Arms v. SAIF

To properly analyze a claim, the court must first determine whether a claimant has a compensable injury and whether he sought medical services for a condition that was “caused in material part by” that injury. If it was, the court is to consider whether any of the limitations identified in ORS 656.245(1)(a) apply — namely, the limitations set out in ORS 656.225 and the limitations for consequential or combined conditions.

Tommy Arms (Arms) suffered a compensable spinal injury while working for employer in 2003; he underwent surgery. Later, Arms requested his employer’s workers’ compensation insurer authorize further surgery, claiming the 2003 surgery had worsened a prior injury. The ALJ concluded that ORS 656.225 did not apply under the circumstances and that the proposed surgery was not compensable under a consequential-condition analysis because the preexisting disease was the major contributing cause of the injury. The Workers’ Compensation Board (WCB) found the surgery was directed at a combined condition, as opposed to a preexisting condition, and concluded that ORS 656.225 did not apply and the surgery was not compensable. On appeal, Arms argued that ORS 656.225 creates an entitlement to compensation for medical services for preexisting conditions that are worsened by work conditions or events. SAIF responded that ORS 656.245(1)(a) is the sole statutory source of entitlement to compensation for medical services, and that the statute merely places limits on the compensability of preexisting conditions. The Court found the WCB order was based on factual findings that the surgery was directed to a combined condition, which was not supported by substantial evidence or reason. Reversed and remanded.