269 P.3d 62
Or. Ct. App.2011Background
- Claimant is Sherrian M. Stephens, injured June 13, 2007 at work; SAIF initially accepted lumbar contusion/strain and later closed the claim with no permanent disability.
- Claimant continued tailbone pain; Dr. Kelly diagnosed coccydynia, while SAIF questioned whether coccydynia is a condition or a symptom.
- Claimant sought acceptance of a new/omitted medical condition (coccydynia) in Feb 2008; SAIF amended its notice in Mar 2008 to include coccyx bone bruise rather than coccydynia.
- Board concluded SAIF’s March 28, 2008 amendment did not satisfy ORS 656.262(7)(a) or ORS 656.267(1) and that SAIF’s failure to respond constituted a de facto denial, awarding fees and penalties.
- On judicial review, the court held SAIF was not required to accept coccydynia, the de facto denial finding was reversed, and penalties/fees were not upheld; the matter was reversed to SAIF.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether SAIF’s amendment satisfied processing requirements | Stephens argues SAIF failed to accept/deny within 60 days. | SAIF contends coccyx bruise satisfies the underlying condition. | SAIF not required to accept coccydynia; amendment insufficient for denial. |
| Whether coccydynia is a condition or a symptom | Stephens asserts coccydynia is a compensable condition. | SAIF contends it is a symptom of the underlying bruise. | Substantial evidence does not support treating coccydynia as a separate condition. |
| Whether there was a de facto denial and penalties/fees were proper | Stephens seeks penalties/attorney fees for de facto denial. | SAIF argues processing delay was not unreasonable given unsettled law. | Finding of de facto denial reversed; penalties/fees not upheld. |
| Effect of Crawford and Young on the case | Stephens relies on Crawford to require acceptance/denial within 60 days. | SAIF relies on medical categorization to avoid formal denial. | Board’s reasoning rejected; coccydynia not accepted as a condition. |
Key Cases Cited
- Crawford v. SAIF, 241 Or.App. 470 (2011) (processing of omitted condition claim requires written acceptance/denial within 60 days)
- Young v. Hermiston Good Samaritan, 223 Or.App. 99 (2008) (definition of 'condition' as physical status; symptom as radiculopathy analogy)
- Deatherage v. Pernsteiner, 239 Or.App. 161 (2010) (substantial evidence standard for determining whether a condition is a symptom or disease)