Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Apprentice
Apprenticeship Agreement
Bona fide equipment/vehicle lease
agreement
Calendar Quarter:
Casual Worker
Church
Construction Contract
Coverage
Elective Coverage
Emergency Management Worker
Employee
Employer
Entry-level Trainee
General Contractor
Household Worker
Independent Contractor
“Leasing Onto” Agreement
Minister
Ohio Organized Militia
Owner-Operator
Peace Officer
Placeholder Policy
Pre-apprentice
Professional Employer Organization
(PEO)
Subcontractor
Sub-subcontractor
State Active Duty
Statutory Employer
Temporary Service Agency
Transportation Network Company
Transportation Network Company Driver
IV. POLICY
A. Injured Worker Coverage
B. Special Coverage
Circumstances
V. PROCEDURE
A. Standard Claim File
Documentation
B. Initial Review and
Investigation
C. Decision
D. Independent Contractors
E. Elective Coverage
F. Transportation Network
Company
G. Temporary Service
Agencies
H. PEO
I. Apprenticeship
J. Casual or Household
Worker
K. Emergency Management
Worker
L. Responders to an
Inherently Dangerous Situation
M. Ohio Organized Militia
(Ohio National Guard, Ohio Naval Militia, Ohio Military Reserve)
N. Performing Special
Services for the State or a Political Subdivision
O. Individuals Injured or
Killed While Performing a Request or Order of a Duly Authorized Public Official
P. Injuries Incurred While
Participating in a Rehabilitation Plan
Q. Coverage Exemption for
Religious Sects
R. No
Coverage/Non-Complying Employer Claims
The purpose of this policy is to ensure BWC staff
appropriately recognizes when an IW is considered an employee for workers’
compensation coverage purposes and other circumstances that determine the
nature of the applicable workers’ compensation coverage.
This policy applies to claims services staff and employer
services.
Apprentice:
An individual at least sixteen (16) years of age, who is in a registered
apprenticeship program to learn a skilled occupation pursuant to a registered
apprenticeship agreement. For purposes of this policy “apprentice” shall
include a:
·
Pre-apprentice;
·
Entry-level trainee;
·
Journeyperson.
Apprenticeship
Agreement: A written agreement, registered with the apprenticeship
council, providing for not less than two thousand hours of reasonably
continuous employment, and for participation in an approved schedule of work
experience through employment, which must be supplemented by a minimum of one
hundred forty-four hours per year of related and supplemental instructions.
Bona fide
equipment/vehicle lease agreement: An arrangement between the owner
of a truck and a driver, where the driver is given legal control of the vehicle
to use as if he/she is the owner in exchange for a payment to the owner for
such use. In the transportation industry, a bona fide lease agreement contains
commercially reasonable terms made with earnest intent, without fraud or
deceit.
Calendar
Quarter: One fourth of a calendar year as follows:
1st quarter – January 1
through March 31;
2nd quarter - April 1
through June 30;
3rd quarter - July 1
through September 30;
4th Quarter - October 1
through December 31.
Casual
Worker: An individual whose work is occasional and not on a regular
basis. A casual worker can include a member of a labor crew brought to a job site
to labor on completing the task a contractor is responsible to perform.
Church:
An established and legally recognized, congregation, denomination, society,
corporation, fellowship, convention or association formed primarily or
exclusively for religious purposes.
Construction
Contract: An oral or written agreement involving any activity
in connection with the erection, alteration, repair, replacement, renovation,
installation, or demolition of any building, structure, highway, or bridge.
Coverage:
For purposes of this policy, reference to an injured worker’s inclusion in a
workers’ compensation policy, whether mandated by law or elective.
Elective
Coverage: Workers’ compensation coverage an employer or individual
may obtain pursuant to R.C. 4123.01, for workers that are not defined as
employees for purposes of workers’ compensation. The following are entities or
persons not defined as employees who must elect to purchase workers’
compensation coverage to be covered:
·
Entity: a sole proprietorship, a partnership, a limited
partnership, an individual incorporated as a corporation with no employees, a
family farm corporation or an LLC filing a federal tax form as a sole
proprietor or partnership.
·
Person: a sole proprietor, a member of a partnership, a
member of a limited partnership, an individual incorporated as a corporation
with no employees, an officer of a family farm corporation, or an individual
member of a limited liability company (LLC) filing a federal tax form as a sole
proprietor or partnership., a duly ordained, commissioned, or licensed minister
or assistant or associate minister of a church (or equivalent position and
organization) in the exercise of a ministry.
Emergency
Management Worker: An individual who has registered for
service pursuant to R.C. 5502.34,
in connection with the development, maintenance, and operation of any state or
local emergency management agency authorized by law, and who has met the
minimum requirements of R.C. 4123.031-4123.037,
or who has been registered as an emergency management worker pursuant to R.C. 5502.34 during a disaster or
emergency.
Employee:
As defined in R.C. 4123.01(A), the term “employee” includes the
following persons that do not meet the definition of independent contractor and
are:
·
In the service of the state or political subdivision (e.g., a
county, township, school district), including:
o
Regular members of lawfully constituted police and fire
departments, whether paid or volunteer;
o
Executive officers of boards of education; and
o
Elected officials.
·
In the service of any person, firm, or private corporation,
including any public service corporation, that employs one or more persons
regularly in the same business or establishment;
·
Household or casual workers who earn one-hundred sixty-dollars or
more in cash in any calendar quarter from a single household or employer; or
·
Performing labor or other services pursuant to a construction
contract.
·
Operating a vehicle in the performance of services for or on
behalf of a motor carrier transporting property, unless the person is an
owner-operator (see owner-operator definition below).
Employer:
As defined in R.C. 4123.01(B) the term “employer” includes:
·
The state, including state hospitals; each county, municipal
corporation, township, school district; and hospital owned by a political
subdivision or subdivisions other than the state; (also known as a “Public
Employer”).
·
A person, firm, professional employer organization, and private
corporation, including any public service corporation, that (a) has in service
one or more employees or shared employees regularly in the same business or in
or about the same establishment under any contract of hire, express or implied,
oral or written, or (b) is bound by any such contract of hire or by any other
written contract, to pay into the insurance fund the premiums as provided by
law (Also known as a “Private Employer”).
Entry-level
Trainee: An individual who possesses experience that qualifies the
individual as a journeyperson but for the existence of certain other
disqualifying conditions, and who receives on-the-job training accompanied by
classroom instruction outside of normal working hours.
General
Contractor: An entity with whom a principal/property owner directly
contracts to perform certain jobs. Some or all of the enumerated tasks are
subsequently contracted to other entities (subcontractors) for performance.
·
For general contractor relationships to exist there must be three
parties: 1) a principal/property owner, 2) an independent contractor, and 3) a
subcontractor hired by the independent contractor (making the independent
contractor a general contractor).
Household
Worker: A worker hired to perform services in the home (e.g.,
housekeeper, nanny, and gardener).
Independent
Contractor: An entity with whom the principal/owner directly
contracts to perform a certain task or tasks. Independent contractors are
generally engaged to perform operations not within the usual trade or business
of the principal/owner and such tasks are contract-specific.
“Leasing Onto” Agreement: An arrangement between
an owner-operator of a vehicle and a motor carrier whereby the owner-operator
drives their own vehicle under the motor carrier’s USDOT operating authority.
Minister:
A duly ordained, commissioned, accredited, or licensed minister, member of the
clergy, rabbi, priest, or Christian Science practitioner. This definition
includes assistant ministers and associate ministers.
Ohio
Organized Militia: Members of one of the following:
·
The Ohio National Guard, which includes both the Ohio Air
National Guard and the Ohio Army National Guard;
·
The Ohio Naval Militia;
·
The Ohio Military Reserve.
Owner-Operator:
A person who owns and may operate a vehicle that is used to transport property.
In the event the owner-operator is operating a vehicle in the performance of
services for or on behalf of a motor carrier transporting property, they are
considered an independent contractor if all of the following factors apply:
·
The person owns the vehicle, or leases the vehicle under a bona
fide equipment/vehicle lease agreement;
·
The person is responsible for supplying the necessary personal
services to operate the vehicle or vessel used to provide the service;
·
The compensation paid to the person is based on factors related
to work performed, including on a mileage-based rate or a percentage of any
schedule of rates, and not solely on the basis of the hours or time expended;
·
The person substantially controls the means and manner of
performing the services, in conformity with regulatory requirements and
specifications of the shipper.
·
The person enters into a written contract with the carrier for
whom the person is performing the services that describes the relationship
between the person and the carrier to be that of an independent contractor and
not that of an employee.
·
The person is responsible for substantially all of the principal
operating costs of the vehicle and equipment used to provide the services,
including maintenance, fuel, repairs, supplies, vehicle insurance, and personal
expenses, except that the person may be paid by the carrier the carrier’s fuel
surcharge and incidental costs, including tolls, permits, and lumper fees.
·
The person is responsible for any economic loss or economic gain
from the arrangement with the carrier.
Peace
Officer: For purposes of this policy, an individual legally
vested with law enforcement rights who generally works for a city, county or
state public employer and can be either “traditional” (e.g., police officer) or
“non-traditional” (e.g., certain park rangers, tax agents or liquor agents).
Placeholder Policy: An employer policy number that is created when an
alleged employer has never established a policy with BWC, BWC no longer has a record
of the policy number, or the policy is in a “cancelled” status and the date of
injury occurred after the policy was cancelled. Previously known as a dummy risk number.
Pre-apprentice:
An individual receiving formal classroom training designed to provide basic
education, attitudes, skills, trade knowledge, and motivation necessary to
enter a formal apprenticeship program.
Professional
Employer Organization (PEO): A sole proprietor, partnership,
association, limited liability company or corporation that enters into an
agreement with one or more employers, known as client-employers, for the
purpose of co-employing all or part of the client-employer’s work force at the
client-employer’s work site.
Subcontractor: An entity who
is hired by a general contractor (or prime contractor, or main contractor) to
perform a specific task as part of the overall project and is normally paid for
services provided to the project by the originating general contractor.
Sub-subcontractor:
An individual or firm having a contract with a subcontractor to perform a
portion of the work.
State Active
Duty: Status of a member of the Ohio organized militia
who is performing duty by order of a state authority, and while in this state
active duty status injury and occupational disease benefits are not provided by
the federal government.
Statutory
Employer: An entity in any industry who is responsible for a
claim by operation of law due to using an uninsured independent contractor or subcontractor,
or where ten or more of R.C. 4123.01(A)(1)(c) employee criteria are
applicable when a person is performing labor or providing services pursuant to
a construction contract.
Temporary
Service Agency: An entity that as part of its trade or business
provides workers to unrelated third-party clients to perform services on a
temporary basis and derives revenue or other benefits from providing the
workers.
Transportation
Network Company: A corporation, partnership, association, limited
liability company, proprietorship, or any other entity operating in this state
that uses a digital network to connect transportation network company riders to
transportation network company drivers who provide transportation network
company services.
Transportation
Network Company Driver: An individual to whom both of the
following apply:
·
The individual receives connections to passengers and potential
passengers and related services from a transportation network company in
exchange for the payment of a fee to the company.
·
The individual uses a personal vehicle to offer or provide
transportation network company services to riders upon connection through a
digital network controlled by a transportation network company in return for
compensation or payment of a fee.
1. It is the policy
of BWC to consider an injured worker (IW) to be covered for possible Ohio
Workers’ Compensation benefits when:
a. The IW meets the
definition of employee; or
b. Does not meet
the definition of employee but has elective coverage.
2. It is the policy
of BWC to:
a. Recognize that
the existence of workers’ compensation coverage for an employer does not
automatically mean a particular IW is covered; and
b. Investigate
fully all coverage issues in a claim prior to making a determination.
1. When special
circumstances exist, BWC will properly apply relevant sections of the Ohio
Revised Code when making coverage determinations.
2. Special
circumstances are defined by Ohio Revised Code and outlined throughout the
procedure below.
1. BWC staff shall
refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note requirements; and
2. Shall follow any
other specific instructions for claim notes included in this procedure.
1. When a new claim
is filed, claims services staff must:
a. Review the
information in the claim file and, if necessary, investigate and gather
evidence to determine:
i. If
the alleged employer has an existing policy and whether the policy was active
at the time of injury; and
ii. If the IW
is an employee, or if the IW does not meet the definition of employee, whether
the IW has elective coverage.
b. Investigate
whether any special provisions of the Ohio Revised Code exist that may impact
the IW’s coverage or right to participate in the Ohio workers’ compensation
system.
i. Types
of coverage that may have special provisions are detailed in sections V.D-V.R
of this procedure, and include:
a) Independent
contractors;
b) Elective
coverage;
c) Transportation
network companies;
d) Temporary
service agencies;
e) Professional
Employer Organizations (PEO);
f) Apprenticeships;
g) Casual or
household workers;
h) Emergency
management workers;
i) Responders
to inherently dangerous situations;
j) Ohio
organized militia;
k) Individuals
performing special services for the state or a political subdivision;
l) Individuals
killed while performing requests or orders of a duly organized public official;
m) Injuries incurred
while participating in a vocational rehabilitation plan;
n) Coverage
exemption for religious sects; and
o) No-coverage/Non-complying
employers.
ii. All claims
involving the special provisions of Ohio Revised Code listed above and further
discussed in this policy and procedure must be staffed with a BWC attorney.
2. If claims
service staff has difficulty finding an employer policy:
a. Claims services
staff shall complete and enter a referral on the EM referral tracker requesting
assistance in locating the employer policy. The referral must include:
i. The
IW’s claim demographic information;
ii. All
available demographic information of the alleged employer; and
iii. The following
verbiage in the reason for referral:
a) “Based on the
initial investigation, it appears that the employer has never had a policy and the
IW alleges they were injured at this place of employment.”; or
b) “Based on the
initial investigation, it appears that the employer had a cancelled policy at
the time the IW alleges they were injured at this place of employment.”
b. If, upon completion
of the EM investigation, the IW’s employee or employer coverage status is
unclear, claims services staff must seek assistance from a BWC attorney.
1. After completion
of the investigation, claims services staff must either allow the claim if it
meets all of the criteria outlined above and those outlined in the Jurisdiction
(Statute of Limitations, Statutory Life of a Claim) and Compensable
Injuries policies and procedures; or
2. Disallow the
claim based on coverage issues if:
a. The IW is not an
employee,
b. The IW is not
otherwise covered by an elective coverage policy, and
c. The IW is
not entitled to coverage under any of the specific Ohio Revised Code sections
discussed in this policy and procedure.
D. Independent Contractors
1. If information
received in a claim asserts the IW is a subcontractor or independent contractor,
claims services staff must send the IW and the alleged employer the Independent
Contractor/Employee Questionnaire, or obtain answers to the questionnaire
during an interview of the IW and the employer, documenting all the answers in
the claims management system. Claims services staff must also:
a. Review
documentation of the IW’s wages;
b. Request from the
employer and/or IW any written agreement between the IW and the alleged
employer;
c. Review
other claims against the same employer; and
d. Seek any other
information available that may help clarify the IW’s employment status.
2. If the claim
involves the construction industry and the alleged employer claims the IW is a
subcontractor or independent contractor, claims services staff must attempt to
identify the contractor tier for the project using the job aid, Project
Contractor Investigation Sheet, on COR.
3. If the claim
involves the trucking industry and the alleged employer claims the driver is an
independent contractor, claims services staff must request:
a. Motor vehicle
crash report, if applicable; and
b. Any agreements
between the driver and alleged employer. These agreements may have titles like
“Independent Contractor Agreement”, “Driver Agreement”, “Lease Agreement”, or
“Leasing Onto” Agreement;
c. Settlement
sheets or statements for one month prior to the date of injury.
4.
Once all the available documentation is received, claims services staff
must staff the issue with a BWC attorney to determine employee status and if a
different employer than listed on the FROI is responsible for the claim by
operation of law.
5. Upon completion
of the staffing with a BWC attorney, claims services staff will publish an
order with one of the following findings:
a. The IW is an
employee of the original alleged employer;
b. The statutory
employer is responsible for the claim.
i. In
this case, claims services staff must use the applicable statutory employer
order language found on COR on the Coverage policy page;
ii. Update the
statutory employer’s policy number as the insured employer in the claims
management system; and
iii. Add the original
alleged employer as an additional recipient on the order;
c. The IW is
an independent contractor.
i. Claims
services staff must retain the name of the alleged employer in the claim for
due process purposes but shall deny the claim.
ii. The order
must indicate that:
a) There is no
proof of an employee/employer relationship; and
b) The IW is an
independent contractor.
1. Some categories
of workers are not required to have workers’ compensation coverage. Thus, an
employer may have coverage for the business, but has elected not to have
coverage for an individual.
2. Indicators that
an elective coverage situation may exist include:
a. The IW’s last
name is also the name of the business;
b. The IW’s address
is the same as the business address;
c. The IW's
phone number and the business phone number are the same or very similar;
d. The IW is listed
as an owner, sole proprietor, partner, principal, or officer on the First
Report of an Injury Occupational Disease or Death (FROI);
e. The IW appears
to be a family farmer;
f. The
IW’s social security number and the employer’s Federal Tax ID number are the
same;
3. If it appears
the claim may involve an elective coverage situation, claims services staff must
research the employer customer record in the claims management system to see if
the IW is listed as having elective coverage when the IW is:
a. The owner of a
sole proprietorship;
b. A member of a
partnership;
c. An
individual in a limited liability company (LLC) acting as a sole proprietorship
or partnership;
d. An officer of a
family farm corporation;
e. An individual
incorporated as a corporation (with no employees);
f. A
duly ordained, commissioned, or licensed minister or assistant or associate
minister of a church (or equivalent position and organization) in the exercise
of a ministry which can be covered electively under the church or under their
own sole proprietor policy.
4.
When an employer has elected coverage for any individual listed above,
claims services staff must not provide workers’ compensation benefits or
compensation until elective coverage is verified for the date of injury. To
verify elective coverage, claims services staff must:
a. From with the
open claim, select the Participants section of the left side header;
b. Highlight the
Insured’s name;
c. Click the
Details tab;
d. Under Policy
Individuals, see if they are checked as covered; and
e. Coverage Status
dropdown verifies whether the employer of record had coverage on the date of
injury.
5. The employer of
record must have coverage on the date of injury for the elective coverage to be
valid.
6. Pursuant to R.C.
4123.01(A)(2), a volunteer officer of a nonprofit corporation is
specifically excluded from the definition of employee and the employer does not
have the option to elect coverage.
7. Claims services
staff may obtain further guidance and/or evidence regarding elective coverage
issues by:
a. Referring to “Viewing EM Information for IM”
on COR and other job aids, as needed;
b. Contacting the
IW and employer to clarify coverage status; or
c. Staffing
with the Employer Services Specialist (ESS) or supervisor.
8. Before making a
final determination of the status of elective coverage, claims services staff must
staff the claim with a BWC attorney.
1. If the IW
appears to be a transportation network company driver (for example, the
employer is listed as UBER or LYFT), claims services staff must determine if:
a. The
transportation network company has an agreement with the transportation network
driver to provide workers’ compensation coverage; or
b. The
transportation network driver has purchased workers’ compensation coverage for
him or herself.
2. Claims services
staff must review these claims with a:
a. Supervisor;
b. Employer
Management (EM) staff; and/or
c. BWC
attorney.
1. When a claim
involves an IW who is employed by a temporary agency but is performing services
for a third-party client, claims services staff must identify the temporary
agency as responsible for coverage in the claim.
2. Refer to the Violation
of Specific Safety Requirement (VSSR) policy and procedures for
exceptions concerning Violations of a Specific Safety Requirement awards following
the initial coverage determination.
1. Claims services
staff must identify the PEO as the employer responsible for coverage in a claim
involving an employee of the PEO, regardless if the IW/employee is co-employed
by a client of the PEO.
2. When a PEO has
been identified as the employer, claims services staff must verify the PEO
information by contacting BWC’s PEO Unit supervisor and providing:
a. The claim
number;
b. The date of
injury;
c. The policy
number of the employer the claim has been filed under; and
d. Any information
pertaining to the PEO contained in the claim file.
3. Claims services
staff must note any corrections to the PEO information made by the PEO Unit.
4. See the BWC Employer
Services Professional
Employer Organizations (PEOs) policy for further information.
1. If it appears
the IW may be an apprentice pursuant to R.C.
4123.038 and 4123.039
(including pre-apprentice, entry-level trainee or journeyperson), claims
services staff must contact the IW and/or the identified employer and:
a. Verify the IW’s
status as an apprentice;
b. Determine if the
IW is covered by an Apprenticeship
Elective Coverage Contract (U-80) with BWC; and
c. Determine
if, in addition to being an apprentice, the IW is an employee of the identified
employer.
2. Claims services
staff must email BWC Policy Processing if there are any
questions regarding apprenticeship coverage under a U-80.
1. Before
determining if the IW is a casual or household worker that qualifies for
coverage pursuant to R.C. 4123.01(A)(1)(a)(iii)(b), claims services
staff must first determine if the IW is an independent contractor, as described
above.
2. If the IW is not
an independent contractor, claims services staff must determine if the IW meets
the following criteria to be covered as a casual or household worker:
a. The IW earns one
hundred sixty dollars ($160) or more in any calendar quarter during the year of
injury from a single household or employer.
b. This includes
situations where:
i. At
the time of injury, the IW already earned $160 or more during the calendar
quarter; or
ii. But for
the injury, the IW would have earned $160 or more during the calendar quarter.
3. To establish
this, claims services staff must request documentation such as:
a. Copies of
paychecks or documentation from electronic money transfer systems showing
payment for services transactions (e.g., PayPal, Venmo, Bitcoin)
b. Tax documents
showing how the IW reports the income;
c. Any
written agreement between the IW and the alleged employer.
1. Pursuant to R.C.
4123.031-4123.037, an emergency management worker, whether
paid or volunteer, is eligible for benefits payable on account of total
disability, loss of member, or death. Volunteer emergency management workers
qualify for the maximum benefits applicable to accidental injury or death.
2. If the IW is
filing a claim as an emergency management worker, claims services staff must
verify that the IW:
a. Is registered
for service as an emergency worker and has taken the appropriate state or
federal oath;
b. Was acting in
good faith in performing his or her emergency management duty, function, or
act,
c. Was
performing such duty in conjunction with the development, training, maintenance,
or operation of the emergency management agency; and
d. Was under
express or constructive instruction or orders of a duly appointed director or
an authorized staff member of the emergency management agency charged with the
authority and responsibility for issuing such instructions or orders.
3.
Prior to receiving any compensation or benefits, claims services staff
shall require the IW or other claimant to provide:
a. A copy of the
“loyalty oath” filed with the political subdivision; and
b. A certified copy
of the permanent record attesting to the participation of the IW as an
emergency management worker in the emergency management activity during, or as
a result of which the claim is being made.
1. An IW is covered
by workers’ compensation pursuant to R.C.4123.01(A)(1)(a) when:
a. The IW is one of
the following:
i. A
peace officer;
ii. A
firefighter, of a lawfully constituted fire department;
iii. A
first-responder, emergency medical technician-basic, emergency medical
technician-intermediate, or emergency medical technician-paramedic of an
ambulance service organization or emergency medical service organization
pursuant to R.C. 4765.01;
b. The situation
being responded to is inherently dangerous;
c. The
situation requires immediate response on the part of the worker; and
d. The worker is
responding in the same manner as he or she would when on-duty.
2. Claims services
staff must apply this provision even if the injury occurred outside of the IW’s
regular jurisdiction and regardless of whether the IW works in a paid or
volunteer position.
1. If it appears
the IW is filing a claim as a member of the Ohio Organized Militia (the State
of Ohio would most likely be listed as the employer), claims services staff must
verify that the IW meets the following criteria to be covered by workers’
compensation pursuant to R.C. 4123.021-4123.024:
a. The IW must have
been in a state active duty status at the time of injury; and
b. Injury and
occupational disease benefits are not otherwise provided by the federal
government.
2. Claims services
staff must request from the IW a copy of his or her order to report to duty or
other documentation to establish the duty status.
3. Claims services
staff must contact the Ohio Adjutant General’s Department for assistance in
determining whether that IW is eligible to apply for Ohio workers’ compensation
benefits or federal workers’ compensation benefits.
1. Claims services
staff must consult with EM staff to determine if a public employer has an
applicable Contract
for Coverage of State Agency or Political Subdivision (U-69) when a
claim is received alleging an injury while the IW was acting in the following
capacity, pursuant to R.C. 4123.03:
a. The IW was
performing community service (typically an individual on probation or
performing community service in lieu of a criminal conviction);
b. The IW was
incarcerated in a state or local correctional facility participating in an
inmate work program;
c. The IW was
working as a non-emergency volunteer; or
d. The IW was
serving as a juror.
2. Claims services
staff may refer to BWC Employer Services Contract
for Coverage of State Agency or Political Subdivision policy for
further information.
1. If an IW is not
otherwise covered by elective coverage of a public employer, claims services
staff shall find the IW covered pursuant to R.C.
4123.025 when:
a. The injury or
death is a direct result of performing any act at the request or order of a
duly authorized public official of
i. The
state, or any institution or agency of the state, or
ii. Any
political subdivision, including a county, township, or municipal corporation;
and
b. The request or
order was made in a time of emergency.
2. If the criteria
above are met, claims services staff must consider the IW or the IW’s
dependents eligible for all workers’ compensation benefits as provided by law.
3. Claims services
staff must ensure any payments made under this provision are charged to the
Surplus Fund.
1. Claims services
staff will verify that the alleged injury occurred while participating in an
active BWC vocational rehabilitation plan.
2. Claims services
staff shall ensure the correct policy number has been assigned to any claim
involving an IW injured while participating in a vocational rehabilitation
program.
3. Claim services
staff may contact the Rehab Policy unit as needed.
4. BWC shall charge
all compensation and benefits paid in this type of claim to the Surplus Fund,
provided the employer in the source claim pays into the Surplus Fund.
1. If an IW and
employer indicate to claims services staff that they hold a religious exemption
(e.g. Amish) from workers’ compensation coverage, claims services staff must
verify with EM staff that the employer and the IW both have an approved
religious exemption before finding that the IW is not covered by workers’
compensation.
2. In general:
a. BWC may approve
an employer and employee exemption from workers’ compensation coverage upon the
filing of an Application
for Exemption from Ohio Workers’ Coverage and Waiver of Benefits
(U-3E);
b. The employer and
the employee must both file the U-3E and obtain approval for the waiver;
c. An
employer may have some employees that are exempt from coverage and some that
are not; and
d. The employer and
employee do not have to be members of the same religious sect.
1.
Following a claim investigation pursuant to the Initial
Claim Determination policy and procedures, claims services staff must investigate
to determine whether:
a. The correct
employer has been identified; and
b. The correct
employer has:
i.
Never had an established policy with BWC; or
ii. A policy
that is so old that BWC no longer has record of the policy number (for
occupational disease claims);
iii. A policy is in
“cancelled” status, and the date of injury occurred after the policy was
cancelled (see occupational disease exception below).
2.
If claims services staff determines the employer lacks workers’
compensation coverage, claims services staff must obtain a new policy number
(known as a “placeholder policy”) by:
a. Inserting the
following information on Request for Placeholder Policy form:
i. Legal
business name or homeowner name;
ii. Primary
physical location of business or homeowner;
iii. Business/homeowner
phone, if available;
iv. A notation of “Placeholder
Policy - claim number #xx-xxxxxx” and the date of injury; and
v. A brief
description of the accident.
b. Sending the Request
for Placeholder Policy to the “BWC PPD Rush” email box using the subject
line: “Placeholder Policy Due to Claims”.
3.
The responsibilities regarding obtaining placeholder policy number may
be assigned to various claims services staff members within the service office
at management discretion.
a. The Claims
Service Specialist (CSS) in the lost time service offices must:
i. Refer
the policy issue to Employer Management (EM) staff for investigation, via an IM
to EM referral, to ensure that an employer policy number does not already
exist; and
ii. Request
creation of a placeholder policy number if EM staff verifies no policy
currently exists for the alleged employer.
b. Medical Claims
Supervisors in Central Claims will complete an employer investigation in the
claims management system then, if appropriate, refer the request from their
staff directly to Policy Processing to obtain a placeholder policy.
4. The Policy
Processing Department must manually place an installment block on all placeholder
policies to prevent installments from billing. This block does not prevent
invoices and documents from being sent to the employer.
5. If claims
services staff discover or identify an existing policy number for the employer
that appears to be applicable to the claim after obtaining a placeholder policy
number, claims services staff must email Policy Underwriting via the “BWC Combine
Unit Inquiries” mailbox and request the policy numbers be reviewed and possibly
combined. For example:
a. Claims services
staff’s investigation of the correct employer determines the correct employer
to be ABC Garage, but ABC Garage has no policy number or coverage. Therefore, a
placeholder policy number is requested for the employer.
b. After the
placeholder policy number is obtained, it is discovered that ABC Garage did
have a policy number and coverage when the placeholder policy number was
requested.
c. Claims
services staff will contact Policy Underwriting via the “BWC Combine Unit
Inquiries” mailbox and request the review the two policy numbers assigned to
ABC Garage to determine if the two policies should be combined.
6. If the claim is
for an occupational disease and the correct employer policy is in a “cancelled”
status, the creation of a placeholder policy is not necessary. Claims Services
Staff must update the coverage override drop down to “Cov-active on DOO” in the
Insured Participant details tab so the employer policy will reflect a covered
status for that claim.