Bauman v. State Acc. Ins. Fund Corp.

• Decision Date: 25 October 1983
• Docket Number: No. 80-04870,80-04870
• Citation: 670 P.2d 1027,295 Or. 788
• Parties: In the Matter of the Compensation of Steven Bauman, Claimant. Steven BAUMAN, Respondent on review, v. STATE ACCIDENT INSURANCE FUND CORPORATION, Petitioner on review. ; CA A24941; SC 29596.
• Court: Oregon Supreme Court

Page 1027

670 P.2d 1027

295 Or. 788

In the Matter of the Compensation of Steven Bauman, Claimant Steven BAUMAN, Respondent on review, v. STATE ACCIDENT INSURANCE FUND CORPORATION, Petitioner on review.

No. 80-04870; CA A24941; SC 29596.

Supreme Court of Oregon.

Argued and Submitted Aug. 3, 1983.

Decided Oct. 25, 1983.

Darrell E. Bewley, Appellate Counsel, Salem, argued the cause and filed the petition and brief for petitioner on review.

Gerald C. Doblie, Portland, argued the cause for respondent on review. With him on the brief was Doblie, Francesconi & Welch, P.C., Portland.

In banc. ^*

JONES, Justice.

This case arises under the Workers' Compensation Act. We allowed review to determine the permanency of SAIF's original acceptance of a claim for medical benefits. We hold that once an insurer has accepted a claim under ORS 656.262(6), which requires acceptance or denial of a workers' compensation claim within 60 days after the employer has notice or knowledge of the claim, the insurer may not subsequently deny the compensability of the underlying claim.

FACTS

Claimant was a tool and die maker at Omark Industries. In October of 1977, claimant alleged that a bursitis condition was compensable as connected with his employment. On November 16, 1977, his claim was accepted by Omark and its compensation carrier, State Accident Insurance Fund Corporation (SAIF), as a nondisabling "medical only claim" and SAIF thereafter began paying medical benefits to the claimant. In February of 1980, claimant's condition worsened and his treating physician petitioned SAIF to reopen the claim, stating that claimant was in need of additional medical treatment. SAIF denied this request stating that "unless there is time loss and/or impairment involved, it is not necessary that we reopen the claim to pay for the necessary treatment." In November of 1980, SAIF halted further medical payments concluding independently that the initial bursitis condition was not a compensable injury, as it did not arise out of and in the course of claimant's employment. SAIF reversed its acceptance of the claim and denied the original claim for compensation benefits. Claimant thereafter timely requested a hearing within the 60-day period provided for in ORS 656.262(7).

The referee, apparently relying on our decision in Frasure v. Agripac, 290 Or. 99, 619 P.2d 274 (1980), found that SAIF's denial was timely made and correct. Upon appeal, the Board upheld the referee also concluding that SAIF possessed the authority to reopen and reconsider a previously accepted claim and upon reevaluation of the compensability issue to deny benefits. On the merits the Board found that the medical opinion presented at the hearing supported the conclusion that claimant's condition was not compensable.

We said in Frasure v. Agripac, supra:

" * * * It is better to encourage prompt payment than it is to discourage it by holding that the insurer who makes payment of medical expenses under ORS 656.245 is estopped to contest coverage with respect to an aggravation claim under ORS 656.273. We hold that the payment of medical expenses under ORS 656.245 following the filing of a claim for aggravation does not amount to an acceptance of the aggravation claimed by the employer or the insurer, and does not estop the employer or insurer from contesting the causal connection between the previously determined compensable injury and the claimant's present symptoms." Id. at 106, 619 P.2d 274, quoting Jacobson v. SAIF, 36 Or.App. 789, 793, 585 P.2d 1146 (1978).

Frasure involved an aggravation claim and two distinct and separate employers. The first employer and its insurer accepted the claimant's aggravation claim and awarded time loss only. Between the time of the award and a requested hearing, the claimant's doctors changed their opinion and concluded the claimant's injury was a "new injury" rather than aggravation of an old injury. We held that the first employer was not estopped by his earlier acceptance of the aggravation claim from denying responsibility at the hearing requested by the claimant. In the present case, the Court of Appeals, 62 Or.App. 323, 661 P.2d 105, concludes that our holding in Frasure does not foreclose the possibility that there can be finality to an employer's or insurer's acceptance of a claim. This is a correct reading of the rule in Frasure and this is an appropriate case to clarify any confusion that may exist. In Frasure, we said:

"One of the manifest purposes of Oregon's Workers' Compensation Law is to achieve prompt payment of claims to injured workers. The responsibility for making such payments is imposed on compensation carriers and direct responsibility employers, and such payments are to be made 'promptly and directly to the person entitled thereto upon the employer's receiving notice or knowledge of a claim, except where the right to compensation is denied by the direct responsibility employer or corporation.' ORS 656.262(2). The first payment must be paid 'no later than the 14th day after the subject employer has notice or knowledge of the claim.' ORS 656.262(4). Written notice of acceptance or denial of the claim must be given to the claimant within 60 days 'after the employer receives notice or knowledge of the claim.' ORS 656.262(5). ORS 656.262(8) provides for a 25 percent penalty for unreasonable delay * * * in acceptance or denial of a claim. The legislature further provided, in the same statute, that acceptance of a claim or payment of compensation did not prevent the employer or carrier from subsequently denying the claimant's right to compensation. ORS 656.262(7) provides:

'(7) Merely paying or providing compensation shall not be considered acceptance of a claim or an admission of liability, nor shall mere acceptance of such compensation be considered a waiver of the right to question the amount thereof.' " Id. 290 Or. at 105, 619 P.2d 274.

We must retreat slightly from what we said in Frasure. We are dealing with the statutory scheme found in the relevant parts of ORS 656.262. ¹ Former ORS 656.262(7) (now codified as subsection (8)), relates to the provisions found in ORS 656.262(4), supra n. 1, which requires the insurer to begin payments within 14 days after notice or knowledge of a claim. In Frasure, we indicated that former ORS 656.262(7) allowed an employer to accept a claim and then subsequently to deny the right to compensation. This is not correct. Former ORS 656.262(7) merely provides protection to the insurer who begins payments without accepting a claim from having the payments interpreted as acceptance of the claim. What we should have clearly stated was that because an employer complies with the provisions found in subsection (4) and begins making compensation payments no later than the 14th day after notice of the claim, the employer is not subsequently barred from denying the claimant's right to compensation. This is the rule found in former subsection (7). This is so because the threshold payment of benefits within 14 days is not contingent upon a determination of compensability and simple compliance with the statute does not constitute acceptance of a claim by an insurer.

In this case, SAIF specifically accepted a claim as compensable by providing the claimant with an acceptance letter and subsequently...