Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Causal Relationship (Causality)
Claimant
Common Law Marriage
Death Benefits
Dependent
Emergency Management Worker
Guardian
Legal Presumption
Natural Parent
Partial Dependent
Prospective Dependent
Whole Dependent
IV. POLICY
A. Notice of Death
B. Filing an Application
for Death Benefits
C. Funeral and Medical
Expenses
D. Statute of Limitations
E. Eligibility for Death
Benefits
F. Level of Dependency:
Whole, Partial and Prospective
G. Death Benefits Rates and
Apportionment
H. Claimant Annual Contact
I. Claimant Status
Change(s) and Reapportionment
J. Family Support
K. Overpayments
L. Scheduled Loss
Compensation
M. Claimant Incarceration
N. Lump Sum Advancement and
Lump Sum Settlement
V. PROCEDURE
A. Standard Claim File
Documentation
B. Processing a Notice of
Death
C. Processing an
Application for Death Benefits
D. Establishing Level of
Dependency and Documentation Requirements
E. Determination of the
Claim and Death Benefits
F. Claimant Annual Contact
G. Dependency Status
Changes and Reapportionment
H. Overpayments
I. Lump Sum Advancement
and Lump Sum Settlement of Death Benefits
The purpose of this policy is to ensure that BWC processes a
notice of death of an injured worker (decedent) and requests for death benefits
and payment of medical and funeral expenses consistently, appropriately, and in
compliance with law.
This policy applies to BWC Claims Services staff.
Causal Relationship (Causality): Medical and legal concepts are
both necessary to establish a compensable death claim:
·
A medical concept describing a relationship between the
condition(s) and the industrial accident or occupational disease and death; and
·
A legal concept that establishes a relationship between the
employment and accident or occupational disease that led to the death of a
decedent.
Claimant: One who asserts a right, demand
or claim for workers’ compensation benefits. For purposes of this policy,
“claimant” typically refers to the surviving spouse, other dependents or a
provider that is seeking reimbursement or payment for services pertaining to
the decedent’s death (e.g., a funeral home).
Common Law Marriage: A marriage
relationship created by agreement and cohabitation rather than by ceremony.
Ohio law recognizes these marriages only if
established in Ohio prior to October 10, 1991, or if
established after that date in another state or nation that recognizes the
validity of common law marriages, consistent with the laws of that state or
nation.
Death Benefits: Benefits payable pursuant
to R.C. 4123.59 and R.C. 4123.60 to a dependent of an injured worker who has
died as a result of an injury or occupational disease received in the course
of, and arising out of, the injured worker’s employment.
Dependent: A member of the family of the
decedent, for example a surviving spouse or a blood relative, such as child,
step-child, parent or other blood relative who relied on the decedent, in whole
or in part, for financial support as provided by law. A dependent is not a
fiancé(e), live-in significant other, or a foster child, etc.
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 to 4123.037, or who has been registered as an emergency
management worker pursuant to R.C. 5502.34 during a disaster or emergency.
Guardian: Any person appointed by the
probate court to have the care and management of the person, the estate, or
both of an incompetent or minor person.
Legal Presumption: A conclusion based upon
a particular set of facts, combined with established laws, logic or reasoning.
Natural Parent: The legally recognized
parent of a child, whether biological or adoptive.
Partial Dependent: A claimant who has
received some financial support from the decedent and they are unable to
support themselves.
Prospective Dependent: A member of the
family of the decedent, for example a surviving spouse or a blood relative,
such as child, step-child, parent or other blood relative not found to be a
whole or partial claimant, but whose circumstances clearly indicate a need for
potential financial support and there is evidence of an intention or commitment
of the decedent to provide such financial support.
Whole Dependent: A claimant that is presumed
or found to have relied on the decedent for financial support, to a greater
degree than a partial or prospective claimant (e.g., a surviving spouse and
minor children are presumed wholly dependent).
1. When a
decedent dies as the result of a work-related injury or occupational disease, a
notice of death may be initiated via:
a. A First
Report of Injury, Occupational Disease or Death (FROI);
b. An
Application for Death Benefits and/or Funeral Expenses (C-5);
c. An Application
for Accrued Compensation (C-6);
d. A Motion
(C-86);
e. Telephone
notification;
f. In
person notification;
g. Online
through the BWC website;
h. Email
notification; or
i. Any
other electronic or written communication.
2. BWC shall
request supporting documentation and when necessary, obtain a written notice of
death.
1. The
claimant, when filing for death benefits, must submit to BWC:
a. A C-5; and
b. For new claims:
i. A
FROI;
and
ii. Supporting
documentation to establish a causal relationship
for death benefits.
c. For
existing claims, supporting documentation to establish a causal relationship for death benefits.
2. If the
claimant has an authorized representative (e.g., legal counsel), the claimant
must file an appropriate authorization with BWC.
a. Any
authorization made by the decedent expires upon their death and is not
applicable to the claimant.
b. See the Authorized
Representatives policy for further information.
1. In
addition to the death benefits discussed above, an application may be made for
reimbursement of, or payment for:
a. Medical,
nurse, hospital services, and medicine related to the decedent’s work-related
injury or occupational disease; and
b. Funeral
expenses up to the maximum allowed by law.
2. An
individual or provider that incurred the expense and making the application
must provide supporting documentation such as an invoice or receipt.
3. In
addition to funeral expenses, BWC may pay for related exceptional
transportation costs; e.g., returning the body of the decedent when the death
occurs outside the area where the decedent lived.
D. Statute of
Limitations
1. Applying
for Death Benefits with a Date of Injury Prior to 09/29/2017:
a. An
Application for death benefits, except emergency management workers, where the
decedent’s death is due to a work-related injury must be filed within two years
from the date of death.
b. An
application for death benefits for an emergency management worker employed by
the state or a political subdivision, who dies in the performance of their
duties as an emergency management worker, must be filed:
i. Within
one year of the date of the death; or
ii. If
the emergency management worker filed an injury claim within one year of an
injury, and the emergency management worker subsequently dies from that injury,
within six months after the date of death.
2. Applying
for Death Benefits with a Date of Death On or After 09/29/2017:
a. An
application for death benefits, including emergency management workers,
employed by the state or a political subdivision, where the decedent’s death is
due to a work-related injury must be filed within one year from the date of
death.
b. If the
emergency management worker filed an injury claim within one year of an injury,
and the emergency management worker subsequently dies from that injury, the
application for death benefits must be filed within six months after the date
of death.
3. Death due
to an occupational disease claim occurring:
a. Before
Sept. 28th, 2021 must be filed within two years after death.
b. On or
after Sept. 28th, 2021 must be filed within one year after death.
4. See the Jurisdiction
policy for further information.
1. To be
eligible for death benefits:
a. The
claimant must be a dependent;
b. An
application must be made within the required time frames described above; and
c. The
death must have occurred in the course of and arising out of the decedent’s
employment.
2. To be
eligible for funeral expenses only:
a.
Must establish a compensable claim under the law; and
b. Provide a
copy of the funeral bill invoice.
3. To be
eligible for medical services:
a. Must
establish a compensable claim under the law; and
b. Provide a
copy of the medical bill invoice to the MCO for payment.
4. The status
of the decedent as an undocumented worker or public work-relief employee does
not by itself negate the decedent’s dependents from eligibility for death
benefits.
1. BWC shall,
based on the evidence and circumstances at the time of the decedent’s death,
identify a dependency level as whole, partial or prospective.
2. The time
of death is a snapshot of the circumstances to establish dependency.
3. The
following are presumed to be a whole dependent:
a. The
surviving spouse:
i. Lives
with the decedent at the time of death; or
ii. Lives
separately from the decedent due to the decedent’s aggression.
b. A child of
the decedent living with the decedent at the time of death and for whom the
decedent was contributing more than 50% of the child’s financial support, or
for whose maintenance the decedent was legally responsible; and the child is:
i. Under
the age of 18;
ii. 18
years old but less than 25 years old and pursuing a full-time educational
program while enrolled in an accredited educational institution and program; or
iii. 18 years
old or older and physically or mentally incapacitated from earning.
c. An
unborn child, when born and with proof of paternity, is eligible for death
benefits beginning on the date of birth of the child.
4. It is a
legal presumption that there is sufficient dependency to entitle a surviving
natural parent(s), share and share alike, with whom the decedent was living at
the time of the decedent's death, to a total minimum award of three thousand
dollars.
5. There may
be a combination of dependency (whole, partial and prospective) in a claim.
1. The weekly
rate for death benefits for a whole dependent is 66 2/3% of the decedent’s
average weekly wage (AWW); but:
a. The weekly
rate shall not exceed the statewide average weekly wage for the year of death;
and
b. The weekly
rate shall not be less than 50% of the statewide average weekly wage (SAWW) for
the year of death.
2. The weekly
rate for a partial dependent is 66 2/3% of the decedent’s AWW; but:
a. The weekly
rate shall not exceed the SAWW for the year of death; and
b. There is
no minimum weekly rate.
3. The
benefit for a prospective dependent is based on the amount of support that was
received or expected to be received from the decedent; and
a. The award
for all prospective dependents (excluding natural parents deemed prospective
dependents) shall not exceed a total amount of three thousand dollars.
b. Natural
parents determined to be prospective dependents shall receive a minimum total
award of three thousand dollars.
4. For an IW
who is receiving total disability compensation at the time of death, the
claimant’s rate of benefits that is based upon the IW’s AWW will not be subject
to the SAWW minimum and maximum rates for the year of injury. The claimant’s
rate will be subject to the SAWW minimum and maximum rates for the decedent’s
year of death.
5. Apportioning
Death Benefits Among Dependents
a. When there
are two or more whole or partial dependents eligible for death benefits, BWC
will apportion the amount of the benefit among the whole and partial dependents
equitably, considering the circumstances of each particular case.
i. If
there is at least one whole dependent, the one benefit, as calculated based on
the whole dependent, shall be apportioned among the whole and partial
dependents.
ii. Payment
of benefits to any prospective dependent(s) does not factor into the benefits
paid or apportioned among whole and partial dependents.
b. An award
to natural parents living with the decedent at the time of death that are
determined to be prospective dependents shall be equally apportioned.
c. If
there is more than one prospective dependent (excluding natural parents) the
award to the prospective dependents will be apportioned among the prospective
dependents as BWC determines equitable.
1. A claimant
is required to immediately notify BWC when there is a change to their
dependency status (e.g., surviving spouse remarries, a child stops attending a
full-time educational program, a claimant’s death).
2. BWC shall
send an annual contact letter to the claimant to verify continuing
eligibility. A claimant is required to:
a. Complete
and sign the letter acknowledging and verifying the information in the letter;
and
b. Return the
signed letter and any required documentation. A scanned, or faxed copy of the
completed and signed letter will fulfill the signature requirement.
c. If
the annual contact letter is not returned, BWC may suspend benefits until
continued eligibility is verified.
3. In
addition to an annual contact letter, a claimant/student receiving benefits is
required to submit to BWC, for each educational period (e.g., semester,
quarter):
a. Proof of
continued enrollment in a full-time educational program (e.g., class
registration); and
b. Proof of
participation in, and completion of the previous educational period for which
benefits were received (e.g., a grade report).
4. The
failure of a claimant to respond to an annual contact letter or submit the
required documentation, including the documentation required from a student for
each educational period, may result in the suspension of the claimant’s
benefits.
1.
When a whole or partial dependent’s status changes and benefits were
originally apportioned by BWC shall reapportion the benefit among the active
dependents and issue an order with the reapportioned rates to each of the
impacted dependents.
2. When
benefits were originally apportioned by the Industrial Commission (IC), a
status change of a dependent and potential reapportionment shall be referred to
the IC.
3. Death
benefits will be reapportioned when:
a. Benefits
were awarded and apportioned to one or more dependents and subsequently an
additional dependent is identified and awarded benefits; or
b. A whole or
partial dependent’s eligibility status changes.
1. BWC shall
deduct any family support that the claimant is ordered to pay from the claimant’s
death benefits.
2. See the Family
Support Orders and Attorney Fees Paid Pursuant to Deductions of Child Support
from Lump Sum Payments policy.
1. If the
decedent has an existing overpayment, the overpayment does not carry over to
the claimant’s death claim benefits.
2. If the
claimant has an existing overpayment, the overpayment shall be recouped from
the claimant’s death benefits.
3. Overpayments
shall be processed consistent with the Overpayments
policy.
1. BWC shall consider upon application a
request for scheduled loss compensation, in accordance with the Scheduled Loss Compensation policy.
2. When scheduled loss compensation awards
are granted or paying but there remains an amount unpaid prior to the
decedent’s date of death, BWC shall pay in accordance with the Scheduled Loss Compensation and Accrued Compensation policies.
3. When scheduled loss compensation awards
are granted before or after death, and there is scheduled loss compensation
payable after the date of death, BWC shall pay in accordance with the Scheduled Loss Compensation policy.
1. BWC shall
terminate benefits to a claimant effective the date of incarceration and may
resume benefits upon release of the claimant, if the claimant is otherwise
eligible.
2. See the Incarceration
policy for further information.
1. Upon
remarriage of the surviving spouse, BWC shall pay a two-year lump sum award
minus any previous lump sum advancement or overpayment.
2. A request
for a lump sum advancement shall be processed consistent with the Lump
Sum Advancement policy.
3. A claimant
is eligible to file an application for death benefits when a decedent’s claim
was previously settled or denied.
4. A claimant
may seek to settle a death claim consistent with the Lump
Sum Settlement policy.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy for claim note
requirements; and
2. Shall
follow any other specific instructions for claim notes included in this
procedure.
1. No
Existing Claim
a. Claims
services staff shall recognize that only a claimant may have a compensable
death claim, not an employer or MCO. An employer, MCO, or provider may file a FROI
or other documentation as notice that an employee has died.
b. When claims
services staff receives a notice of death of an employee and there is no
existing claim, claims services staff shall:
i. Assign
a claim number;
ii. Assign
the claim to the appropriate team:
a) Survivor
Benefits team;
b) Stat OD team;
c) SI
Bankrupt team.
iii. Contact
the employer to obtain contact information for any next of kin;
iv. Take any other
reasonable steps to identify the decedent’s next of kin, as necessary; and
v. Send
an “Initial Contact Letter-No Claim” to the family of the decedent.
a) The letter
shall be sent to a next of kin, if one has been identified.
b) If a next
of kin has not been identified, the letter shall be sent to the decedent’s last
known address.
c. If
an application for death benefits is not received within 28 days from the date
of the “Initial Contact Letter-No Claim” claims services staff shall:
i. Issue
the “No Claim Filed” letter to the employer, MCO and potential claimant(s), if
any were identified; and
ii. Place
the claim in “dismissed” status in the claims management system.
d. If an
application for death benefits is subsequently filed, claims services staff
shall:
i. Place
the claim in “pending” status; and
ii. Process,
determine and manage the claim consistent with this policy.
2. Application
for Death Benefits: When an application for death benefits or the payment of
medical or funeral expenses is filed where there is no existing claim, claims
services staff shall:
a. Assign a
claim number; and
b. Ensure the
claim is assigned to the appropriate team or claims services staff member.
3. Existing
Claim
a. When
claims services staff receive notice of the death of an injured worker in an
existing claim, claims services staff shall:
i. Verify
the death through a Social Security cross match, a death certificate, a
published obituary, a police report or other reliable means;
ii. Update
the claim with the validated date of death;
iii. Discontinue
any ongoing compensation;
iv. Abate pending
applications consistent with the Abatement
policy; and
v. Determine
any accrued compensation consistent with the Accrued
Compensation policy.
b. If claims
services staff receive a verbal request for death benefits, claims services
staff shall:
i. Provide
the claimant with a C-5 and request
that the claimant returns it as soon as possible; or
ii. If
the request is for medical or funeral expenses only, request that the claimant
submit a written request (which may be a C-5) with an
appropriate invoice or receipt.
c. If
claims services staff receives a written request for death benefits, claims
services staff shall reassign the claim to the appropriate team or claims
services staff member. In general:
i. If
the request is made in an existing claim assigned to the Self-Insured Bankrupt team,
is a special handling claim or is a self-insuring claim, the claim will remain
with the team or self-insuring employer handling the claim.
ii. All
other state-fund death claims shall be assigned to the centralized Survivor
Benefits team and an email sent to the injury management supervisor (IMS) for
the centralized Survivor Benefits team.
d. BWC
management may make assignment exceptions on a case-by-case basis or based on
operational need. Claims services staff shall consult with their supervisor or
the IMS for the Survivor Benefits team for direction when in doubt as to the
appropriate assignment of a death claim.
e. If
resolving pending matters in an existing claim will significantly delay
reassigning the claim to the Survivor Benefits team (after a request for death
benefits is received), the IMS of the team assigned the existing claim and the
Survivor Benefits team IMS shall consult and agree upon a plan to resolve the
pending matters and begin processing the death benefits request in a timely and
efficient manner.
f. If
an application for death benefits is made in a settled claim or in a claim
where the statute of limitations has expired, claims services staff shall:
i. Reopen
the claim;
ii. Update
the status reason to “Accepted”; and
iii. Update the
nature of injury category to “Death”.
g. Claims
services staff shall address authorized representative issues consistent with
the Authorized
Representatives policy.
4. If, after
the filing of a death claim, another claimant is identified and/or comes
forward, claims services staff shall:
a. Advise the
subsequent claimant that he/she needs to file a C-5 or other
written application for death benefits;
b. Once the
application is received, ensure it is imaged and made part of the existing
death claim;
c. Send
the new claimant an “Initial Contact” letter; and
d. Continue
the process of determining compensability and dependency consistent with this
policy.
5. Parties to
the Death Claim
a. Claims
services staff shall ensure all parties to the claim are entered as:
i. A
customer in the claims management system; and
ii. A
participant to the claim.
a) The
surviving spouse is identified as the “Beneficiary”;
b) All other
claimants are identified as “Dependent”.
6. Prior to
adding a customer, claims services staff shall conduct a thorough customer
search to determine if the claimant has previously been entered into the claims
management system as a customer.
1. Public
Employment Risk Reduction Program (PERRP) Referrals
a. If the
claim involves a public employer, claims services staff shall send a
notification to the PERRP unit via the “BWC PERRP Fatality” mailbox and copy
the IMS. The notification shall contain:
i. The
claim number;
ii. The
date of death;
iii. The
decedent’s name;
iv. The employer’s
name; and
v. The
employer’s policy number.
b. Claims
services staff shall enter a claim note indicating notification was sent to the
PERRP.
2. Gathering
Information and Documentation and Making Initial Contacts
a. Issuing
the Initial Contact Letter(s) to the Claimant(s):
i. When
a death claim has been filed by a claimant(s), within seven days claims
services staff shall send the claimant(s) the “Initial Contact” letter
informing the claimant(s) of:
a) The claim
number;
b) The name
and contact information of the assigned claims service specialist (CSS);
c) The right
to seek legal counsel; and
d) Any
information or documentation needed from the claimant to make a determination
for death benefits.
ii. If
not already filed by the claimant, claims services staff shall send a C-5 with the
initial contact letter for the claimant to complete and return.
iii. When a
death claim has been filed by a claimant(s), within seven days claims services
staff shall send the employer notice of the request for death benefits.
b. As
applicable to the claim, claims services staff shall request the following
documentation from the agency or service provider that created the document:
i. The
death certificate;
ii. Police
reports;
iii. Emergency
service reports;
iv. Hospital
records;
v. Coroner’s
report;
vi. Autopsy and
toxicology reports; and
vii. Any other relevant
records and reports necessary to make a determination for death benefits.
c. Claims
services staff shall use any correspondence and/or forms identified for
specific requests for documentation, available in the claims management system
and/or available on the Claims Online Resource (COR).
d. As
available, claims services staff shall obtain from the Internet or other
resources:
i. The
decedent’s obituary or other published notification of death;
ii. Any
news stories related to the decedent’s death;
iii. Any other
readily available, relevant information to assist with making a determination
in the claim; and
iv. Claims services
staff, when appropriate, may repeat steps above V.C.2.d.i.-iii.
e. Employer
Contact: Within a reasonable time, claims services staff shall contact the
employer by telephone and:
i. Provide
the claim number and claims services staff’s name, mailing address, telephone
number, fax number and email address; and
ii. Request
the following information, as applicable:
a) Description
of the accident and the accident report;
b) Names,
addresses and telephone numbers of the surviving spouse and/or other potential claimant(s)
or other contacts the employer is aware of;
c) Earnings
information for the decedent for the 52 weeks prior to the date of death;
d) Names and
contact information of any witnesses;
e) Names and
contact information for any investigating authority and related reports; and
f) Any
Occupational Safety & Health Administration reports or other related
investigation reports.
f. Claimant
Contact: Within a reasonable time, claims services staff shall contact the
claimant(s) by telephone (this verbal request shall not substitute for an
initial contact letter) and:
i. Provide
the claim number and claims services staff’s name, mailing address, telephone
number, fax number and email address; and
ii. As
appropriate, request the following information/documentation from the claimant:
a) Names and
addresses of the surviving spouse and children;
b) If no
surviving spouse or children, the names and addresses of the decedent’s
relatives who lived with the decedent at the time of death;
c) Earnings
information of the decedent for one year prior to death (including multiple
employers);
d) The
marriage license of the decedent and the surviving spouse;
e) If the
decedent or surviving spouse was previously married, a copy of the divorce
decree or separation agreements;
f) Birth
certificates of children of the decedent;
g) Social
security numbers of claimants; and
h) Additional
medical records and/or a list of medical providers, as may be relevant to the
claim.
g. Managed
Care Organization (MCO) Contact: Within a reasonable time, claims services
staff shall contact the MCO by telephone and:
i. Provide
the claim number and claims services staff’s name, mailing address, telephone
number, fax number and email address; and
ii. Request
the following information, as applicable:
a) Medical
records relating to the death of the decedent;
b) Medical
history of the decedent;
c) Records of
hospitalizations;
d) Other
medical information that may be relevant in making a determination for
compensability of the claim.
h. Claims
services staff shall identify, conduct interviews and obtain written
statements, as needed of any other witnesses or individuals that may have
information pertinent to the claim.
3. Claims
services staff may consult with a BWC attorney, the Special Investigation Unit
or a medical services specialist (MSS) for assistance obtaining documentation,
as needed.
1. Claims
services staff shall verify, for any individual claiming to be a claimant that:
a. The
individual is a member of the family of the decedent; and
b. The
individual relied on the decedent, in whole or in part, for financial support
or meets the criteria for presumed dependency.
2. Surviving
Spouse
a. The
surviving spouse was living with the decedent at the time of death; or
b. The reason
the surviving spouse was not living with the decedent was due to decedent’s aggression.
3. Claims
services staff shall verify the surviving spouse and dependency through:
a. A marriage
certificate establishing a valid marriage; and
b. Divorce
decrees or death certificates from any former spouse(s) of the decedent or the
decedent’s surviving spouse; and
c. Proof
of residence with the decedent at the time of death (e.g., personal check with
both names and same address, death certificate with decedent’s address and
funeral home bill addressed to surviving spouse with address), or if the
surviving spouse was not living with the decedent at the time of death:
i. Evidence
showing that the separation was due to the decedent’s aggression (e.g., police
reports, court records);
ii. Evidence
of dependency if the spouse and decedent were not living together at the time
of death; or
iii. The
decedent and surviving spouse separation was intended to be temporary (e.g.,
temporarily living separately due to job transfer or one spouse living with and
caring for a family member).
a) Example 1:
The surviving spouse lives in Cincinnati, Ohio. The decedent, at the time of
death was working in Youngstown, Ohio. The surviving spouse states that the
decedent was working a temporary assignment of approximately six months in
Youngstown and living in an extended-stay hotel. Documentation that would help
establish that the separation was temporary includes, but is not limited to:
i) A
personal check, bank statement, or lease agreement that shows the names of both
the surviving spouse and the decedent at the same address;
ii) The
employer’s statement verifying the decedent was working a temporary assignment;
iii) The employer’s
written policy or other document explaining the living arrangements during the
work assignment;
iv) If the decedent
was paying for lodging directly, receipts for the lodging.
b) Example 2:
The surviving spouse indicates she has been living in her parents’ home for the
three months prior to the decedent’s death. She states her mother is terminally
ill and she has been caring for her, but her intention was to eventually return
to the home she previously shared with the decedent. Documentation that would
help establish that there was an intent to cohabitate in the future includes
but is not limited to:
i) A
personal check, bank statement, or lease agreement that shows the names of both
the surviving spouse and the decedent at the same address;
ii) A
statement from the mother’s doctor or other medical record verifying the
mother’s condition;
iii) The obituary of
the decedent that lists the surviving spouse;
iv) Personnel
records from the employer that lists the surviving spouse and his/her address;
v) Emails,
letters or other communications that indicate the decedent and surviving
spouse’s continuing relationship and/or expectation of living together again in
the future.
d. If the
surviving spouse claims a common law marriage established after October 10,
1991, evidence that shows the common law marriage was established in compliance
with the laws of the state or nation in which they were cohabitating.
e. If the
surviving spouse claims a common law marriage established in Ohio, supporting
evidence must be produced showing that the marriage was established prior to
October 10, 1991; supporting documentation needs to show that:
i. The
couple represented themselves to their community as married (e.g., the
surviving spouse listed as spouse on personnel records, shared bank accounts,
other business records showing the decedent and surviving spouse used the same
last name);
ii. The
couple was treated by their community as husband and wife (e.g., mail addressed
to the decedent and surviving spouse as a couple or Mr. and Mrs.);
iii. The couple
cohabitated;
iv. The couple had
the legal capacity to enter into the marriage (e.g., if the decedent or
surviving spouse was previously married, a divorce degree or a death
certificate of the previous spouse); and
v. Legal
finding of common law marriage through any legal proceeding prior to the
decedent’s death.
f. A
surviving spouse who does not qualify as a whole dependent, may qualify as a
partial or prospective dependent if the surviving spouse provides documentation
showing some support from the decedent.
4. Dependent
Children
a. Claims
services staff shall presume a child of the decedent is a whole dependent when:
i. The
child is under the age of 18;
ii. The
child is under the age of 25 and pursuing a full-time educational program while
enrolled in an accredited educational institution and program;
iii. The child
is 18 years old or older, living with the decedent at the time of death, and
has a physical or mental condition that prevents the child from generating
earnings; and
iv. The decedent was
contributing more than one-half of the support for the child or was legally
responsible for the maintenance of the child at the time of decedent’s death.
v. A
step child may be a dependent if the decedent is married to the surviving
spouse/mother of the step child and providing more than one-half support and in
addition, the other biological parent of the step child is not contributing to
the child’s support.
b. Claims
services staff shall obtain the birth certificate of any biological or adopted
child of the decedent’s for which benefits are being requested, in addition to
documentation that may be required based on the child’s circumstances as
described in sections V.D.4.c.-k. immediately below.
c. Child
18 but less than 25 years old, pursuing a full-time educational program in an
accredited educational institution at the time of death:
i. Claims
services staff shall require supporting documentation, such as:
a) Class
registration or schedule;
b) Report of
grades for completed courses;
c) Proof of
payment of fees and/or tuition;
d) School
transcript;
e) Letter of
acceptance into an educational institution; and/or
f) Proof
of the school’s accreditation.
ii. Claims
services staff may request more than one type or source of documentation as is
reasonably necessary to establish the child is pursuing a full-time educational
program in an accredited educational institution and program at the time of the
decedent’s death.
iii. Claims
services staff shall ensure the documentation adequately identifies the child,
the educational institution and the time period the information addresses
(e.g., year and semester).
iv. Claims services
staff shall ensure documentation received is reasonably reliable and accurate
(e.g., appears printed from a school website, contains the school’s
letterhead).
v. Claims
services staff may supplement the documentation with information readily
available on the Internet (e.g., academic calendar to establish dates of
educational periods, such as semester beginning and ending dates, school
information regarding accreditation, information on what constitutes full-time
attendance).
vi. Claims services
staff shall continue paying death benefits during a break, providing the break
does not last longer than one grading period during any academic year
(semester, quarter, etc.).
vii. Claims services staff
shall only consider grades to the extent they may indicate the child is not
attending classes, withdrawn or otherwise not pursuing a full-time program.
viii. Claims services staff may refer
potentially fraudulent requests for death benefits to the Special
Investigations Unit for further investigation.
d. Adult
dependent(s) 18 years old or older with a mental or physical condition that
prevents the adult dependent from generating earnings:
i. Claims
services staff shall require medical documentation verifying the adult
dependent’s mental or physical disability, including the anticipated duration
of the condition that prevents the adult dependent from generating earnings.
ii. Claims
services staff may request more than one type or source of documentation as is
reasonably necessary to establish the adult dependent is physically or mentally
incapacitated from earning.
iii. Claims
services staff shall not disqualify an adult dependent otherwise qualifying as
a dependent under this provision due to the adult dependent working in a
sheltered workshop, if the adult dependent does not earn more than two thousand
dollars in any calendar quarter.
iv. Claims services
staff may refer potentially fraudulent requests for death benefits to the
Special Investigations Unit for further investigation.
e. If the
child is adopted, claims services staff shall require:
i. A
birth certificate listing the decedent as the child’s parent;
ii. A
copy of the court documents establishing the adoption; or
iii. If the
adoption is not finalized at the time of the decedent’s death, legal documentation
or other evidence establishing the level of support that was being provided by
the decedent.
f. If
the decedent and the child’s other parent were never married, claims services
staff shall require:
i. A
birth certificate listing the decedent as the child’s parent or other
documentation showing the decedent is the biological parent of the child (e.g.,
court ordered child support, paternity test, etc.); and
ii. An
affidavit or other evidence that confirms the child has not been adopted by
another.
g. If the
child is living with the decedent’s ex-spouse, claims services staff shall
require an affidavit confirming the child has not been adopted by another.
h. If the
decedent is alleged to be the parent of an unborn child, and the mother is not
the decedent’s spouse, once the child is born claims services staff shall
require documentation verifying the decedent is the biological parent.
i. A
stepchild is not presumed to be a whole dependent, but documentation may be
submitted which supports a determination that the stepchild is a whole,
partial, or prospective dependent, based on the circumstances and level of
support the decedent was providing the stepchild. In addition to the
documentation described in this section and V.E.
below, evidence necessary to make this determination includes:
i. Documentation
of the marriage of the decedent and natural parent;
ii. Documentation
showing the stepchild was living with the decedent at the time of the
decedent’s death;
iii. Documentation
showing that the decedent was financially supporting the stepchild at the time
of the decedent’s death; and
iv. Documentation
showing that the other biological parent is not paying child support and
providing any financial support to the stepchild.
j. Guardians
i. If
the decedent’s minor child is living with the surviving parent, claims services
staff shall verify (verbally or in writing) that the surviving parent is the
guardian of a decedent’s minor child and no further documentation shall be
routinely required.
ii. If a
claimant has a court appointed guardian, claims services staff shall request
from the guardian or whatever source necessary a copy of the court documents
appointing the guardian.
iii. If a minor
child does not have a guardian (a surviving parent or court appointed
guardian), claims services staff shall withhold benefits until a guardian is
appointed, or until BWC receives a court order directing it to pay benefits.
k. Claims
services staff shall require any other additional documentation as may be
necessary based on the circumstances.
5. Other
Potential Whole Dependents: Any family member living with the decedent at the
time of death may be determined to be a whole dependent if claims services
staff obtains evidence that shows the decedent was responsible for at least
half of the family member’s support.
6. Partial
Dependents: Claims services staff shall verify partial dependents with
documentation showing:
a. The claimant
was a family member of the decedent.
b. The claimant
was living with the decedent at the time of death; and
c. The
decedent provided the claimant some financial support for living expenses
(e.g., payment of rent or mortgage, medical bills, groceries, utilities).
7. Prospective
Dependents: Claims services staff may identify a prospective dependent when:
a. The claimant
was a family member of the decedent;
b. The
prospective claimant was living with the decedent at the time of death; and
c. There
are circumstances that clearly indicate a financial need on the part of the
claimant and that the decedent intended to provide some support. (e.g., bank
statements showing past payment of utilities or other living expenses of the
claimant, affidavits from claimant, other family members or friends).
8. Surviving
Natural Parent
a. Claims
services staff shall verify the natural parent of the decedent with the
decedent’s birth certificate.
b. Claims
services staff may determine the natural parent living with the decedent at the
time of death is a whole or partial claimant.
c. If
claims services staff determine that the natural parent living with the
decedent at the time of death is not a whole or partial claimant, claims
services staff shall presume the natural parent is a prospective claimant and
shall make a minimum award of $3,000 as required by law.
9. Claims
services staff shall consider a presumption of dependency to be rebuttable.
Claims services staff shall determine when a claimant is a dependent and the
level of dependency in accordance with the facts of each particular claim.
E.
Determination of the Claim and Death Benefits
1. Determination
of the Claim
a. Claims
services staff shall review the documentation in the claim.
b. Claims staffing
i. For
claims assigned to the Survivor Benefits team, a formal multi-disciplinary
staffing shall occur, prior to issuing an order.
ii. The
death benefits formal staffing shall include the following team members:
a) The IMS;
b) An MSS;
c) A
representative from Claims Policy;
d) A legal
representative from the Legal Services Division;
e) Claims
services staff assigned to the claim; and
f) Other
staff as needed based on the issue(s) in a claim.
iii. To
expedite claim determinations, each staffing team member shall, to the extent
reasonably possible, review the claim prior to the scheduled staffing.
iv. The
multi-disciplinary staffing shall address matters related to determining the
claim and as needed, matters related to dependency.
v. Members
of the staffing team shall provide input and assistance based on the member’s
respective area of expertise.
vi. When the
staffing team identifies the need for additional information or documentation,
the IMS may schedule an additional staffing or discuss the issue through email,
as necessary.
c. When
determined necessary to clarify the cause of death and the relatedness to the
injury or occupational disease, claims services staff shall request a physician
file review.
i. The
MSS shall assist with identifying when a referral is appropriate and making the
referral, consistent with the Independent
Medical Exams and Physician File Reviews policy.
ii. The
MSS and BWC attorney shall collaborate as necessary, in preparing the
appropriate questions to be addressed by the physician completing the file
review.
d. The
determination of a death claim shall be made by claims services staff and the
IMS based on all the evidence in the claim. The evidence in the claim must
prove each element of compensability.
e. Claims
services staff shall issue the initial claim determination by order.
f. Claims
services staff shall address the order to the selected claimant, with a copy to
any other claimants, the employer and any authorized representatives.
i. If
the claim is allowed, the order shall include the following, as applicable:
a) A brief
statement of the reason for and the evidence supporting the decision;
b) A listing
of the claimant(s) including name, date of birth, the determined level of
dependency (whole, partial or prospective) and the period of payment;
c) If there
is evidence available, the average weekly wage, or the minimum or maximum rate
used to calculate the weekly benefit;
d) The weekly
benefit and the apportionment;
e) The effect
of remarriage of the surviving spouse and the limitations/requirements for
continuing benefits for children;
f) Funeral
expenses payable; and
g) Any other
related issue(s).
ii. If
the claim is denied the order shall include a brief statement of the reason for
and the evidence supporting the denial.
g. In an
existing claim claims services staff shall:
i. Change
the claim type from “accident” or “OD” to “death” if the claim is allowed; or
ii. Keep
the claim type as accident or OD if the claim is denied.
h. For
purposes of processing in the claims management system only, when a new claim
is allowed, claims services staff shall enter “allowed” conditions supported by
the evidence.
i. If
a request for death benefits is withdrawn by the claimant, claims services
staff shall dismiss the claim.
2. Funeral
Expenses
a. Claims
services staff shall award verified funeral expenses in an allowed claim up to
a maximum allowed by law.
i. Prior
to issuing any payment for funeral expenses, claims services staff shall verify
the amount of the balance or payment in full of the funeral expenses. Payment
shall be made directly to the individual that made payment and/or to the unpaid
service provider.
ii. Funeral
costs deducted from the proceeds of an insurance policy shall typically be
reimbursed to the beneficiary of the insurance policy.
iii. Claims
services staff shall consult with the IMS and BWC attorney if there is any
question regarding reimbursable/payable funeral expenses.
b. In
addition to standard funeral expenses, claims services staff may pay
exceptional costs related to the transportation of the decedent’s body.
Examples:
i. The
decedent died outside his/her state of residence while seeking BWC approved
medical treatment for an allowed condition;
ii. The
decedent died while working far enough away from the decedent’s residence to
incur exceptional costs to transport the decedent’s body.
iii. The
determination of reimbursement or payment of exceptional costs related to the
transportation of the decedent’s body shall be made by claims services staff,
the IMS and the BWC attorney, when necessary.
3. Medical
Expenses
a. Medical
expenses related to the decedent’s death are submitted to the MCO and processed
pursuant to standard procedure for medical bill payments
b. See the MCO
Policy Reference Guide for further information.
4. Payment of
Death Benefits
a. Benefits
to a claimant(s) shall begin the day after the death of the decedent and
continue until the claimant’s status changes and benefits terminate.
b. Benefits
to an unborn child begin the day the child is born.
c. Benefits
to a claimant with a guardian shall be payable to the claimant, consistent with
the Custody,
Guardianship, Power of Attorney and Incapacitation policy.
d. Whole
Dependent Benefit Rates
i. Claims
services staff shall calculate the benefit for a whole dependent(s) at 66 2/3%
of the decedent’s average weekly wage.
ii. The
weekly rate shall not exceed the statewide average weekly wage for the year of
death or be less than 50 percent of the statewide average weekly wage for the
year of death.
e. Partial
Dependent Benefit Rates
i. Claims
services staff shall calculate the benefit for a partial dependent(s) at 66
2/3% of the decedent’s average weekly wage.
ii. The
weekly rate shall not exceed the statewide average weekly wage for the year of
death.
iii. There is
no minimum weekly rate
f. Prospective
Dependent Benefit Rates
i. Claims
services staff shall calculate the benefit for a prospective dependent based on
the amount of support that was received or expected to be received from the
decedent, but the award for all prospective dependents (excluding natural
parents deemed prospective dependents) shall not exceed a total amount of
$3,000.
ii. The
minimum benefit claims services staff shall award to a natural parent(s) living
with the decedent at the time of death and determined to be a prospective
dependent(s) is a total of $3,000.
iii. Claims
services staff shall calculate the benefit for a prospective dependent(s)
separate from the amount of the benefit apportioned among the whole and partial
dependents.
5. Apportioning
Death Benefits Among Claimants
a. When there
are two or more whole and/or partial dependents, claims services staff shall
apportion the one benefit among all the eligible dependents fairly, considering
the circumstances of each particular case.
i. If
there is at least one whole dependent, claims services staff shall apportion
the one benefit, as calculated based on the whole dependent, among the whole
and partial dependent(s).
ii. Claims
services staff shall not factor a prospective dependent and the prospective
dependent’s benefit award into the benefit apportioned among the whole and/or
partial dependent(s).
iii. Claims
services staff shall utilize “Guidelines for Apportioning Death benefits Among
Dependents” available on COR.
b. Claims
services staff shall apportion an award to natural parents, living with the
decedent at the time of death determined to be prospective dependents, equally.
c. If
there is more than one prospective dependent, excluding a natural parent(s),
claims services staff shall apportion the award fairly among the prospective
dependents.
d. Claims
services staff shall staff unusual cases with an IMS, BWC attorney and/or the
Survivor Benefits team for guidance,
6. Family
Support: If there is a family support order against a dependent, claims
services staff shall refer to the Family
Support Orders and Attorney Fees Paid Pursuant to Deductions of Child Support
from Lump Sum Payments policy.
1. Annual
Contact
a. Claims
services staff shall confirm the status of the surviving spouse and/or other
dependent(s) receiving benefits, no less than once every 12 months, to verify
that:
i. The
address is still correct;
ii. The
dependent(s) has not died;
iii. The
dependent is not incarcerated, or has not been incarcerated during the past 12
months; and
iv. There has
otherwise been no change in dependency status affecting eligibility to receive
benefits.
b. Claims
services staff shall use an annual contact letter (available in the claims
management system and/or on COR).
c. The
annual contact letter shall ask the dependent (or recipient of the letter)
whether:
i. The
address is still correct;
ii. The
dependent(s) has died;
iii. The
dependent is incarcerated, or has been incarcerated during the past 12 months;
and
iv. There has
otherwise been any change in dependency status affecting eligibility to receive
benefits.
d. The
dependent shall be required to:
i. Sign
the letter acknowledging and verifying the information provided in the letter;
and
ii. Return
the signed letter and any required documentation to BWC within a stated period
of time. A scanned or faxed copy of the signed letter will fulfill the
signature requirement.
2. Additional
Claimant-Specific Requirements: In addition to the requirements described
immediately above, claims services staff shall take the following steps based
on the circumstances of the claimant:
a. Minor
Child with Guardian: The annual contact letter sent to the listed guardian of a
dependent child under the age of 18 shall verify:
i. The
guardianship is still active; and
ii. The
correct guardian is identified.
b. Surviving
Spouse: The annual contact letter sent to the surviving spouse shall verify
that the surviving spouse has not remarried.
c. Child
Reaching Age 18: Claims services staff shall send a letter to a child who will
be turning age 18 to notify the child he/she is subject to the termination of their
benefits and explaining under what conditions benefits may continue.
d. Child
Pursuing a Full-time Educational Program
i. Every
educational period (e.g., semester, quarter) claims services staff shall
communicate via letter, email or text and require the child to provide:
a) Proof of
continued enrollment in a full-time educational program (e.g., class
registration); and
b) Proof of
participation in and completion of the previous educational period, if
applicable (e.g., a grade report).
ii. Claims
services staff shall continue to send and require the child to sign and return
an annual contact letter.
e. An adult
dependent over the age of 18 with a mental or physical condition that prevents
the adult dependent from generating earnings.
i. Temporary
incapacity: If the original medical documentation indicates the adult
dependent’s incapacitating condition is temporary, claims services staff shall
request updated medical information as deemed appropriate, but no less than
annually.
ii. Permanent
incapacity: When the claim documentation (e.g., the original benefits order)
indicates the adult dependent has a permanent mental or physical incapacity:
a) Claims
services staff shall review the claim to ensure the claim contains the
supporting medical documentation and to determine if there is any reason to
believe the incapacitating condition could have changed.
b) If the
medical documentation in the claim is adequate to support the ongoing permanent
incapacitation, claims services staff shall not request updated medical
documentation.
c) If there
is inadequate medical documentation in the claim to support permanent
incapacitation or there is otherwise reason to request updated documentation
claims services staff:
i) Shall
staff the issue with the IMS; and
ii) If
the IMS approves requesting updated medical documentation, document in claim
notes the reason for the additional medical documentation and that the IMS has
approved the request.
iii. Claims
services staff may refer any potentially fraudulent requests to the Special
Investigations Unit for further investigation.
f. Claims
services staff may request additional documentation from a dependent at any
time to verify continuing eligibility status as is reasonably necessary.
3. Non-Response
to a Contact and/or Information Request: If the dependent(s) does not respond
and/or provide required documentation within the time period required by BWC
via letter or other form of communication, claims services staff shall:
a. Take
reasonable steps to locate and contact the dependent, which may include but is
not limited to:
i. Sending
a second letter to the dependent;
ii. Telephoning
the dependent at the last known phone number;
iii. Contacting
any attorney of record for that dependent;
iv. Reviewing
information in any other workers’ compensation claim the dependent may have for
contact information or an employer or attorney of record;
v. Using
the internet to find:
a) Another
phone number and/or address;
b) Any
information indicating the dependent has died; or
c) Any other
information that may help locate and contact the dependent; and
d) Consulting
and/or referring the issue to the Special investigations Unit for further
investigation into the status of the dependent.
b. Suspend
benefits when reasonable attempts to establish contact and verify the
dependent’s ongoing dependency status have been unsuccessful.
i. Claims
services staff shall not suspend benefits prior to staffing with the IMS, and
BWC attorney if necessary.
ii. If
determined appropriate following staffing, claims services staff shall:
a) Suspend
benefits to the non-responsive dependent only, beginning the next available
benefit period. (Any other dependents shall continue to receive his/her regular
benefit amount); and
b) 30 days
following the date the benefits are first suspended, issue an order terminating
benefits to the non-responsive dependent and reapportion. See Orders,
Waivers, Appeals and Hearings policy for further information.
1. When a
whole or partial dependent’s status changes and benefits were originally
apportioned by BWC, claims services staff shall reapportion the benefit among
the active dependents and issue an order with the reapportioned rates to each
of the impacted dependents.
2. When
benefits were originally apportioned by the IC, a status change of a dependent
and potential reapportionment shall be referred to the IC.
3. Dependency
status changing events include but are not limited to:
a. Remarriage
of a surviving spouse:
i. Upon
remarriage of the surviving spouse, claims services staff shall award two years
of compensation to the surviving spouse in a lump sum payment, using the date
of remarriage as the payment begin and end date. No further compensation shall
be paid to the surviving spouse.
ii. Claims
services staff shall calculate the award using the rate the surviving spouse
was receiving at the time of the remarriage. For example:
a) Surviving
spouse weekly rate at time of remarriage: $400.00
b) Two years
= 104 weeks
c) $400.00 ×
104= $41,600 Total Award
iii. Claims
services staff shall deduct the remaining balance of any lump sum advancement
still in effect at the time of remarriage from the two-year lump sum award,
consistent with the Lump
Sum Advancement policy.
b. Death of a
Claimant: Claims services staff shall terminate benefits to a claimant upon
death and reapportion the benefit among the remaining active claimants.
c. Child
Reaches 18 Years of Age
i. Claims
services staff shall terminate benefits to a child on the day prior to the
child’s 18th birthday, unless the child is enrolled in a full-time
educational program at an accredited educational institution and program,
including high school; or qualifies as an incapacitated child unable to earn
wages.
ii. If
benefits are terminated at age 18 and the child later enrolls in a full-time
educational program at an accredited educational institution and program,
benefits shall be awarded (if otherwise qualified), and reapportioned, if
multiple dependents are receiving benefits. Such award and reapportionment
shall be effective the first day of classes, until the day prior to the child’s
twenty-fifth birthday or until the child stops attending school.
d. Child
Reaches 25 Years of Age or Stops/Starts Attending School
i. Claims
services staff shall terminate benefits for a dependent child that has been
enrolled in a full-time educational institution and program:
a) The day
prior to the child’s twenty-fifth birthday; or
b) When he or
she stops attending the accredited educational institution and program
full-time, whichever comes first.
ii. Benefits
terminated prior to the child’s twenty-fifth birthday may be reinstated if the
child starts attending school again and is otherwise eligible, effective the
first day of classes.
e. Mental or
Physical Incapacity Ends
i. Claims
services staff shall staff a claim with the BWC attorney if evidence indicates
that the adult dependent is receiving earnings and/or the condition that caused
the mental or physical incapacity has resolved to determine if benefits should
discontinue or otherwise change.
ii. Claims
services staff shall issue a BWC order or notice of referral to the IC
indicating whether the benefits are being terminated or reduced and language
that there is no longer evidence of a physical or mental incapacity that
prevents the adult dependent from generating earnings.
f. Claimant
is Incarcerated or Released from Incarceration
i. Claims
services staff shall terminate benefits to a claimant effective the date of
incarceration and may resume benefits upon release of the claimant, if the
claimant is otherwise eligible.
ii. See
the Incarceration
policy for further information.
1. Claims
services staff shall process consistent with the Overpayment of Compensation
policy when:
a. There is
an overpayment of death benefits; or
b. The
claimant has a separate workers’ compensation claim in which there is an
overpayment.
2. Claims
services staff shall refer to and follow the Overpayment
of Compensation policy.
1. Claims
services staff shall approve or deny a request for a lump sum advancement on
death benefits consistent with the Lump
Sum Advancement policy.
2. Claims
services staff shall refer a request for lump sum settlement to the appropriate
LSS team for processing.
3. The LSS
team may settle a death claim consistent with the Lump
Sum Settlement policy.