Sedgwick Claims Management Services v. Jones

166 P.3d 547, 214 Or. App. 446, 2007 Ore. App. LEXIS 1141
CourtCourt of Appeals of Oregon
DecidedAugust 15, 2007
DocketH05008; A129373
StatusPublished
Cited by3 cases

This text of 166 P.3d 547 (Sedgwick Claims Management Services v. Jones) 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
Sedgwick Claims Management Services v. Jones, 166 P.3d 547, 214 Or. App. 446, 2007 Ore. App. LEXIS 1141 (Or. Ct. App. 2007).

Opinion

*448 WOLLHEIM, J.

Sedgwick Claims Management Services petitions for judicial review of a final order of the Workers’ Compensation Division that held that Sedgwick was responsible for the purchase of a new wheelchair-accessible modified van as a reasonable and necessary medical service under ORS 656.245. We review for errors of law, ORS 183.482(8)(a). Because, as Sedgwick argues, the division did not consider its administrative rules in ordering Sedgwick to provide the van, we reverse and remand.

The facts are undisputed. In 1978, claimant, while working for a noncomplying employer, was injured in a logging accident that resulted in a T9 compression fracture and paraplegia. As a result of his injuries, claimant is confined to a wheelchair. Consistent with the Workers’ Compensation Law at the time of claimant’s injury, SAIF was assigned to process this claim for the noncomplying employer. A 1987 determination order declared claimant to be totally and permanently disabled.

In 1986, claimant’s then-attending physician wrote a prescription for a modified vehicle so that claimant could drive independently. After initially denying the request, SAIF rescinded its denial by stipulation. SAIF then issued a partial denial, arguing that it was not responsible for specific equipment that the attending physician prescribed. In 1988, a referee issued an opinion and order setting aside SAIF’s partial denial and ordering SAIF to purchase a new wheelchair-accessible modified van for claimant as prescribed by his then-attending physician. The referee determined that “[t]he van * * * is, under ORS 656.245, a type of‘prosthetic appliance [.’ ”] SAIF did not request board review, and the opinion and order became final. SAIF eventually purchased a new 1989 van for claimant.

In 2003, claimant informed Sedgwick — the current claim processor for the noncomplying employer — that he was having problems with his 14-year-old van. Specifically, the transmission was faulty such that the van would not stay in park, despite having been removed and serviced three times by a transmission mechanic. In response, Sedgwick advised *449 claimant that it would “make necessary modifications to a vehicle that [claimant]purchase[s].” (Emphasis added.)

In early 2004, claimant’s attending physician, Dr. Hitzman, prescribed a new van, along with a list of accessories and modifications, to replace claimant’s malfunctioning 1989 van. Claimant’s physician indicated that the wheelchair-accessible modified van was medically necessary due to claimant’s “Mack of mobility and/or extremity function with need for transportation especially during winter season.” Claimant’s physician indicated that the van would assist claimant in achieving “Mndependence in driving” and serve as an “extension of [claimant’s] wheelchair mobility.” The prescription also referenced the fact that, in 1989, SAIF had purchased a new wheelchair-accessible modified van and that it had been previously determined that the van was a type of prosthetic appliance for claimant.

Despite the precedent of the 1988 opinion and order and the 2004 prescription, Sedgwick did not purchase a replacement van. Claimant requested administrative review by the Medical Review Unit (MRU). Sedgwick conceded that claimant needed a modified van and that it was responsible for van modifications, but Sedgwick did not believe that it was required to purchase a new van. The MRU, in an administrative order, concluded that a “modified wheelchair accessible van is a reasonable and appropriate compensable medical service.” Sedgwick was ordered to replace claimant’s malfunctioning van with a new wheelchair-accessible modified van, as prescribed by claimant’s attending physician.

Sedgwick appealed the administrative order and requested a contested case hearing before an administrative law judge (ALJ). 1 The ALJ issued a proposed order, which became the division’s final order when neither party filed exceptions. The order concluded that “[t]he administrative order correctly determined that the insurer is required to pay *450 for a new, wheelchair-accessible van with modifications as prescribed by [claimant’s physician].”

Sedgwick petitions for judicial review and advances two assignments of error. First, Sedgwick argues that the division erred when it concluded that the purchase of a new modified wheelchair-accessible van was a medical service pursuant to ORS 656.245. Second, Sedgwick argues that the division erred in failing to consider its own administrative rules in concluding that a new modified van was reasonable and necessary. Sedgwick asserts that OAR 436-010-0230(1) and (10), when properly applied to this case, proscribe such a conclusion. 2

Before we address the assignments of error, we pause to discuss the procedural posture of this case. As an initial matter, claimant had the burden of proving that he is entitled to the requested medical service under ORS 656.245. In this case, claimant met his burden of proof before the MRU. By challenging the administrative order, Sedgwick bore the burden of proving that the administrative order was not supported by substantial evidence in the record. Before us, Sedgwick argues that the division erred, as a matter of law, in requiring Sedgwick to purchase a new modified van. To the extent that Sedgwick is arguing that ORS 656.245 does not authorize the purchase of a modified van for this claimant, we agree that we review that question as a matter of law. However, to the extent that Sedgwick is arguing that ORS 656.245 does not authorize the purchase of a new modified van, we disagree that we review the “newness” question as a matter of law. Rather, whether claimant is entitled to a repaired, used, or new modified van is a question of fact, which we review for substantial evidence.

The only evidence in the record below was that claimant’s 1989 van could not be repaired. His attending physician prescribed a new modified wheelchair-accessible van. Sedgwick presented no evidence (1) that the 1989 van could be repaired; (2) that a different used van would be adequate; (3) of the price of a different used van; or (4) that the price of a different, but adequate, new van would be less than the *451 price of the van prescribed by the attending physician. Although Sedgwick made those arguments, it presented no evidence to support them.

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

Related

Landis v. Liberty Northwest Insurance Corp.
383 P.3d 349 (Court of Appeals of Oregon, 2016)
McIntyre v. Feeman
179 P.3d 723 (Court of Appeals of Oregon, 2008)

Cite This Page — Counsel Stack

Bluebook (online)
166 P.3d 547, 214 Or. App. 446, 2007 Ore. App. LEXIS 1141, Counsel Stack Legal Research, https://law.counselstack.com/opinion/sedgwick-claims-management-services-v-jones-orctapp-2007.