Oregon Department of Consumer and Business Services, Workers' Compensation Division
Nondisabling and Disabling Claim Reclassification
(1) General. If the insurer changes the classification of an accepted claim, the insurer must:(a) Notify the director under OAR 436-060-0011 (Insurer Reporting Requirements);(b) Send the worker and the worker’s attorney, if any, a “Modified Notice of Acceptance” explaining the change in status; and(c) Close the claim under ORS 656.268 (Claim closure)(5), if the claim qualifies for closure.(2) Reclassification of a nondisabling claim. The insurer must reclassify a nondisabling claim to disabling:(a) Within 14 days of receiving information that:(A) Temporary disability is due and payable;(B) The worker is medically stationary within one year of the date of injury and the worker will be entitled to an award of permanent disability; or(C) The worker is not medically stationary, but there is a reasonable expectation that the worker will be entitled to an award of permanent disability when the worker does become medically stationary; or(b) Upon acceptance of a new or omitted condition that meets the disabling criteria in this section.(3) Worker request for reclassification. A worker may request the insurer review the classification of a nondisabling claim under ORS 656.277 (Request for reclassification of nondisabling claim) if the claim has been classified as nondisabling for one year or less after the date of acceptance and the worker believes the claim was or has become disabling.(a) The request for classification status review must be first made to the insurer in writing.(b) Within 14 days of receipt of the worker’s request, the insurer must review the claim and:(A) If the classification is changed to disabling, provide notice under this rule; or(B) If the insurer believes evidence supports denying the worker’s request to reclassify the claim, the insurer must mail a “Notice of Refusal to Reclassify” to the worker and the worker’s attorney, if any. The notice must include the following statement, in bold print:(c) If the worker disagrees with the insurer’s decision in the Notice of Refusal to Reclassify, the worker may appeal to the director under section (7) of this rule:(A) The appeal must be made no later than the 60th day after the mailing date of the Notice of Refusal to Reclassify; and(B) A copy of the insurer’s Notice of Refusal to Reclassify must be provided to the director.(d) If the insurer does not respond to the worker’s request for reclassification within 14 days of receipt of the worker’s request:(A) The worker may request review by the director under section (7) of this rule as if the insurer issued a Notice of Refusal to Reclassify;(B) The director may assess civil penalties under OAR 436-060-0200 (Assessment of Civil Penalties); and(C) The director may assess an attorney fee under ORS 656.386 (Recovery of attorney fees, expenses and costs in appeal on denied claim)(3).(e) If the worker is represented by an attorney, and the attorney is instrumental in obtaining an order from the director that reclassifies the claim from nondisabling to disabling, the director may award the attorney a reasonable assessed attorney fee under ORS 656.277 (Request for reclassification of nondisabling claim).(4) Time frame for aggravation rights. A claim for aggravation under ORS 656.273 (Aggravation for worsened conditions) must be filed within five years after:(a) The first valid closure of a claim that is reclassified from nondisabling to disabling within one year from the date of acceptance; or(b) The date of injury of a claim that is not reclassified from nondisabling to disabling within one year from the date of acceptance.(5) Claims for aggravation on nondisabling claims. When a claim has been classified as nondisabling for at least one year after the date of acceptance, a worker who believes the claim was or has become disabling may submit a claim for aggravation under ORS 656.273 (Aggravation for worsened conditions).(6) Reclassification of a disabling claim. If a claim has been accepted and classified as disabling:(a) All aspects of the claim are classified as disabling and may not be reclassified, unless:(A) The claim has been classified as disabling for less than one year from date of acceptance;(B) The insurer determines the criteria for a disabling claim were never satisfied; and(C) The insurer has notified the worker and the worker’s attorney, if any, by issuing a Modified Notice of Acceptance. The Modified Notice of Acceptance must include the following:(b) Any subsequently accepted conditions or aggravations must be processed as disabling claims; and(c) Claim closure must be processed under ORS 656.268 (Claim closure).(7) Appeal of insurer’s classification decision. If a worker disagrees with an insurer’s decision to not reclassify the worker’s claim from nondisabling to disabling, the worker may appeal the decision by requesting review by the director:(a) The request must be submitted to the division by mail, hand-delivery, fax, or phone within 60 days from the date of the insurer’s notice;(b) The worker may use Form 2943, “Worker Request for Claim Classification Review,” for requesting review of the insurer’s claim classification decision; and(c) The worker does not need to be represented by an attorney to appeal the insurer’s reclassification decision under section (3) or (6) of this rule. If a worker appeals an insurer’s reclassification decision:(A) The worker’s appeal must be copied to the insurer;(B) The director will acknowledge receipt of the appeal in writing to the worker, the worker’s attorney, if any, and the insurer, and initiate the review;(C) Within 14 days of the director’s acknowledgement:(i) The insurer must provide the director and all other parties with the complete medical record and all official actions and notices on the claim. The director may impose penalties against an insurer under OAR 436-060-0200 (Assessment of Civil Penalties) if the insurer fails to provide claim documents in a timely manner; and(ii) The worker may submit any additional evidence for the director to consider. Copies must be provided to all other parties at the same time; and(D) After receipt and review of the required documents, the director will issue an order:(i) The worker and the insurer have 30 days from the mailing date of the order to appeal the director’s decision to the board; and(ii) The director may reconsider, abate, or withdraw any order before the order becomes final by operation of law.