Beginning February 1, insurers will have new rules to follow in the State of Oregon for COVID-19 workers compensation claims.
This new ruling shifts the burden of proof onto the insurer, and away from the employee, which is the case in many states’ infectious disease statutes.
According to OAR 436-060-0141, insurers must “conduct a reasonable investigation before denying any claim”.
There are four subsections outlining what constitutes a “reasonable investigation”. These include:
- Investigate whether there was likely exposure to COVID-19 or SARS-CoV-2 that arose out of and in the course of the worker’s employment;
- Investigate the source of the worker’s exposure to COVID-19 or SARS-CoV-2, which must include obtaining a medical or expert opinion, if, before a compensability denial is issued, the worker tests positive for COVID-19 or a medical service provider diagnoses a presumptive case of COVID-19, the insurer is aware of the test results or presumptive diagnosis, and the source of the exposure is unclear;
- Determine whether the worker did not work for a period of quarantine or isolation at the direction of a medical service provider, the Oregon Health Authority Public Health Division, a local public health authority as defined in ORS 431.003, or the employer, for purposes of discovering information that may be relevant to the compensability determination; and
- Determine whether medical services were required as a result of potential workplace exposure to COVID-19 or SARS-CoV-2, even if the worker ultimately did not test positive for COVID-19.”
The state of Oregon will audit denied claims and insurers who do not comply with the requirements outlined in the new ruling may be subject to civil penalties.
As always, Broadspire’s compliance and claims team have adjusted accordingly and are prepared to follow all new rulings required by the State of Oregon.
