It was a windy day in Portland, Oregon, when Elvia Garcia-Solis was seriously injured in a work accident. She was struck on the head by a falling tent pole while working at an outdoor event.
She was hospitalized for nearly a month with a closed head injury, open wounds, and nerve injuries. Her doctor also referred her to psychiatric care for “PTSD-like” symptoms.
Because Ms. Garcia-Solis was injured on the job, she had to file a workers’ compensation claim. Farmers Insurance (the employer’s insurance company) accepted the claim, acknowledging that her injuries and medical conditions were a direct result of a work accident.
But, they declined to cover the cost of the recommended psychiatric referral for PTSD.
The Workers’ Compensation Board agreed: they decided that insurance did not have to pay for the referral for the recommended PTSD screening.
Attorney Marcia Alvey appealed the Board’s decision for Ms. Garcia-Solis. She argued that the cost of the referral for PTSD screening should also be covered by workers’ compensation.
The insurance company lawyers said the claimant didn’t prove that the psychological referral was related to any of the medical conditions that they had accepted.
Appealing a Workers’ Compensation Board Decision
The Board’s decision was appealed by Attorney Julene Quinn. The Court of Appeals reviewed Ms. Garcia-Solis’ claim and the Board’s decision.
Ms. Quinn argued that the PTSD consultation should be covered under workers’ compensation insurance because the consultation was related to the work injury.
Citing an Oregon case, Brown v. SAIF (361 Or 241, 283 2017), the Court of Appeals said a “compensable injury” only included the medical conditions that had already been accepted – which did not include a referral for a PTSD screening.
The Court of Appeals sided with the insurance company and upheld the decision of the Workers’ Compensation Board.
The Court said Ms. Garcia-Solis had failed to prove that the referral for PTSD was related to any of the medical conditions accepted in the workers’ compensation claim.
In short, the insurance company didn’t have to pay for the doctor-recommended referral for a PTSD screening.
The Oregon Supreme Court decision
In 2019, the Oregon Supreme Court reversed both the Court of Appeals and the Workers’ Compensation Board decisions.
The Opinion states:
… ‘injury’ means work accident is context-specific to exactly two uses in the first and second sentences of ORS 656.245(1)(a). It does not apply to the second use in the first sentence of ORS 656.245(1)(a). We do not decide or suggest that it applies to any other statute in the workers’ compensation system.”
In other words, the law says that the insurance company is responsible for covering medical care related to the work accident. That means Ms. Garcia-Solis – and others who are hurt on the job – should be able to get the recommended psychiatric care for PTSD.
The Supreme Court decision in Garcia-Soils v. Farmers Insurance Company was a major win for injured workers in Oregon.
Read the full Oregon Supreme Court opinion: Garcia-Solis v. Farmers Insurance Company, 365 Or 26 (May 31, 2019).