Alvarado-Depineda v. SAIF

When ambiguities are present in medical information regarding a claimant, it is the insurer’s duty to pursue clarification. Walker v. Providence Health Systems Oregon, 267 Or. App. 87, 407-408 P.3d 91 (2014) (Walker I), modified on recons, 269 Or. App. 404, 344 P.3d 1115 (2015) (Walker II).

Claimant appealed the Workers’ Compensation Board determination that held post-closure reports were only available subsequent to SAIF having closed the claim, therefore SAIF was unable to reasonably know the facts which modified claimant’s award. Claimant assigned error to the Board’s conclusion and argued SAIF should have clarified the ambiguous reports which reasonably would have led to SAIF finding claimant’s privilege to disability. SAIF argued that evidence supported the board’s interpretation because SAIF could not have known about post-closure reports. When ambiguities are present in medical information regarding a claimant, it is the insurer’s duty to pursue clarification. Walker v. Providence Health Systems Oregon, 267 Or. App. 87, 407-408 P.3d 91 (2014) (Walker I), modified on recons, 269 Or. App. 404, 344 P.3d 1115 (2015) (Walker II). The Court held that because there were ambiguities present before closing, and SAIF reasonably should have seen the ambiguities, SAIF should have reasonably sought to clarify such ambiguities in the record. Reversed and remanded.