OAR 436-060-0141
Claims for COVID-19 or Exposure to SARS-CoV-2

(1) Definitions. For the purpose of this rule:

(a)

“COVID-19” means a disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

(b)

“Isolation” means the physical separation and confinement of a person who is infected or reasonably believed to be infected with COVID-19 from nonisolated persons to prevent or limit the transmission of COVID-19 to nonisolated persons.

(c)

“Medical service provider” means a person duly licensed to practice one or more of the healing arts.

(d)

“Presumptive case” means:

(A)

The person has not tested positive for COVID-19;

(B)

The person has an acute illness with at least two of the following symptoms: shortness of breath, cough, fever, new loss of smell or taste, or radiographic evidence of viral pneumonia;

(C)

There is no more likely alternative diagnosis; and

(D)

The person, within the 14 days before illness onset, had close contact with a confirmed case of COVID-19.

(e)

“Quarantine” means the physical separation and confinement of a person who has been or may have been exposed to COVID-19 or SARS-CoV-2 and who does not show signs or symptoms of COVID-19, from persons who have not been exposed to COVID-19 or SARS-CoV-2, to prevent or limit the transmission of COVID-19 to other persons.

(f)

“SARS-CoV-2” means the strain of coronavirus that causes COVID-19.
(2) Reasonable investigation. Under OAR 436-060-0140 (Acceptance or Denial of a Claim)(1), insurers must conduct a “reasonable investigation” before denying any claim. For claims filed on or after Feb. 1, 2021, for COVID-19 or exposure to SARS-CoV-2, in addition to the requirements of OAR 436-060-0140 (Acceptance or Denial of a Claim)(1), a reasonable investigation must include the steps in subsections (a) through (d) of this section. The steps in subsections (a) through (d) are not required if the claim is denied for procedural reasons not related to the worker’s exposure to COVID-19 or SARS-CoV-2 (for example, the claim was filed with the wrong insurer, the insurer did not provide coverage, or the worker is nonsubject).

(a)

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;

(b)

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;

(c)

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 (Definitions), or the employer, for purposes of discovering information that may be relevant to the compensability determination; and

(d)

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.
(3) Auditing and monitoring.

(a)

The director shall audit denied claims for COVID-19 or exposure to SARS-CoV-2 that were reported to the director under OAR 436-060-0011 (Insurer Reporting Requirements) before Oct. 1, 2020, if:

(A)

The insurer had reported a total of five or more claims for COVID-19 or exposure to SARS-CoV-2 before Oct. 1, 2020, regardless of whether those claims were accepted or denied; and

(B)

The denial is final by operation of law by the date of the audit.

(b)

The director shall audit additional denied claims for COVID-19 or exposure to SARS-CoV-2. The specific claims to be audited will be selected based on criteria determined by the director.

(A)

Audits of claims filed before Oct. 1, 2020, will focus on whether a reasonable investigation was conducted as required by OAR 436-060-0140 (Acceptance or Denial of a Claim)(1).

(B)

Audits of claims filed on or after Oct. 1, 2020, but before Feb. 1, 2021, will focus on, but not necessarily be limited to, whether the insurer complied with OAR 436-060-0141 (Claims for COVID-19 or Exposure to SARS-CoV-2)(2), effective 10⁄1/2020 (WCD Admin. Order 20-061).
(C) Audits of claims filed on or after Feb. 1, 2021, will focus on, but not necessarily be limited to, whether the insurer complied with section (2) of this rule.

(c)

Failure to comply with requirements in ORS chapter 656, OAR chapter 436, or orders of the director may subject an insurer to civil penalties under ORS 656.745 (Civil penalty for inducing failure to report claims)(2).

Source: Rule 436-060-0141 — Claims for COVID-19 or Exposure to SARS-CoV-2, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=436-060-0141.

436–060–0003
Purpose, Applicability, Forms, and Bulletins 436–060–0005
Definitions 436–060–0008
Administrative Review and Contested Cases 436–060–0010
Employer Responsibilities 436–060–0011
Insurer Reporting Requirements 436–060–0012
Notices and Correspondence Following the Death of a Worker 436–060–0015
Required Notice and Information 436–060–0017
Release of Claim Documents 436–060–0018
Nondisabling and Disabling Claim Reclassification 436–060–0019
Determining and Paying the Three Day Waiting Period 436–060–0020
Payment of Temporary Total Disability Compensation 436–060–0025
Worker’s Weekly Wage Calculation and Rate of Temporary Disability Compensation 436–060–0030
Payment of Temporary Partial Disability Compensation 436–060–0035
Supplemental Disability for Workers with Multiple Jobs at the Time of Injury 436–060–0040
Payment of Permanent Partial Disability Compensation 436–060–0045
Payment of Compensation During Worker Incarceration 436–060–0055
Payment of Medical Services on Nondisabling Claims 436–060–0060
Lump Sum Payment of Permanent Partial Disability Awards 436–060–0075
Payment of Death Benefits 436–060–0095
Medical Examinations 436–060–0105
Suspension of Compensation for Insanitary or Injurious Practices, Refusal of Treatment or Failure to Participate in Rehabilitation 436–060–0135
Injured Worker, Worker’s Attorney Responsible to Assist in Investigation 436–060–0137
Vocational Evaluations for Permanent Total Disability Benefits 436–060–0140
Acceptance or Denial of a Claim 436–060–0141
Claims for COVID-19 or Exposure to SARS-CoV-2 436–060–0147
Worker Requested Medical Examination 436–060–0150
Timely Payment of Compensation 436–060–0153
Electronic Payment of Compensation 436–060–0155
Penalty to Worker for Untimely Processing 436–060–0160
Use of Sight Draft to Pay Compensation Prohibited 436–060–0170
Recovery of Overpayment of Benefits 436–060–0180
Designation and Responsibility of a Paying Agent 436–060–0190
Monetary Adjustments among Parties and Department of Consumer and Business Services 436–060–0195
Miscellaneous Monetary Adjustments Among Insurers 436–060–0200
Assessment of Civil Penalties 436–060–0400
Penalty and Attorney Fee for Untimely Payment of Disputed Claims Settlement 436–060–0500
Reimbursement of Supplemental Disability for Workers with Multiple Jobs at the Time of Injury 436–060–0510
Reimbursement of Permanent Total Disability Benefits from the Workers’ Benefit Fund
Last Updated

Jun. 8, 2021

Rule 436-060-0141’s source at or​.us