Teitelman v. SAIF

When an insurer submits an Independent Medical Examination (IME) as evidence to support denial of a worker’s claim, the denial is “based” on an IME such that the worker is eligible for a Worker Requested Medical Examination (WRME) under the terms of ORS 656.325(1)(e).

Claimant, a personal representative of worker Cardoza's estate, sought review of the Workers’ Compensation Board order denying Cardoza’s eligibility for a Worker Requested Medical Examination (WRME) after denial of Cardoza’s claim. Respondent SAIF denied Cardoza’s request for a WRME before requiring Cardoza to comply with an Independent Medical Examination (IME). Claimant argued there was no distinction in ORS 656.325(1)(e) between an IME completed before or after a denial of claim, therefore, the denial was “based” on the IME even if it was completed after the denial. SAIF argued Cardoza's claim was denied before an IME was completed, and under the terms of ORS 656.325(1)(e) he was ineligible for a WRME because the denial was not based on IME findings. WRME eligibility is based on three statutory requirements: (1) a timely request for a hearing; (2) the denial of the worker’s claim be based on an IME; and (3) the attending physician’s statement of nonconcurrence with the IME. ORS 656.325(1)(e). The Court concluded when SAIF used Cardoza’s IME report as proof to support its denial of his claim, the denial was “based” on the IME such that Cardoza was thus eligible for a WRME under ORS 656.325(1)(e). Reversed and remanded.