to be a symptom of previously accepted conditions. Because there was no new or omitted condition, SAIF argues, it was not obligated under ORS 656.262(7)(a) to formally accept or deny claimant’s request within 60 days. Because it was not obliged to respond, SAIF asserts that it did not unreasonably fail to accept or deny the purported claim.

This court has already answered that question. So, too, has the board. In SAIF v. Stephens, 247 Or App 107, 109, 269 P3d 62 (2011), a claimant asserted a claim for a new or omitted condition of coccydynia. When SAIF [71]

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Related

Coleman v. SAIF
466 P.3d 967 (Court of Appeals of Oregon, 2020)
SAIF Corp. v. Traner
365 P.3d 1078 (Court of Appeals of Oregon, 2015)

Cite This Page — Counsel Stack

Bluebook (online)
346 P.3d 1248, 270 Or. App. 67, Counsel Stack Legal Research, https://law.counselstack.com/opinion/saif-corp-v-traner-orctapp-2015.