Court Opinion

ID: 9540629
Source: CourtListenerOpinion
Date Created: 2023-08-07 16:18:27.910724+00
Date Added: 2024-06-11T15:00:05.405213
License: Public Domain

De MUNIZ, J.,
concurring.
If I were writing on a clean slate, I would conclude that the referee and the Board were correct in awarding attorney fees under ORS 656.386(1) and a penalty under ORS 656.262(10). However, the Supreme Court has indicated that an insurer’s failure to timely respond to a claim for compensation may not be construed as a de facto denial. If that is the case, then the lead opinion’s conclusion that claimant is not entitled to attorney fees is correct, because an initial denial is a prerequisite to the recovery of attorney fees under ORS 656.386(1).
In my view, an insurer’s failure to timely accept or deny a claim ought to be considered a denial, and that should entitle the claimant to attorney fees under ORS 656.386(1), which provides, in part:
“In all cases involving accidental injuries where a claimant finally prevails in an appeal to the Court of Appeals or petition for review to the Supreme Court from an order or decision denying the claim for compensation, the court shall allow a reasonable attorney fee to the claimant’s attorney. In . such rejected cases where the claimant prevails finally in a hearing before the referee or in a review by the board itself, then the referee or board shall allow a reasonable attorney fee. If an attorney is instrumental in obtaining compensation for a claimant and a hearing by the referee is not held, a reasonable attorney fee shall be allowed.”
The first sentence of ORS 656.386(1) governs the award of attorney fees when either of Oregon’s appellate courts review a claim for compensation. That sentence clearly makes “an order or decision denying the claim” a prerequisite to an award of attorney fees by the court.
The second sentence governs the award of attorney fees in cases decided by a referee or by the Board. - That sentence begins with the words, “[i]n such rejected cases.” That phrase establishes that a claimant who prevails in a *188hearing is entitled to attorney fees only if the claim has initially been rejected (i.e., denied) by the insurer.1
Before 1990, ORS 656.386(1) did not contain any provision for the award of attorney fees in the absence of a hearing. Or Laws 1990, ch 2, § 29; Jones v. OSCI, 107 Or App 78, 810 P2d 1318, mod 108 Or App 230, 814 P2d 558 (1991). Now, an attorney fee is required if the claimant’s “attorney is instrumental in obtaining compensation,” even though no hearing is held. The purpose of the 1990 amendment is to assuage the effects of resistance to a valid claim that is resolved in favor of a claimant before a hearing is held. The third sentence in ORS 656.386(1) does not expressly state whether an initial denial is a prerequisite to the recovery of attorney fees when no hearing is held, but that requirement is implicit when the structure of ORS 656.386(1) is viewed as a whole.
The third sentence is important in cases like this one, where a recalcitrant insurer realizes that it has no chance of prevailing at a hearing, and it therefore capitulates. Here, SAIF failed to formally accept or deny the claim until claimant requested a hearing. Apparently, claimant’s request for a hearing was necessary to get SAIF’s attention, and SAIF paid the last of claimant’s bills just before the hearing.
Even though SAIF conceded all issues of compensability, a hearing was still necessary for the purpose of determining attorney fees and penalties. The referee found that it was “doubtful that the bills would have been paid if it had not been for claimant’s attorney’s efforts.” There is substantial evidence to support that finding, and the Board adopted it.
The majority and I part ways when it asserts that “the compensability of claimant’s injuries was not at issue in the hearing.” 124 Or App at 186. The initial inquiry is whether SAIF made a “decision denying the claim for compensation.” ORS 656.386(1). “ ‘Compensation’ includes all *189benefits, including medical services, provided for a compensable injury.” ORS 656.005(8). “ ‘Claim’ means a written request for compensation.” ORS 656.005(6).
Everyone agrees that claimant suffered a compensable injury to her back while working for Rose’s Restaurant. On March 14, 1991, claimant’s attorney wrote to SAIF and sent it copies of unpaid medical bills. It cannot be gainsaid that her attorney’s letter, accompanied by those bills, was a written request for compensation. SAIF was required to either accept or deny the claim, in writing, by June 12,. 1991. ORS 656.262(6). It failed to do so.
SAIF contends:
“A de facto denial occurs only when the reason the benefits are not being paid is because the insurer is contesting their compensability and informally rejecting payment.”
I wish I could disagree. An insurer should not be permitted to sit idly by and allow the statutorily mandated deadline to pass without giving claimant a definitive response or paying her claim in full.2 In my opinion, SAIF’s failure to do either was, in effect, a decision denying the March 14 claim for compensation.
However, the Supreme Court has indicated that “[a]n insurer’s failure to respond to a claim [as required by ORS 656.262(6)] is neither acceptance [n]or denial.” Johnson v. Spectra Physics, 303 Or 49, 58, 733 P2d 1367 (1987). The issue in that case was whether an insurer’s inaction could be construed as acceptance of a claim. The conclusion that inaction does not constitute denial is therefore dictum. I question whether the Supreme Court really intended claimants to languish while insurers failed to obey the law that requires them to accept or deny claims in a timely fashion.

 The term “shall” in ORS 656.386(1) indicates that the referee’s duty to allow attorney fees is nondiscretionary. Dika v. Dept. of Ins. and Finance, 312 Or 106, 109, 817 P2d 287 (1991); Benzinger v. Oregon Dept. of Ins. and Finance, 107 Or App 449, 451, 812 P2d 36 (1991).

 SAIF did pay some of the bills in April and others in May. However, it did not pay the remaining bills until September.