OhioBWC - Basics: (Policy library) - File

Compensable Injuries P&P with TOC

Policy and Procedure Name:	Compensable Injuries
Policy #:	CP-03-10
Code/Rule Reference:	R.C. 4123.01; R.C. 4123.54
Effective Date:	9/23/22
Approved:	Patricia Harris, Chief Operating Officer
Origin:	Operational Policy and Support
Supersedes:	Policy # CP-03-10, effective 11/05/20
History:	Previous versions of this policy are available upon request

Table of Contents

I. POLICY PURPOSE

Preponderance of the Evidence

Proximate Cause

Repetitive Motion Injury

Substantial Aggravation

IV. POLICY

A. Elements of a Compensable Injury

B. Occupational Diseases

C. Special Circumstances

V. PROCEDURE

A. General Claim Note and Documentation Requirements

B. Compensability of an Injury

I. POLICY PURPOSE

The purpose of this policy is to ensure BWC staff recognize and understand the required elements of a compensable injury. (Requirements related to determining the compensability of an occupational disease (OD) are contained in the Occupational Disease Claims policy).

II. APPLICABILITY

This policy applies to BWC claims services staff.

III. DEFINITIONS

Acceleration: A medical finding that the progress of a pre-existing condition has been substantially hastened by the injury or occupational disease.

Aggravation: A medical finding that a condition that pre-existed an injury or occupational disease is worsened by the injury or occupational disease and has an adverse impact, no matter how slight.

Cumulative Injury: An injury developing gradually over time as a result of the performance of an injured worker’s job-related duties.

Flow-Through Injury: A subsequent loss or impairment of bodily functions developing in a part or parts of the body not originally alleged, but due to the original injury.

Injury: As defined by R.C. 4123.01(C) - Harm or damage suffered by an injured worker (IW), caused by external accidental means or accidental in character and result, received in the course of, and arising out of the IW’s employment.

Occupational Disease: As defined by R.C. 4123.01(F) - A disease contracted in the course of employment, which by its causes and the characteristics of its manifestation or the condition of the employment results in a hazard which distinguishes the employment in character from employment generally, and the employment creates a risk of contracting the disease in greater degree and in a different manner from the public in general.

Physical Injury: Any traumatic damage or attack on the physical structure of the body, which results in a wound, tear or abnormal condition.

Precipitation: A medical finding that a dormant pre-existing condition manifested itself due to the work-related injury or occupational disease.

Preponderance of the Evidence: A standard of proof which is met when a party’s evidence on a fact indicates that it is “more likely than not” that the fact is as the party alleges it to be.

Proximate Cause: That which, in a natural and continuous sequence, unbroken by any intervening cause, produces injury, and without which the injury would not have occurred.

Repetitive Motion Injury: A family of muscular conditions resulting from repeated movements performed in the course of normal work activities, usually the result of unnatural or awkward motions such as twisting the arm or wrist, overexertion, incorrect posture or muscle fatigue.

Substantial Aggravation: A medical finding that a condition that pre-existed an injury or occupational disease is worsened considerably in amount, value or extent solely because of the injury or occupational disease.

IV. POLICY

A. Elements of a Compensable Injury

1. It is the policy of BWC to determine an injury is compensable when, by a preponderance of the evidence, it is shown that:

a. The injured worker (IW):

i. Suffered a physical injury; or

ii. Has a psychiatric injury that arose from a compensable physical injury or forced sexual conduct (See the Psychiatric Conditions policy for further information); and

b. The injury was accidental in nature; and

c. The injury was sustained in the course of and arising out of employment.

2. The physical or mental injury must be of the following type:

a. An injury directly caused by the work related accident;

b. An aggravation or substantial aggravation of a pre-existing condition (refer to the Aggravation and Substantial Aggravation of a Pre-Existing Condition policy for more information);

c. A flow-through injury;

d. A pre-existing condition whose progress has been accelerated/hastened by the work-related injury;

i. The acceleration of the pre-existing condition must be a substantial period of time (e.g., causing death two years sooner than would have been expected without the acceleration); and

ii. The acceleration is a direct and proximate result of the work-related injury; or

e. The precipitation of a pre-existing condition (e.g., an IW has latent tuberculosis which becomes active due to a renewed exposure in the workplace).

3. The injury must be accidental in nature:

a. BWC will determine an injury is accidental in nature when caused by external accidental means or accidental in character and result (i.e., the accidental injury is unintended and unexpected).

b. An accidental injury may occur:

i. Suddenly (e.g., a roofer falls through a damaged roof and sustains contusions); or

ii. Gradually (derived from Village v. General Motors Corp., (1984) 15 Ohio St 3d 129). Gradual accidental injuries include:

a) Cumulative trauma: The injury occurs over a short period of time with no particular incident that can be pointed to as causing the injury (e.g., a worker in an automotive manufacturing plant incurs a back injury after several days of lifting and installing car batteries); and

b) Repetitive motion injuries (often used interchangeably with the term cumulative trauma): An injury caused by repeated motions performed in the course of normal work activities.

c. A condition that develops gradually and is a cumulative effect of repetitive motion or repeated exposures may be a compensable injury or may be a compensable OD pursuant to the Occupational Disease Claims policy, depending upon the facts of the claim.

4. The injury must be sustained in the course of and arising out of employment:

a. BWC will find:

i. An IW is in the course of employment when performing duties on behalf of the employer ( i.e., the IW was engaged in activity consistent with the contract for hire and logically related to the employer’s business at the time of injury or contraction of an OD).

ii. An injury arises out of employment when, based on the totality of the evidence, it is shown the injury was caused by the employment.

b. In determining whether an injury was sustained in the course of and arising out of employment, BWC will consider, but not be limited to, the following factors:

i. The location of the accident: Did the injury occur at a site under the employer’s control (i.e., “zone of employment”)?

ii. The reason the IW was at the location of the accident: Would the IW have been at the location where the injury occurred but for the IW’s employment?

iii. The nature of the employment: Did the employment itself create a risk distinctive in nature or quantitatively greater than the risk to the general public (i.e., a “special hazard” of employment)? and

iv. Whether the IW was commuting to or from a fixed work site:

a) Generally, an injury sustained by an IW commuting to and from the IW’s fixed work site is not in the course of or arising out of the employment (the “coming and going rule”).

b) The coming and going rule may not apply when:

i) The IW has a fixed or semi-fixed work site but is required to travel to one or more other locations for work purposes;

ii) The IW does not have a fixed work site and the travel is interrelated with the nature of the employment;

iii) The injury occurs on property controlled by the employer (e.g., parking lot, ingress or egress from the work site).

B. Occupational Diseases

1. A disease may be compensable as an injury or as an OD.

2. To determine if a disease meets the definition of, and/or is compensable as an OD, refer to the Occupational Disease Claims policy.

C. Special Circumstances

1. Act of Nature

a. An injury caused solely by natural phenomena (e.g., flood, earthquake, tornado) is not compensable; but

b. The injury may be compensable if the act of nature activated a hazard unique to the employment and the hazard caused the injury.

c. Example: While reporting from the site of a hurricane a news reporter is injured by blowing debris.

2. Physical Altercation

a. An injury caused by a fight or other physical altercation a worker is involved in and that is of a purely personal nature is not compensable; but

b. An injury from a fight or other physical altercation over a work-related matter may be compensable; or

c. An injury to another worker not involved in the fight or physical altercation may be compensable for that worker.

3. Horseplay

a. An injury incurred from horseplay is not compensable; but

b. If the IW was an innocent bystander not involved in the horseplay but injured due to it, the injury may be compensable for that worker.

4. Work from Home

a. An injury that occurs in a work area located within the employee’s home is NOT compensable unless all of the following apply:

i. The injury or disability arises out of the employee’s employment;

ii. The injury or disability was caused by a special hazard of the employee’s employment activity; and

iii. The injury or disability is sustained in the course of an activity undertaken by the employee for the exclusive benefit of the employer.

b. It is BWC’s policy to review this type of injury with an Injury Management Supervisor (IMS).

5. Natural Physical Condition and Intervening Hazard of Employment

a. If an injury is caused solely by a non-work related natural physical condition, it is not compensable; but

b. If, in the course of injury from the non-work related condition, there is an intervening hazard unique to the workplace, which causes another injury, the injury caused by the intervening hazard may be a compensable allowed condition.

c. Example: A truck driver has a heart attack due to a non-work related condition and crashes his truck into a guardrail. The injuries from the crash may be allowable conditions.

6. Intoxication, Under the Influence and Rebuttable Presumption

a. BWC will apply the rebuttable presumption that the IW’s injury was caused by the IW’s intoxication or due to being under the influence of a controlled substance not prescribed by a physician when:

i. An IW tests positive on a qualifying chemical test or refuses to be tested; and

ii. The requirements of R.C. 4123.54 have been met.

b. See the Intoxication, Under the Influence and Rebuttable Presumption policy for further information.

7. Exposure

a. BWC will not allow a claim for exposure if there is no accompanying physical injury.

b. However, post-exposure medical diagnostic services and preventive treatment may be paid by BWC when certain criteria are met.

c. See the Exposure policy and procedure for further information.

8. Recreational or Fitness Activities: It is the policy of BWC that an injury or disability incurred in voluntary participation in an employer sponsored recreation or fitness activity is not compensable if the IW signed a waiver of the IW’s right to workers’ compensation or benefits prior to engaging in the recreation or fitness activity.

9. Additional Allowance: See the Additional Allowance policy for requests or recommendations made after the initial allowance of a claim.

V. PROCEDURE

A. General Claim Note and Documentation Requirements

1. BWC staff must refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note and documentation requirements; and

2. Must follow any other specific instructions for claim notes and documentation included in this procedure.

B. Compensability of an Injury

1. Claims services staff must review the elements of, and apply the requirements for compensability of an injury as defined and described in this policy:

a. During initial claim determination; and

b. When an additional allowance is requested or recommended .

2. Claims services staff may also reference the Initial Claim Determination policy and procedure and the Additional Allowance policy and procedure for further information.

3. If an IW files a claim alleging or appearing to be related to an OD, claims services staff must refer to the Occupational Disease Claims policy and procedure for further instruction.

4. Cardiac cases, hernia cases and assault cases: If the injury alleged is cardiac-related (non-OD), a hernia, or resulting from an assault, claims services staff may refer to the respective “Claim Guide” available on COR (“Tips and Tools”) to assist in the investigation.

5. Parking lot injuries: If the IW’s injury allegedly occurred in a parking lot owned by and/or under the control of the employer, claims services staff may review the legal reference “Parking Lot Injuries” available on COR.

6. Subject-Matter Specific Policies: Claims services staff may reference the following policies for additional information related to specific topics (not a comprehensive list):

a. Aggravation and Substantial Aggravation of a Pre-Existing Condition;

b. Exposure;

c. Intoxication, Under the Influence and Rebuttable Presumption;

d. Occupational Disease Claims; and

e. Psychiatric Conditions.