Current through Register Vol. 63, No. 9, September 1, 2024
(1) Following the
timely filing of a completed application, PERS may, at its discretion, request
an independent medical exam, physical capacity evaluation, or vocational
evaluation. If PERS requests one or more of these exams or evaluations, PERS
will pay the reasonable associated expenses.
(a) PERS is not required or obligated to
request any examination or evaluation. The burden of proof for eligibility for
a disability benefit is upon the applicant, whether or not PERS requests any
examination or evaluation. Situations in which PERS may exercise its discretion
to request an examination or evaluation include, but are not limited to:
(A) When PERS receives conflicting opinions
from two physicians of the same specialty;
(B) When an applicant cannot afford to see a
physician of the appropriate specialty under OAR 459-076-0010(4) because:
(i) The applicant does not have health
insurance;
(ii) The examination or
evaluation will not be covered by the applicant's health insurance;
or
(iii) No such physician
practices medicine within 50 miles of the applicant's home and the cost of
traveling to such a physician would create a financial hardship for the
applicant.
(C) When an
applicant has been examined by a physician of the appropriate specialty under
OAR 459-076-0010(4), but the physician declines to provide an opinion to PERS
as to the applicant's claimed disability.
(b) For independent medical exams and
physical capacity evaluations, PERS will inform the applicant in writing and
postmarked not less than ten days prior to a scheduled examination or
evaluation, of the identity of the person or entity selected to examine or
evaluate the applicant, together with location, date and time.
(c) For vocational evaluations, the
vocational consultant or locator service shall inform the applicant of the
location, date and time of the scheduled examination.
(d) If the applicant fails to meet the
scheduled appointment or fails to reschedule the examination within five days
of notification, PERS will not reschedule an examination at PERS' expense
unless the applicant can demonstrate good cause for having failed to meet the
scheduled appointment or reschedule the appointment as required.
(e) Good cause includes, but is not limited
to:
(A) Physical or mental incapacitation
preventing the member from meeting or rescheduling the examination;
(B) Failure of PERS or the vocational
consultant or locator service to send the member notice as described above;
or
(C) A death in the member's
immediate family.
(f)
Good cause does not include:
(A) A member's
refusal to attend the scheduled appointment;
(B) A member's failure to meet the
appointment with no reason provided; or
(C) A member's failure to make appropriate
transportation arrangements.
(2) When PERS requires an applicant to travel
to be examined by a physician, vocational consultant, or other professional,
PERS will reimburse the applicant's reasonable transportation costs based on
the least costly alternative and on availability. Travel by private vehicle
will be compensated at the rate applicable to travel by unrepresented state
employees on state business. Transportation by taxi, bus, rail, or other public
carrier will be paid only upon presentation of receipts from the providers.
Lodging and subsistence will be allowed only when a stop-over is necessary and
will be paid at the rate applicable to unrepresented state employees traveling
on state business. Reimbursements will be reduced by the amount of any penalty
assessed PERS because of a member's failure to meet a scheduled
appointment.
(3) In the event a
member fails to meet a scheduled examination in accordance with section (1) of
this rule, and PERS is assessed a penalty by the service provider for the
failure to meet the scheduled appointment, the disability applicant will bear
the cost of the penalty as follows:
(a) If the
disability application is not approved, by making direct payment to the service
provider who assessed the penalty; or
(b) If the disability application is
approved:
(A) By making direct payment to the
service provider who assessed the penalty; or
(B) By having the amount of the penalty
deducted from the monthly disability benefit, as provided for under ORS
238.715,
payable to the member until the invoice is satisfied.
(4) The Director, or the
Director's designee, is hereby authorized to approve or deny a disability
benefit application. Upon receipt and review of all necessary documentation,
staff will present applicant's claim to the Director, or the Director's
designee, with a recommendation to approve or to deny a disability benefit. The
Director, or the Director's designee, may accept or reject the staff's
recommendation, or refer the application back to staff for further
documentation and review.
(a) If the
disability claim is approved, the staff will notify the applicant and the
applicant's employer of such approval.
(b) If the disability claim is denied, the
staff will issue an Intent to Deny letter by regular and certified mail, return
receipt requested. The Intent to Deny letter will advise the applicant that
additional information to substantiate the claim, or a request for an extension
of 30 days to present additional information, may be submitted to the staff in
writing within 30 days of the date of the Intent to Deny letter.
(5) Following the issuance of an
Intent to Deny letter, staff will review any additional information submitted
within 30 days from the issuance of the Intent to Deny letter.
(a) If the additional information results in
a recommendation to approve the application, staff will resubmit the
application to the Director, or the Director's designee, with the
recommendation.
(b) If the
additional information does not result in a recommendation to approve the
application, PERS will issue a final denial letter by regular and certified
mail, return receipt requested.
(c)
If no additional information is received, PERS will issue a final denial letter
by regular and certified mail, return receipt requested.
(6) The final denial letter will provide the
applicant with notification of the right to request a contested case hearing as
provided for in OAR 459-015-0030 and 459-001-0035.
(7) A contested case hearing on the denial of
disability benefits shall be conducted according to OAR 459-015-0030,
459-015-0035, and 459-015-0040.
(8)
PERS will notify the most recent employer of the approval or the denial of an
application for a disability benefit, a request for review of the Director's
determination, and the Director's final action. Such notification will not
contain any confidential information as defined in OAR
459-076-0001(3).
Statutory/Other Authority: ORS
238A.450
Statutes/Other Implemented: ORS
238A.235
