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In re Compensation of Garcia-Solis

Supreme Court of Oregon, En Banc

May 31, 2019

In the Matter of the Compensation of Elvia Garcia-Solis, Claimant.
v.
FARMERS INSURANCE COMPANY; and Yeaun Corporation, dba Green Papaya and Sunset Deli, Respondents on Review. Elvia GARCIA-SOLIS, Petitioner on Review,

          Argued and submitted January 17, 2019

          On review from the Court of Appeals. (WCB 12-03622), (CA A156734) [*]

          Julene M. Quinn, Portland, argued the cause and fled the briefs for petitioner on review.

          James W. Moller, Wilsonville, argued the cause for respondents on review. Vera Langer, Lyons Lederer, LLP, Salem, fled the brief.

          James S. Coon, Thomas, Coon, Newton & Frost, Portland, fled the brief for amicus curiae Oregon Trial Lawyers Association.

          Julie Masters, Appellate Counsel, SAIF Corporation, Salem, fled the brief for amici curiae SAIF Corporation and Timber Products Company.

         [365 Or. 27] Case Summary:

         After a 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.

         Held:

         The 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.

         The 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.

         [365 Or. 28] GARRETT, J.

         Claimant 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 reverse.

         I. FACTS

         A. Legal Background

         This case involves the state workers' compensation system. A brief overview will give context for the discussion that follows.

         Oregon's 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[.]"

         If 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[1]) 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 compensable conditions").

         In 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).

         The 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 in part:

"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."

         B. Facts

         The facts, which are undisputed, are largely taken from the opinion of the administrative law judge (ALJ).

         In 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.

         It is 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

         [365 Or. 30] In 2011, insurer also accepted the following conditions:

• concussion
• closed head injury
• chronic headache syndrome
• facial scarring
• right supraorbital nerve ...

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