A worker suffered an injury on the job and submitted a workers’ comp claim which was accepted, along with certain medical conditions associated with the accident. Because she exhibited psychological symptoms her doctor recommended a psychological referral to diagnose her for possible post-traumatic stress disorder (PTSD). Her insurer denied responsibility for the cost of the psychological referral because they claimed she had failed to prove it was related to any of the accepted medical conditions.

The Oregon Supreme Court reversed earlier rulings on this, determining that the psychological evaluation should have been covered under workers’ comp.

Elvia Garcia-Solis was injured in 2009 when the wind blew down a tent pole at an event where she was working, and the tent pole struck her on the head and then she was slammed against a wall. Farmers accepted her claim for multiple fractures, lacerations, contusions and head injuries including a concussion and chronic headache syndrome. She reported to her doctor that she felt psychological problems when it was windy, she became frightened and tearful. Her son reported that she still was reacting fearfully in 2011 and her physician recommended a psychology referral to address PTSD like symptoms.

Her insurer refused to authorize this referral, saying it was not causally related to any of the conditions accepted by the insurer. An Administrative Law Judge ruled that since she was not officially diagnosed with PTSD and her doctor did not state that the referral was caused by any accepted conditions, she could not meet the burden of proof. The Workers’ Compensation Board affirmed this ruling, reiterating that the psychology referral was connected only to the work injury, and not the accepted conditions.

She appealed, arguing that diagnostic medical services did not need to relate to an accepted condition only the work injury. The Supreme Court reversed the decision and remanded the case. The insurer was correct in determining that “compensable injury” only means accepted conditions, but the statues mandate that an insurer also provide services for conditions “caused in material part” by the compensable injury and requires medical services for those conditions. The court ruled the injury is the accident that caused medical conditions warranting medical services and is not limited to conditions that the insurer accepted at the time initial medical services were sought.

Read the case here and read more here.