Workers’ Compensation: Basic Elements of a Compensable Claim in Washington and Oregon

INTRODUCTION

Employers, insurance companies and third party claims professionals should be aware of the basic elements required to establish a compensable workers’ compensation claim for industrial injury or occupational disease in Washington and/or Oregon.  A clear understanding of the prerequisites of a claim will aid in the determination whether and to what extent an injured worker is entitled to benefits under the state statutory systems.

Workers in Washington or Oregon who require medical treatment or suffer disability from a condition proximately caused by a workplace incident or conditions of  employment may allege entitlement to benefits under the Industrial Insurance Act of the State of Washington [i] or the Workers’ Compensation Law of the State of Oregon. [ii]  The following is a brief summary of the basic definitions of and requirements for compensable Industrial Injuries and Occupational Diseases.

 WASHINGTON

The Washington State Legislature has repeatedly declared the Industrial Insurance Act shall be liberally construed in favor of injured workers. [iiii] Though any ambiguities in the law must be reasonably interpreted in favor of injured workers, the Courts have held that persons who claim entitlement to benefits should be held to strict proof of their right to receive compensation and medical treatment under the Act. [iv]

Industrial Injury

An industrial injury is a specific workplace incident that causes a condition that requires medical treatment and/or produces disability. [v]  The incident must be a “sudden and tangible happening of a traumatic nature” that occurs during the course of employment. [vi]  An event is a “sudden and tangible” when it is something of notoriety, fixed as to time and susceptible of investigation. [vii]

In addition to a specific workplace incident, there must be a resulting physical or mental condition and/or disability before an industrial incident constitutes an “injury.” [viii]  Moreover, the causal relationship between the physical condition and the workplace incident must be established by expert medical evidence. [ix]

The analytical focus to determine compensability is directed to whether a qualifying event occurred.  Thus, a specific workplace incident need be only “a” cause rather than “the” cause or the “major” cause of a condition.  The fact that preexisting infirmities contributed to a medical condition does not defeat a claim for benefits. [x]  If the workplace incident is one among several causes of the condition is sufficient to determine causation for purposes of compensability.

Washington lacks a statutory requirement that the workplace incident and resultant condition “arise out of employment.”  Accordingly, conditions caused by activities unrelated to employment but that occur in the workplace are generally deemed compensable. [xi]

Occupational Disease

An occupational disease is a condition that arises naturally and proximately out of employment, [xii] which involves a 2-prong test for compensability.  The first prong is proximate cause: an event from which an injury results as a natural, direct, uninterrupted consequence and without which the injury would have not occurred.  The second prong, “naturally,” requires proof that the condition arose from “distinctive conditions of employment.” [xiii] Only when both prongs are established by persuasive, credible evidence should a claim for occupational disease be allowed.

OREGON

A claimant of Oregon workers’ compensation benefits has the burden to establish by a preponderance of the credible evidence that the claim is compensable and s/he is entitled to medical and/or disability benefits .[xiv]

Course of Employment

Proof of compensability of an industrial injury or occupational disease requires evidence that the injury occurred or the disease arose “in the course of employment,” which refers to the causal relationship between employment and a condition that requires medical services or results in disability. [xv]  “In the course of employment” is a requirement of “time, place and circumstances” that typically demands the injury or harmful exposure occur at work or during an employment activity. [xvi]

Arise Out of Employment 

Unlike Washington’s workers’ compensation system, an injured workers’ medical condition and/or disability must “arise out of employment” to establish compensability in Oregon.  Thus, the work activities or occupational environment must materially contribute to cause the medical condition or disability.

Compensability is a relatively vague concept.  The following factors should be considered when assessing whether a claim is compensable:

Whether the activity was for the benefit of the employer;

Whether the employer and worker contemplated activity at the time of hire;

Whether the activity was an ordinary risk of, and incidental to, the employment;

Whether the employee received compensation for the activity;

Whether the activity occurred on the premises of the employer;

Whether the employer directed or acquiesced in the activity; and

Whether the worker was on a personal mission.

Affirmative responses to the first six factors tend to favor a work-relationship; whereas, a determination that the worker was engaged in a personal activity contradicts such a relationship.  Though not exhaustive, the list of factors provides a practical structure for analyzing legal causation of a claim for workers compensation benefits in Oregon.

Objective Medical Evidence  

In addition to proof of “legal causation,” a claimant of Oregon workers’ compensation benefits must also establish “medical causation” supported by objective clinical and/or diagnostic medical findings.  An objective medical finding is an observable, reproducible sign that can be seen, heard, felt, or measured.[xvii] Accordingly, a worker claiming workers’ compensation benefits in Oregon must present credible proof of a medical condition, based upon objective findings that arose out of and in the course of employment.

 CONCLUSION

Employers, insurance companies and claims professionals should remain mindful of the basics for compensability of claims for industrial injury or occupational disease.    The workers’ compensation systems of Washington and Oregon require an injured worker to show certain fundamental elements necessary to establish compensability and entitlement to compensation and medical treatment. Adherence to such fundamental elements of proof advances the legitimacy of the workers’ compensation systems.

State systems of workers’ compensation admittedly exist to ensure workers receive compensation and medical treatment for work-related injuries and diseases.  Significant differences with regard to proof of causation prevail between Washington and Oregon.  Notwithstanding such jurisdictional differences, neither state system has formally adopted a general presumption of compensability and entitlement to benefits.  Accordingly, injured workers should be held to establish entitlement to compensation and medical treatment through credible, persuasive evidence of each fundamental element.  To require otherwise would undoubtedly threaten the financial stability and integrity of the systems of workers’ compensation.

If you have questions whether a specific claim or fact-based scenario constitutes a compensable industrial injury or occupational disease in Washington or Oregon, please contact one of our attorneys.

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[i] Title 51 of the Revised Code of Washington.

[ii] Oregon Revised Statute, Chapter 656.

[iii] RCW 51.12.010; RCW 51.04.062.

[iv] Olympia Brewing Company v. Department of Labor and Industries, 34 Wn. 2d 499, 505 (1949), citing Kirk v. Department of Labor & Industries, 192 Wash. 671, 74 P.2d 227; Guiles v. Department of Labor & Industries, 13 Wash. 2d 605, 126 P.2d 195; Clausen v. Department of Labor & Industries, 15 Wash. 2d 62, 129 P.2d 777; Hastings v. Department of Labor & Industries, 24 Wash. 2d 1, 163 P.2d 142; D’Amico v. Conguista, 24 Wash. 2d 674, 167 P.2d 157.

[v] RCW 51.08.100.

[vi] Id.

[vii] In re: Virginia Key, BIIA Dec. 94 4700 (1996) [dissent], citing In re Adeline Thompson, BIIA Dec., 90 4743 (1992); In re: Patsy Schmitz, 68,429 (1986) [dissent]; In re: Renford Gallier, 89 3109 (1990); In re: Donald Cawley, Dec’d., BIIA Dec. 41,864 (1974) [dissent].

[viii] Id.

[ix] In re: Kenneth Heimbecker, BIIA Dec. 41,998 (1975).

[x] In re: Soledad Pineda, BIIA Dec. 08 19297 (2010).

[xi] In re: Marion Lindblom, Dec’d., BIIA Dec. 45,619 (1976) [dissent]; In Re: Philip Carstens, Jr.,  BIIA Dec. 89 0723 (1990). But see, In re: Carol Rivkin, 85 1694 (1986).

[xii] RCW 51.08.140; Dennis v. Department of Labor and Industries, 109 Wn. 2d 467, 745 P. 2d 1295 (1987).

[xiii] .  In re: Forrest Pate, BIIA Dec. 58,399 (1982). See also, In re: Harry Lawrence, Dec’d., BIIA Dec. 54,394 (1980);  In re: Winfred Hanninen, BIIA Dec. 50,653 (1979); and In re: Delbert Monroe, BIIA Dec. 49,698 (1978) [dissent].

[xiv] ORS 656.266.

[xv].  ORS 656.0005(7)(a); Norpac Foods, Inc. v. Gilmore, 318 Or 363, 366 (1994); Rogers v. SAIF, 289 Or 633 (1980).

[xvi] Cope v. West American Insurance Company, 309 Or 232, 239 (1990).

[xvii] See, ORS 656.005(19).