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Insurers providing workers compensation in Oregon will be required to conduct a “reasonable investigation” before denying a claim related to COVID-19 exposure on the job, according to new guidance issued Wednesday by the Oregon Department of Consumer and Business Services, Workers’ Compensation Division.
The new rules, which were introduced on Sept. 23, 2020, and formally adopted Tuesday, will also require an insurer 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 go into effect Feb. 1.
According to documents released Wednesday, the investigation must include an examination of “whether there was likely exposure to COVID-19 or SARS-CoV-2 that arose out of and in the course of the worker’s employment.”
Before denying a claim insurers will also need to investigate the source of the worker’s exposure, details of which must include obtaining a medical or expert opinion that the worker tested positive for COVID-19, or a medical service provider’s diagnosis of a “presumptive case” of COVID-19, which the guidelines state do not require a positive test.
The rules describe a presumption case as one in which 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 evidence of viral pneumonia. … There is no more likely alternative diagnosis; and the person, within the 14 days before illness onset, had close contact with a confirmed case of COVID-19.”
The rules also pose potential “civil penalties” for insurers who do not comply with the guidelines.
More insurance and workers compensation news on the coronavirus crisis here.
Insurers would have to conduct a “reasonable investigation” before denying a workers compensation claim related to exposure to COVID-19 on the job and report to state regulators when it has five or more such claims filed, according to a proposal made public Wednesday by the Oregon Department of Consumer and Business Services, Workers’ Compensation Division.