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Industry Insights

Varney: Material Cause Standard Applies in Combined Condition Claim

  • State: Oregon

On remand from the Oregon Court of Appeals, the Oregon Workers’ Compensation Board recently found that although a combined condition had been accepted and a current combined condition denial, the material cause standard applied for determining compensability of a diagnostic MRI.

Karen S. Varney

Karen S. Varney

In Daniel B. Slater, the worker’s claim was accepted for a medial collateral ligament strain and left medial meniscus tear combined with pre-existing left knee osteoarthritis. SAIF Corp. subsequently denied the current combined condition. A magnetic resonance image was then recommended to confirm the claimant’s ACL was intact, to evaluate the pre-existing and non-compensable arthritis, to confirm there was no new injury and to evaluate how much of the meniscus was left.

The board initially found that because the record established a combined condition, the major cause standard applied when determining compensability of the MRI, and upheld the denial of the imaging.

The court remanded and found that if diagnostic medical services were directed to one of the originally accepted conditions, the claimant need prove only that the service was directed to a condition caused in material part by the injury. However, if the medical services were directed to either a combined or consequential condition, the major cause standard applied.

On remand, the board referenced Garcia-Solis v. Farmers Ins. Co. (which was decided two years after the Court of Appeals decision in Daniel B. Slater, but before this board decision in Daniel B. Slater) noting that the “compensable injury” as referenced in the first and second sentences of ORS 656.245(1)(a) means the “work accident;” does not mean medical conditions; and is not limited to conditions that the carrier has accepted at the time the medical services were sought.

The board concluded that the medical evidence demonstrated the MRI was “for” or “directed to” the accepted meniscal tear and thus compensable even though the MRI would also evaluate the claimant’s non-compensable pre-existing arthritis.

It reasoned that since the meniscal tear was an accepted condition, it was also a condition caused in material part by the work injury, and the MRI was compensable. It explained that the statute does not limit compensability of medical services simply because those services also provide incidental benefits that help or treat non-compensable medical conditions.

Therefore, we cannot assume the major cause standard automatically applies when a claim is accepted as a combined condition.

Karen S. Varney is an attorney with Reinisch Wilson Weier PC, headquartered in Portland, Oregon. This column is republished with permission from the firm’s website.

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