OAR 471-070-2400: Equivalent Plans: Disputes between an Equivalent Plan Employer and Employee, Request for Hearing

(1) As required by ORS 657B.420, the department will provide a dispute resolution process to assist in resolving disputes between employers or equivalent plan administrators, as applicable, and employees regarding coverage and benefits provided under an employer’s approved equivalent plan if the appeal with the employer or administrator is not otherwise resolved. (2) Prior to the department providing a dispute resolution process, the employee and employer or administrator must follow the equivalent plan appeal process described in OAR 471-070-2220(13). (3) In the event that the employee and employer or administrator are unable to resolve an appeal on a coverage or benefit decision through the equivalent plan’s appeal process, the employee may request dispute resolution assistance through the department. The dispute resolution request must: (a) Be in writing, by phone, online, or in another format approved by the department. (b) Include a copy of the employer or administrator’s appealable decision and any documents related to the dispute, including documents supporting or referencing the employer’s or administrator’s decision. (c) Be received within 60 calendar days of the issuance of the appealable decision, or as soon as practicable if there is good cause as described under section (8) of this rule, for the delay beyond 60 calendar days. (4) The department shall review the dispute resolution request and issue a determination based on the equivalent plan benefit requirements within 20 calendar days of the receipt of the dispute resolution request. (5) If an employer or employee disagrees with the determination issued by the department, the employer or employee may file an appeal, as outlined in ORS 657B.410 and related administrative rules, requesting a hearing before the Office of Administrative Hearings. (6) If the employer or administrator does not comply with the department’s determination or does not comply with a final order issued by an Administrative Law Judge or any reviewing authority, the employee may submit a wage claim with the Oregon Bureau of Labor and Industries under ORS chapter 652. (7) The payment of any benefits not placed in issue by the dispute resolution request shall continue during the dispute and appeal processes. (8) Good cause for late dispute resolution request includes, but is not limited to, the following: (a) Difficulty obtaining verification; (b) Factors or circumstances beyond the employee’s, employer’s, administrator’s, or department’s reasonable control that prevented them from providing information; (c) A serious health condition that results in an unanticipated and prolonged period of incapacity and that prevents the employee or employer from timely providing information; or (d) A demonstrable inability to reasonably access a means to respond in a timely manner, such as an inability to file a leave report due to a natural disaster or a significant and prolonged outage.