441 P.3d 655
Or. Ct. App.2019Background
- Claimant filed an occupational disease claim for bilateral carpal tunnel syndrome; insurer denied the claim after a carrier-ordered exam (Dr. Nolan) found it not work-related.
- Claimant produced opinions from his GP (Dr. Lowe) and a hand surgeon (Dr. Woolley); a neurologist (Dr. Taylor) initially concurred but later withdrew support.
- ALJ found claimant prevailed on compensability, crediting Lowe and Woolley over Nolan, and ordered insurer to pay claimant's reasonable costs under ORS 656.386(2) without specifying an amount.
- Claimant submitted a $1,550 cost bill (Lowe $150; Taylor $200; Woolley $1,200); insurer paid $1,500 and refused the extra $50, prompting a hearing on whether "extraordinary circumstances" justified exceeding the $1,500 statutory cap.
- ALJ denied the excess, finding the case ordinary and specialist opinions common; the board reversed, finding extraordinary circumstances because Woolley’s specialist report was necessary and decisive to prevail and ordered the extra $50.
- Insurer sought judicial review; the Court of Appeals reversed and remanded, holding the board failed to show why the facts were extraordinary rather than merely reasonable.
Issues
| Issue | Claimant's Argument | Insurer's Argument | Held |
|---|---|---|---|
| Whether claimant had to identify "extraordinary circumstances" in the cost bill before the insurer could deny payment beyond $1,500 | Cost bill need not label circumstances; claimant can prove extraordinariness at hearing | Cost bill must demonstrate extraordinary circumstances so insurer can evaluate and process claims | Court declined to decide (procedural argument not preserved before board); remanded for merits review by board when properly raised |
| Meaning of "extraordinary circumstances" in ORS 656.386(2)(d) | Means circumstances not usual, regular, common, or customary in the forum (beyond mere reasonableness) | Agrees "extraordinary" must be distinct from "reasonable"; contends board conflated the two | Court: "extraordinary" is an inexact statutory term meaning not usual/common; cannot be satisfied merely because costs were reasonable and exceeded $1,500 |
| Whether the board’s finding of extraordinary circumstances was supported by substantial reason/evidence | Board: Woolley’s specialist opinion was necessary and decisive to prevail; claimant lacked insurance and needed surgery, so extra costs were warranted | Insurer: Specialist opinions are common; claimant’s circumstances were not extraordinary | Court: Board’s reasoning lacked substantial reason; it showed only that claimant reasonably incurred >$1,500, which cannot alone overcome the legislatively negotiated cap; remand for reconsideration |
| Proper role of "reasonable" vs "extraordinary" under ORS 656.386(2) | Reasonableness is prerequisite; extraordinariness is a higher, separate showing | Insurer: Board conflated the two; extraordinariness requires more than necessity or reasonableness | Court: Statute already requires costs be reasonable; "extraordinary" must mean something beyond reasonableness to preserve the cap’s effect |
Key Cases Cited
- Multnomah County Sheriff's Office v. Edwards, 361 Or. 761 (standards for adopting board findings on review)
- SAIF v. Traner, 273 Or. App. 310 (upholding statutory caps absent extraordinary circumstances)
- Springfield Education Assn. v. School Dist., 290 Or. 217 (classification of statutory terms and agency role)
- PGE v. Bureau of Labor and Industries, 317 Or. 606 (plain, natural, and ordinary meaning rule in statutory construction)
- Karjalainen v. Curtis Johnston & Pennywise, Inc., 208 Or. App. 674 (agency role in statute construction)