Insurers providing Oregon employee compensation will need to conduct a "reasonable investigation" before denying a claim related to COVID-19 exposure at work, according to new guidance issued Wednesday by the Oregon Department of Consumer and Business Services, Workers "
The new rules, introduced on September 23, 2020 and formally adopted on Tuesday, will also require an insurance company to report to state regulators when it has five or more such claims filed, which will result in a state audit of claims. The rules come into force on February 1.
According to documents released on Wednesday, the investigation must include an investigation of "whether it was likely exposure to COVID-1
Before denying a claim, insurers will also need to investigate the source of the worker's exposure, the details of which must be include obtaining a medical or expert opinion that the worker has tested positive for COVID-19, or a medical service. the supplier's diagnosis of a 'presumptive case' of COVID-19, according to which the guidelines do not require a positive test.
The rules describe a presumption case as one where “the person has not tested positive for COVID-19. … The person has an acute illness with at least two of the following symptoms: shortness of breath, cough, fever, new loss of smell or taste or radiographic signs of viral pneumonia. … There is no more likely alternative diagnosis; and the person, within the 14 days prior to disease onset, had close contact with a confirmed case of COVID-19.
The rules also constitute potential "civil penalties" for insurance companies that do not comply with the guidelines.
More insurance and work compensation news about the coronavirus crisis here .