In the Matter of the Compensation of Elvia Garcia-Solis, Claimant.
FARMERS INSURANCE COMPANY; and Yeaun Corporation, dba Green Papaya and Sunset Deli, Respondents on Review. Elvia GARCIA-SOLIS, Petitioner on Review,
and submitted January 17, 2019
review from the Court of Appeals. (WCB 12-03622), (CA
M. Quinn, Portland, argued the cause and fled the briefs for
petitioner on review.
W. Moller, Wilsonville, argued the cause for respondents on
review. Vera Langer, Lyons Lederer, LLP, Salem, fled the
S. Coon, Thomas, Coon, Newton & Frost, Portland, fled the
brief for amicus curiae Oregon Trial Lawyers
Masters, Appellate Counsel, SAIF Corporation, Salem, fled the
brief for amici curiae SAIF Corporation and Timber Products
Or. 27] Case Summary:
work-related accident, claimant fled a claim for certain
medical conditions and a psychological referral to diagnose
her for possible post-traumatic stress disorder resulting
from the accident. Insurer accepted most conditions but
denied the psychological referral on the ground that it was
not covered by workers' compensation because, although it
undisputedly was related to the work accident, claimant had
failed to prove that it was related to any of the medical
conditions that insurer had accepted. An ALJ, the
Workers' Compensation Board, and the Court of Appeals
agreed with insurer and affirmed the denial of the claim.
Court of Appeals and Workers' Compensation Board erred in
affirming the denial of the claim. ORS 656.245(1) provides
that an insurer shall provide medical services for
"conditions" that are "caused in material part
by the [compensable] injury." The term
"[compensable] injury," in that context, is not
limited to specific medical conditions that insurer has
accepted at the time medical services are sought but rather
refers to the work accident that caused the medical condition
resulting in the need for medical services.
decision of the Court of Appeals is reversed. The order of
the Workers' Compensation Board is reversed, and the case
is remanded to the Board for further proceedings.
Or. 28] GARRETT, J.
Elvia Garcia-Solis (claimant) was injured in a work-related
accident. Farmers Insurance Company and Yeaun Corporation
(collectively referred to here as insurer) accepted a
workers' compensation claim and certain specified medical
conditions associated with the accident. Because claimant
also showed psychological symptoms, her doctor recommended a
psychological referral to diagnose her for possible
post-traumatic stress disorder (PTSD). Insurer argued, and
the Court of Appeals agreed, that the cost of the
psychological referral was not covered by workers'
compensation because claimant had failed to prove that it was
related to any of the medical conditions that insurer had
accepted. Garcia-Solis v. Farmers Ins. Co., 288
Or.App. 1, 403 P.3d 803 (2017). We allowed review and now
case involves the state workers' compensation system. A
brief overview will give context for the discussion that
workers' compensation law requires employers to provide
compensation to workers who suffer "compensable
injuries." ORS 656.017(1). The term "compen-sable
injury" is defined in ORS 656.005(7)(a) as:
"an accidental injury * * * arising out of and in the
course of employment requiring medical services or resulting
in disability or death[.]"
there is an "accident resulting in an injury or
death," the worker must give the employer notice
"immediately" after the accident. ORS 656.265(1)(a)
(discussing additional time limits). Within 60 days after the
employer has notice or knowledge of a claim, the insurer (or
self-insured employer) must give the employee a written notice
of acceptance or denial. ORS 656.262(6)(a). A written notice
of acceptance must "[s]pecify what conditions are
compensable." ORS 656.262(6)(b)(A); see also
ORS 656.267(1) (employer's [365 Or. 29] notice of
acceptance is sufficient if it "reasonably apprises the
claimant and the medical providers of the nature of the
general, the claimant has the burden to show that an
"injury" is compensable. ORS 656.266(1). If a
claimant believes that a written notice of acceptance
incorrectly omits a compensable condition, he or she may
object at any time and file a claim for the omitted
condition. ORS 656.262(6)(d).
issue in this case involves the medical services that the
insurer must provide. Under ORS 656.245(1)(a), an insurer
must provide services to the injured worker "[f]or every
compensable injury." Specifically, the statute provides
"For every compensable injury, the insurer *** shall
cause to be provided medical services for conditions caused
in material part by the injury for such period as the nature
of the injury or the process of the recovery requires, ***
including such medical services as may be required after a
determination of permanent disability."
facts, which are undisputed, are largely taken from the
opinion of the administrative law judge (ALJ).
2009, high winds blew down a tent pole at an event where
claimant was working as a food server. She was struck on the
head and slammed against a wall. Claimant suffered multiple
injuries and was hospitalized.
not disputed that claimant suffered an accidental injury that
arose out of and in the course of her employment.
See ORS 656.005(7)(a). Insurer initially accepted
the following conditions:
• left midshaft clavicle fracture
• first through third left rib fractures
• C7-T3 spinous process fractures
• full thickness scalp laceration
• left elbow contusion
• T5-T8 compression fractures
Or. 30] In 2011, insurer also accepted the following
• closed head injury
• chronic headache syndrome
• facial scarring
• right supraorbital nerve ...