|
Policy and Procedure Name:
|
Occupational Disease Claims
|
|
Policy #:
|
CP-15-03
|
|
Code/Rule Reference:
|
R.C.
4123.01(F); 4123.511(B) (1); 4123.68
Industrial Commission (IC) Resolution R03-1-02
and R15-1-01.
|
|
Effective Date:
|
08/05/2020
|
|
Approved:
|
Ann M. Shannon, Chief of Claims Policy and Support
|
|
Origin:
|
Claims Policy
|
|
Supersedes:
|
Policy # CP-15-03, effective 09/29/17 and Procedure # CP-15-03.PR1,
effective 05/06/19
|
|
History:
|
Previous versions of this policy are available upon
request
|
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 shall 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 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
injured worker has an allowed occupational disease claim for right carpal
tunnel. The injured worker has surgery, returns to work and carpal tunnel
syndrome has resolved.
ii. The
same injured worker 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 Aggravation and Substantial Aggravation of a Pre-Existing
Condition 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 injured worker to provide:
a. Medical
evidence:
i. A
physician’s statement that addresses the causal relationship between
the alleged occupational disease and the injured worker’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. Injured
worker’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 injured worker alleging a statutory occupational disease to a qualified
medical specialist for an Independent Medical Examination 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 independent
medical examination, 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 shall refer the claim for
a physician file review, not an independent medical examination, prior to the initial claim determination.
5. In cases
of death due to occupational disease, BWC shall refer the claim to a qualified
medical specialist for a physician file review. 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
shall refer to the Standard Claim File Documentation and Altered Documents
policy and procedure for claim note and documentation requirements; and
2. Shall
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, shall 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 injured worker with a mixture of state fund, SI
covered and bankrupt SI employers, shall 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, shall be assigned to the
SI Bankrupt Team.
c. A
firefighter with cancer occupational disease claim, including death claims,
shall be assigned to claims services staff as follows:
i. A
single claim filed alleging cancer - claims services staff handling that injured
worker’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 injured
worker 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 injured worker 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 shall follow the general investigative requirements of the Initial Claim Determination and Compensable Injuries policies
and procedures.
2. Claims
services staff shall ensure that occupational disease claims are timely filed
and meet the statute of limitations. Claims services staff shall 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 shall
ensure that the injured worker has established all required elements of
compensability detailed in the Compensability for Occupational Disease Claims
section of this policy.
4. Medical evidence
a. Claims
services staff shall 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 shall 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 injured worker; 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. Independent
Medical Examinations (IME) and Physician File Reviews (PFR)
a. Claims
services staff shall refer all statutory occupational disease claims for an IME, except statutory occupational
disease death claims, which shall 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 shall create the appropriate medical exam scheduling case or
medical file review case in the claims management system.
6.
Employment information
a. Claims
services staff shall ensure that the injured worker’s detailed employment
history is on file or make at least two attempts to obtain it from the injured
worker and injured worker representative.
b. Detailed
employment history includes, but is not limited to:
i. Injured
worker’s job title and job description(s);
ii. Job-specific
information that could impact the injured worker, 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 shall follow the procedures outlined below.
2. Employment
Information
a. Claims
services staff shall ensure that the injured worker’s detailed employment
history is on file as outlined above in section C.6. a.-b. or make at least two attempts to
obtain it from the injured worker and injured worker representative.
b. Upon
receipt of the injured worker’s detailed employment history, claims services
staff shall:
i. Evaluate
the injured worker’s employment history to determine when the last injurious exposure
causing the occupational disease occurred;
ii. Consider
the injured worker’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 shall 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
shall request the missing information from the injured worker and injured
worker 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.
Independent Medical Exams (IME) and Physician File Reviews (PFR)
a. Claims
services staff shall 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 shall:
i. Only
schedule one IME per injured worker 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.
iii. Claims
services staff shall create the appropriate medical exam scheduling case or
medical file review case in the claims management system.
c. Claims
services staff shall 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 injured worker 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 refer the C-101, via e-mail, 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 shall ensure an injured worker has submitted the
necessary evidence to establish an occupational disease claim and has met the
compensability criteria detailed in the Compensability
for Occupational Disease Claims section 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 shall deny the occupational disease claim.
3. If the
injured worker has not signed the first report of injury and BWC is
recommending denial of the claim, claims service staff shall dismiss the claim
in accordance with the Initial Claim Determination policy and
procedure.
4. Claims
services staff shall:
a. Issue an
initial decision no later than 28 days after receipt of the independent medical
examination 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 shall 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 shall 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 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 shall consult with
a BWC attorney when a %PP request has been made.