A psychological evaluation should have been covered by the workers' compensation. Oregon's Supreme Court held on Friday.
In Compensation of Garcia-Solis against Farmers Insurance Co. in a banc decision, the state's highest court reversed a decision that an injured worker's psychological reference was not covered by workers, since she could not prove that it was related to the medical conditions accepted by the insurer.
In 2009, Elvia Garcia -Solis worked as a food server in a tent when big winds blew down a tent pole that hit her head and hit her into a wall. She suffered from several injuries and was hospitalized. Her employer's workforce, Woodland Hills, California-based Farmers Insurance Co., accepted her terms, including a clavicle fracture, spine and spinal fractures, scalp laceration, elbow contusion, concussion, head injury, chronic headache syndrome, facial scars, and nerve damage. In January 2010, Mrs Garcia-Solis reported to her doctor that she experienced psychological problems when it was windy. The physician recommended a psychological referral to address the post-traumatic syndrome-like symptoms, but Farmers refused to accept the reference on the grounds that there was no causal relationship to any of the conditions the insurer had accepted.
An administrative lawyer judge for farmers, and the Oregon Workers Compensation Board confirmed the decision and claims that "reimbursable damage" refers only to the conditions previously accepted by an insurer and not necessarily all the medical conditions caused by the occupational injuries. Although the doctor said that psychological references were caused "in the material part of the plaintiff's accident at work," the administrative judge and the board confirmed that, since she had not been diagnosed with PTSD, Mrs Garcia-Solis had not fulfilled her burden of proof. However, the judge noted that Mrs. Garcia-Solis was "effectively captured" because she needed the evaluation of psychology to determine if she had a mental health condition that was reliably related to her injury but could not get the insurers to pay for the evaluation because she did not have one. diagnosis "to predict a new disease requirement." The Oregon Court of Appeal confirmed the decision, but divergent judge James Egan concluded that the Oregon statutes "explicitly" equate reimbursable damages with the damage rather than the terms accepted by the insurer.
The Supreme Court of Oregon reversed and suspended the case. While the court argued that the insurer correctly claimed that, under the Oregon statutes, "reimbursable damages" entail only accepted terms, the court stated that the statutes mandated an insurer to provide "medical services for conditions caused in material parts" by the reimbursable damage and required the provision of medical services " directed against medical conditions that are caused to a large extent "by the recoverable damage.
Although the farmers argued that the legislature used "reimbursable damage" to denote "accepted state", the court claimed that the insurers' argument is "strongly based on an assumption of terminological consistency in the Compensation Act …" The Court noted that "injury" is the work accident which caused the medical condition and resulted in the need for medical care and is "not limited to conditions that the insurer has accepted at the time of medical services seeking."
The court reversed and remanded the case to the employment compensation card for further negotiations.
Farmers Insurance did not immediately respond to a request for comment.