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Policy
and Procedure Name:
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Occupational
Disease Claims
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Policy
#:
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CP-15-03
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Code/Rule
Reference:
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R.C. 4123.01(F); 4123.511(B) (1); 4123.68
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Industrial
Commission (IC) Memo/Resolution
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IC
Resolution R15-1-01
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Effective
Date:
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08/05/2020
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Approved:
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Ann
M. Shannon, Chief of Claims
Policy and Support
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Origin:
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Claims
Policy
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Supersedes:
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Policy
# CP-15-03, effective 09/29/17 and Procedure # CP-15-03.PR1, effective
05/06/19
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History:
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Previous
versions of this policy are available upon request
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Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Causal Relationship
Date of Disease
Injurious Exposure
Last Injurious Exposure
Non-scheduled Occupational
Disease
Occupational Disease
Risk
Scheduled Occupational
Disease
Standard Injury Claim
Statutory Occupational
Disease
IV. POLICY
A. Compensability
for Occupational Disease Claims
B. Supporting
Evidence for Occupational Disease Claims
C. Statutory
Occupational Disease Claims
D. Compensation and
Medical Benefits in Occupational Disease Claims
V. PROCEDURE
A. General Claim
Note and Documentation Requirements
B. Assignment of
Occupational Disease Claims
C. Occupational
Disease Claim Investigation
D. Statutory
Occupational Diseases
E. Initial
Determination for Occupational Disease Claims
F. Occupational
Disease Claims and Compensation
The
purpose of this policy is to ensure that BWC determines and manages
occupational disease claims appropriately and in compliance with applicable
laws.
This
policy applies to claims services staff.
Causal Relationship: A connection
between the medical diagnosis, the industrial accident, occupational disease or
death, and the employment that establishes whether an injury or condition is compensable. There
is both a medical and legal aspect to the causal relationship:
- A
medical concept describing a relationship between the injury, condition,
or death and the industrial accident or occupational disease; and
- A
legal concept that establishes a relationship between the injured worker’s
employment and the industrial accident, occupational disease or death.
Date
of Disease: For purposes
of this policy, it is the latest of one of the following events:
- The
date the injured worker first became aware through medical diagnosis that they
were suffering from an occupational disease; or
- The
date the injured worker first received medical treatment for the
occupational disease; or
- The
date the injured worker first quit work because of the occupational
disease.
Injurious Exposure: Contact with a
hazardous substance or process that either proximately causes the occupational
disease, or augments or aggravates a pre-existing occupational disease.
Last
Injurious Exposure: A legal principle which assigns
workers' compensation liability, for occupational diseases with long latency
periods, to the employer last providing hazardous exposure, if the employee has
worked for multiple employers during that time.
Non-scheduled
Occupational Disease: A disease not specifically
listed in R.C. 4123.68, but which otherwise meets the definition of a
compensable occupational disease as defined in R.C. 4123.01.
Occupational
Disease: A disease
contracted in the course of employment, where the employment is shown to create
a risk of contracting the disease in greater degree and in a different manner
from the general public. The disease’s causes and the characteristics of its
manifestation must demonstrate a relationship to the work environment, or the
condition of the employment environment must be shown to result in a hazard
which distinguishes the employment in character from employment generally.
Risk: For purposes
of this policy, exposure to the chance of injury, loss, hazard, or danger.
Scheduled
Occupational Disease: A disease listed in R.C.
4123.68 that an injured worker contracts in the course and scope of employment.
Standard Injury
Claim: A claim
involving a work-related accident, not an occupational disease.
Statutory
Occupational Disease: For purposes of this policy, a
scheduled occupational disease that requires an independent medical examination
prior to claim determination. The following are considered statutory
occupational diseases:
- Berylliosis;
- Any
cardiovascular, pulmonary, or respiratory disease of a firefighter or
police officer caused or induced by the cumulative effect of exposure to
heat, smoke, toxic gases, chemical fumes, and other toxic substances;
- Silicosis;
- Coal
miners’ pneumoconiosis;
- Asbestosis;
and
- Any
other occupational disease of the respiratory tract resulting from
injurious exposure to dust.
A. Compensability
for Occupational Disease Claims
1. A compensable
claim may be established for either a scheduled or non-scheduled occupational
disease. For consistency purposes, the policy will use the language
“occupational disease claim” to reference both.
2. To establish
the compensability of an occupational disease claim, it is the policy of BWC to
require proof of the following:
a. A work-related
exposure to a hazardous substance or process;
b. A harmful
effect that is confirmed by medical diagnosis;
c. A causal
relationship between the work-related exposure and harmful effect that is
confirmed by a medical diagnosis by a physician; and
d. For a
non-scheduled occupational disease, the conditions of employment created a
greater risk to the injured worker (IW) than to the general public.
3. When
determining compensability, it is the policy of BWC to consider evidence
regarding:
a. Mechanism or
agent causing the disease;
b. Type of
employment;
c. Employment
history;
d. Medical
documentation; and
e. Any other
pertinent information.
4. It is the
policy of BWC to establish the date of disease during the initial determination
of the claim.
5. It is the
policy of BWC that a pre-existing disease aggravated during employment is not
compensable as an occupational disease claim, with the following exception:
a. When a
pre-existing disease is aggravated or substantially aggravated by an injury.
This situation may be compensable as an injury claim.
b. For example:
i.
An
IW has an allowed occupational disease claim for right carpal tunnel. The IW
has surgery, returns to work and carpal tunnel syndrome has resolved.
ii. The same IW
subsequently gets injured when a press comes down on the right hand and the
pre-existing carpal tunnel syndrome is aggravated.
iii. The claim may
be allowed for an aggravation or substantial aggravation of a pre-existing
disease.
c. Refer to the Aggravation
and Substantial Aggravation of a Pre-Existing Condition policy for
additional information.
6. In the event a
firefighter’s cancer claim does not meet the presumption in the Firefighters
with Cancer Occupational Disease Claims policy, it is the policy of BWC
to consider the claim for compensability under the requirements of this policy
and procedure.
1. It is the
policy of BWC to require an IW to provide:
a. Medical
evidence:
i.
A
physician’s statement that addresses the causal relationship between the
alleged occupational disease and the IW’s employment;
ii. Diagnostic
evidence specific to the occupational disease alleged.
b. Employment information:
i.
A
detailed and complete employment history, which includes, but is not limited
to:
ii. IW’s job title
and job description(s); and
iii. Date(s) of
employment for each employer worked; and
iv. Specific
information regarding each job.
2. BWC may seek
additional medical evidence and employment information that exceeds the minimum
or may obtain additional diagnostic testing, as necessary, to make an informed
decision.
1. For purposes of
establishing the employer of record, it is the policy of BWC to determine when
and where the last injurious exposure occurred.
2. Prior to making
an initial claim determination, it is the policy of BWC to refer an IW alleging
a statutory occupational disease to a qualified medical specialist for an independent
medical examination (IME) for evaluation and recommendation regarding:
a. Diagnosis;
b. Extent of
disability; and
c. Any other
medical questions concerning the claim.
3. Prior to
referring any alleged claim for silicosis, coal miners’ pneumoconiosis,
asbestosis, or any other occupational disease of the respiratory tract
resulting from injurious exposure to dust (other than mesothelioma) for an IME,
it is the policy of BWC to require the following evidence be submitted:
a. A written
interpretation of:
i.
X-rays
by a certified “B reader”; or
ii. A
high-resolution computed tomography (HRCT);
b. Pulmonary
function studies and interpretation by a licensed physician;
c. An opinion of
causal relationship by a licensed physician.
4. It is the
policy of BWC to handle an alleged mesothelioma claim in the same manner as a
statutory occupational disease claim except that BWC will refer the claim for a
physician file review (PFR), not an IME, prior to the initial claim
determination.
5. In cases of
death due to occupational disease, BWC will refer the claim to a qualified
medical specialist for a PFR. Refer to the Death
Claims
policy for additional information.
1. Compensation
a. It is the
policy of BWC to pay compensation for allowed occupational disease claims only
as permitted by Ohio law.
b. BWC may
consider payment of temporary total disability compensation (TT) in some
allowed occupational disease claims for a period up to six months prior to the
date of disease.
2. BWC may
consider medical services provided for diagnostic examinations and treatment
for payment in an allowed occupational disease claim for a period up to two
years prior to the date of disease.
1. BWC staff will
refer to the Standard
Claim File Documentation and Altered Documents policy and
procedure for claim note and documentation requirements; and
2. Must follow any
other specific instructions for claim notes and documentation included in this
procedure.
1. Occupational
disease claims, including statutory occupational disease claims for any
cardiovascular, pulmonary, or respiratory disease of a firefighter or police
officer caused or induced by the cumulative effect of exposure to heat, smoke,
toxic gases, chemical fumes, and other toxic substances, will remain with the
assigned claims services staff for processing, with the following exceptions:
a. All other
statutory occupational disease claims, including those that have resulted in
death, those filed against a self-insured (SI) employer, or where there are
multiple claims filed for the same IW with a mixture of state fund, SI covered
and bankrupt SI employers, will be assigned to the Stat OD Team.
b. Statutory
occupational disease claims where the only employer is a bankrupt SI employer,
including those that have resulted in death, will be assigned to the SI Bankrupt
Team.
c. A firefighter
with cancer occupational disease claim, including death claims, will be
assigned to claims services staff as follows:
i.
A
single claim filed alleging cancer - claims services staff handling that IW’s
geographic location;
ii. A single claim
filed alleging cancer against a bankrupt SI claim - the SI Bankrupt Team;
iii. A single death
claim filed alleging cancer - the Survivors Benefits team;
iv. An IW with
multiple claims against multiple employers, including death, SI, and bankrupt SI
claims - the Stat OD Team.
2. BWC management
will assign multiple claims filed for the same IW with the same or similar
occupational disease(s) with multiple employers to a single claim’s services
staff member for handling.
3. Exceptions to
claims assignment may be made by BWC management on a case-by-case basis or
based on operational need.
1. In addition to
the requirements of this policy and procedure, claims services staff will follow
the general investigative requirements of the Initial Claim Determination and Compensable
Injuries
policy and
procedure.
2. Claims services
staff will ensure that occupational disease claims are timely filed and meet
the statute of limitations. Claims services staff may refer to the Jurisdiction
(Statute of Limitations, Statutory Life of a Claim) policy and
procedure for additional information.
3. During the
investigation of an occupational disease claim, claims services staff will ensure
that the IW has established all required elements of compensability detailed in
Section IV.A of this policy.
4. Medical evidence
a. Claims services
staff must evaluate all medical evidence on file to:
i.
Determine
if it includes a report from a physician that clearly provides a causal relationship
between the diagnosis and work activity; and
ii. Ensure that it
sufficiently substantiates and supports the diagnosis of the alleged
occupational disease.
b. Medical
evidence may include, but is not limited to:
i.
Office
notes;
ii. Examination
reports;
iii. Diagnostic
testing; and
iv. Pathology
reports.
c. For statutory
occupational disease claims, claims services staff will also:
i.
Request
an Authorization to Release Medical Information (C-101) or any
specialized medical release for a specific health care provider signed by the IW;
and
ii. If the medical
release is not returned to BWC, follow up and document each attempt to obtain
it.
d. For any other
occupational disease claims, claims services staff may request a C-101 or a
specialized medical release for a specific health care provider, as necessary.
5. IME and PFR
a. Claims services
staff will refer all statutory occupational disease claims for an IME, except
statutory occupational disease death claims, which will be referred for a PFR.
See Section V.D of this procedure for additional information.
b. For all other occupational
disease claims, claims services staff may request an IME or PFR to assist in
the investigation, as necessary.
c. Claims services
staff will create the appropriate medical exam scheduling case or medical file
review case in the claims management system.
6. Employment information
a. Claims services
staff will ensure that the IW’s detailed employment history is on file or make
at least two attempts to obtain it from the IW and IW representative.
b. Detailed
employment history includes, but is not limited to:
i.
IW’s
job title and job description(s);
ii. Job-specific
information that could impact the IW, such as:
a) Exposure/use of
chemicals;
b) Exposure/use of
hazardous substances;
c) Exposure/use of
specific tools;
d) Job specific
processes; and
e) Duration of exposure
to the above.
iii. Material safety
and data sheet, if applicable; and
iv. Dates of
employment for each employer worked.
D. Statutory Occupational
Diseases
1. In addition to
the requirements of this policy and procedure, claims services staff will follow
the procedures outlined below.
2. Employment
Information
a. Claims services
staff will ensure that the IW’s detailed employment history is on file as
outlined above in Section V.C.6(a)-(b) above or make at least two attempts to
obtain it from the IW and IW representative.
b. Upon receipt of
the IW’s detailed employment history, claims services staff will:
i.
Evaluate
the IW’s employment history to determine when the last injurious exposure
causing the occupational disease occurred;
ii. Consider the IW’s
employer at the time of last injurious exposure as the employer of record in an
occupational disease claim; and
iii. If necessary,
refer or staff employer policy issues with the Employer Service Specialist.
3. For more
information on determining employer of record when multiple employers are
involved, please see the Coverage
and Employer-Employee Status policy and procedure.
4. Minimum medical
evidence
a. Claims services
staff must verify that the following medical evidence, at a minimum, is
submitted for these specific occupational diseases:
i.
Mesothelioma
a) Pathology
report; and
b) An opinion of
causal relationship by a licensed physician.
ii. Berylliosis
a) Beryllium
Lymphocyte Proliferation Test (BeLPT) results;
b) Lung biopsy or
autopsy; or if pathological tissue cannot be obtained then a high-resolution
computed tomography (HRCT); and
c) An opinion of
causal relationship by a licensed physician.
iii. Silicosis, coal
miners’ pneumoconiosis, asbestosis, or any other occupational disease of the
respiratory tract resulting from injurious exposure to dust (other than
mesothelioma)
a) A written
interpretation of X-rays by a certified “B reader” or HRCT; and
b) Pulmonary
function studies and interpretation by a licensed physician; and
c) An opinion of
causal relationship by a licensed physician.
b. If claims
services staff needs additional medical evidence (over and above the minimum
evidence required) to substantiate and support the alleged occupational
disease, they may consult with the Medical Service Specialist to determine what
additional medical evidence is necessary to make an informed decision in the
claim.
c. In cases where
the minimum evidence is not in the claim, claims services staff must request
the missing information from the IW and IW representative, at least two times,
specifically documenting each attempt in claim notes.
d. In a self-insured
claim where minimum evidence is not in the claim, claims services staff may
contact the self-insuring employer to determine if claims services staff may:
i.
Request
additional medical evidence; or
ii. Hold the claim
while the self-insuring employer requests additional medical evidence; or
iii. Refer the claim
on a notice of referral to the Industrial Commission (IC).
5. IME and PFR
a. Claims services
staff will validate that sufficient medical evidence is in the claim file prior
to referring the claim to a qualified medical specialist for an IME.
b. When referring
a statutory occupational disease claim for an IME, claims services staff must:
i.
Only
schedule one IME per IW regardless of the number of employers listed in the
claim documentation (i.e., multiple claims for the same condition);
ii. Provide any
employment history available in the claim to the IME physician; and
iii. Create the
appropriate medical exam scheduling case or medical file review case in the
claims management system.
c. Claims services
staff will refer the claim for a PFR in cases of statutory occupational disease
death claims. Refer to the Death
Claims
policy and procedure for additional information.
d. Mesothelioma
i.
Mesothelioma
claims are not statutory occupational disease claims and must be determined in
28 days.
ii. Claims services
staff will request the IW sign a C-101 to ensure necessary medical
documentation can be requested, if applicable.
iii. Claims services
staff must review the submitted evidence and all medical documentation on file.
iv. Once the review
is complete, the claims services specialist will report their findings during
the weekly OD staffing.
v. If the
pathology report is not on file or there are deficiencies in the pathology
report on file, the Medical Services Specialist (MSS) will advise the claims
services specialist to request the pathology slides.
vi. Once the claims
services specialist secures a signed C-101:
a) Claims services
staff will email the C-101 to
BWC Disability Evaluation Program (DEP) Central.
b) BWC DEP Central
will:
i)
Request
the pathology slides; and
ii) Notify the
claims services staff if the slides are not received within 14 days.
vii. If the
pathology slides are not received within 14 days from the date of the request,
the MSS will move forward with obtaining the PFR.
1. To allow the
claim, claims services staff must ensure an IW has submitted the necessary
evidence to establish an occupational disease claim and has met the
compensability criteria detailed in Section IV.A of this policy.
2. If information
is missing that is necessary to support allowance and claims services staff has
documented each attempt to obtain the information, claims services staff will
deny the occupational disease claim.
3. If the IW has
not signed the first report of injury and BWC is recommending denial of the
claim, claims service staff will dismiss the claim in accordance with the Initial
Claim Determination policy and procedure.
4. Claims services
staff will:
a. Issue an
initial decision no later than 28 days after receipt of the IME report on a
statutory occupational disease claim; or
b. In SI claims,
update the claims management system with the final decision or refer the issue
on a notice of referral to the IC.
1. Claims services
staff will refer to the Wages policy and
procedure to establish wages in an allowed occupational disease claim.
2. Claims services
staff may consider a request for payment of TT up to six months prior to the
date of disease in an allowed occupational disease claim. Claims services staff
must staff these requests with their supervisor and a BWC attorney.
3. Claims services
staff may pay compensation for cardiovascular, pulmonary, or respiratory
disease for firefighters or police officers; silicosis; asbestosis; coal
miners’ pneumoconiosis; and any other occupational disease of the respiratory
tract resulting from injurious exposure to dust; but are limited to the
following compensation types:
a. TT;
b. Permanent total
disability compensation (PTD);
c. Death benefits;
d. Change of occupation.
4. Claims services
staff may pay compensation for a firefighter with cancer claim that meets the
presumption in the Firefighters
with Cancer Occupational Disease Claims policy but are limited to the
following compensation types:
a. TT;
b. Working wage
loss compensation;
c. PTD;
d. Death.
5. Percentage of
Permanent Partial Disability (%PP)
a. Claims services
staff may process a request for %PP in an occupational disease claim, except
for the following diseases:
i.
Cardiovascular,
pulmonary, or respiratory disease for firefighters or police officers;
ii. Silicosis;
iii. Asbestosis;
iv. Coal Miners’
pneumoconiosis;
v. Any other
occupational disease of the respiratory tract resulting from injurious exposure
to dust; and
vi. Firefighter
with cancer claim that meets the presumption in the Firefighters
with Cancer Occupational Disease Claims policy.
b. For a scheduled occupational disease claim, claims
services staff will consult with a BWC attorney when a %PP request has been
made.