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Policy and Procedure Name:
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Permanent Total Disability (PTD) and Disabled Workers’
Relief Fund (DWRF)
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Policy #:
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CP-16-03.2
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Code/Rule Reference:
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R.C. 4123.411 through 4123.417; 4123.58; 4123.62
O.A.C. 4123-3-31; 4123-3-34
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Effective Date:
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11/17/21
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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-16-03, effective 04/20/2015 and Procedure #
CP-16-03-PR.1, effective 05/06/2019
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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
Disabled Workers’ Relief Fund (DWRF)
DWRF Eligibility Amount
Excess Carrier
Permanent Total Disability (PTD)
PTD Declared Rate
PTD With SSD Maximum Rate
PTD Without SSD Maximum Rate
PTD Minimum Rate
PTD Paid Rate
Social Security Crossmatch
Social Security Disability (SSD)
Social Security Retirement (SSR)
Split PTD
Statutory PTD
Total PTD Declared Rate
Wage Replacement Compensation
Weekly Social Security Disability Rate
– DWRF (SSD-DWRF)
Weekly Social Security Disability Rate
– PTD (SSD-PTD)
Weekly Worker’s Compensation Amount
(WWCA)
IV. POLICY
A. PTD Awards
B. DWRF Awards
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. SSA Crossmatch
C. PTD Declared Rate
D. Determining DWRF
Eligibility and Rates
E. Paying PTD and DWRF
F. Re-calculating the PTD
Declared Rate
G. Re-Evaluating DWRF
Eligibility and Rates
H. Terminating/Suspending
PTD
I. PTD Annual Review
J. DWRF Annual Processing
K. PTD/DWRF and LSS
L. PTD/DWRF and LSA
M. SI Bankrupt and Excess
Carriers
N. PTD and Concurrency
with Other Compensation Types
O. Statutory PTD and Concurrency
with Other Compensation Types and Employer-Paid Benefits in the Same Claim
The purpose of this policy is to ensure that BWC calculates
and pays PTD compensation and Disabled Workers’ Relief Fund (DWRF) benefits in
compliance with the Ohio Revised Code and the Ohio Administrative Code when PTD
is granted.
This policy applies to all claims services staff.
Disabled
Workers’ Relief Fund (DWRF): A
fund, separate from the state fund, established to provide supplemental
benefits to injured workers who are receiving PTD compensation when the total
of the PTD compensation plus the social security disability (SSD) benefit is
less than the DWRF eligibility amount.
DWRF Eligibility
Amount: The
threshold amount, adjusted annually based on the consumer price index, used to
determine an IW’s eligibility for DWRF benefits and established by the BWC DWRF
Unit and BWC’s Actuarial Department.
Excess
Carrier: An insurance entity that assumes the liability of a
self-insured claim that has reached a pre-determined limit.
Permanent Total
Disability (PTD): Compensation granted to an injured
worker for the duration of his/her life when the Industrial Commission of Ohio
(IC) determines that the injured worker is unable to perform any sustained
remunerative employment or is statutory PTD as defined in R.C. 4123.58.
PTD Declared
Rate: The amount of the weekly PTD compensation payable
to an injured worker prior to reduction for repayment of any lump sum
advancement (LSA).
PTD With SSD
Maximum Rate:
For injured workers receiving SSD benefits, a rate equal to 2/3 of
the statewide average weekly wage (SAWW) for the date of injury, also known as
the PTD offset rate.
PTD Without
SSD Maximum Rate: For
injured workers not receiving SSD benefits, a rate equal to the SAWW for the
date of injury.
PTD Minimum Rate:
A rate equal to ½ of the SAWW for the date of injury, unless the average weekly
wage (AWW) for the claim is less than that amount; in that case, the PTD rate
is equal to the AWW.
PTD Paid Rate: The
weekly PTD benefit BWC pays to an injured worker; calculated by subtracting the
amount being collected to recoup any LSA(s) from the PTD declared rate.
Social Security
Crossmatch: The electronic receipt of information from
the Social Security Administration (SSA) which provides the name, date of
birth, date of death (if applicable) and social security benefits received (if
any) associated with a Social Security Number (SSN), used by BWC to validate
information in the claim file and/or to calculate temporary total compensation
(TT), PTD and/or DWRF payment rates.
Social Security
Disability (SSD): Benefits paid by the SSA to persons
who cannot work because they have a medical condition that is expected to last
at least one year or result in death. BWC uses the SSD amount prior to any
reduction for Medicare benefits in calculation of PTD and/or DWRF. SSD is not
used in the calculation of TT.
Social Security
Retirement (SSR): Benefits paid by the SSA to persons who
have met the eligibility requirements. SSR benefits may begin as early as a
person’s sixty-second birthday. SSD benefits automatically convert to SSR at
the person’s full retirement age. BWC does not use SSR benefits in the
calculation of PTD and/or DWRF but may use it in the calculation of TT.
Split PTD: PTD compensation allocated
by the IC to more than one claim for an injured worker. The percentage for
each claim is used to calculate the amount payable per claim.
Statutory
PTD: PTD compensation payable based on the loss or loss
of use of both hands or both arms, or both feet or both legs, or both eyes, or
of any two thereof.
Total PTD Declared
Rate: When PTD is split among two or more claims, the total amount
when the declared rate for all claims in the split are added together.
Wage
Replacement Compensation: Compensation intended to replace an
injured worker’s earnings. This includes TT, living maintenance (LM), living
maintenance wage loss (LMWL), wage loss (working and non-working) (WL), PTD and
salary continuation (SC).
Weekly Social
Security Disability Rate – DWRF (SSD-DWRF): The SSD
amount used for calculation of DWRF benefits. The rate is determined by the
monthly SSD amount for the time period being paid multiplied by 12 and divided
by either 365 days, or 366 days in a leap year, and then multiplying the result
by seven. This rate is recalculated whenever there is a change in the SSD rate.
Weekly Social
Security Disability Rate – PTD (SSD-PTD): The SSD amount used
for the calculation of PTD compensation. For the initial payment of PTD the
rate is determined by the monthly SSD amount as of the PTD begin date being
multiplied by 12 and divided by 52. This rate is recalculated if the SSD
decreases below the rate on the PTD begin date, begins after the PTD begin
date, changes from SSD to SSR, or ends for another reason.
Weekly Worker’s
Compensation Amount (WWCA): A
component of the PTD declared rate calculation that is calculated as follows:
1. If 2/3 of the
AWW is greater than or equal to the PTD with SSD maximum rate, the PTD with SSD
maximum rate is the WWCA; or
2. If the AWW is
less than the PTD minimum rate, the AWW is the WWCA; or,
3. If the AWW is
greater than or equal to the PTD minimum rate, but 2/3 of the AWW is less than
the PTD minimum rate, the PTD minimum rate is the WWCA; or
4. If 2/3 of the
AWW is more than the PTD minimum rate, but less than the PTD with SSD maximum
rate, 2/3 of the AWW is the WWCA, not to exceed the PTD without SSD maximum
rate.
1. PTD Payments
a. It is the policy
of BWC to pay PTD as ordered by the Industrial Commission of Ohio (IC) as
follows:
i. Hold
the payment of PTD until a copy of the IC order is received by BWC from the IC;
ii. Continue
to pay PTD until the death of the injured worker (IW), the PTD claim is settled
or until BWC receives an IC order terminating PTD; and
iii. Continue to pay
PTD to IWs who have been found PTD as the result of a traumatic brain injury
and who return to work in a sheltered workshop earning $2000 or less in any
calendar quarter.
b. It is the policy
of BWC to pay PTD less other wage replacement compensation and/or percentage of
permanent partial (%PP) impairment paid over the same period.
c. The
initial accrued payment of PTD may be issued in care of the IW’s representative
if a properly completed Authorization to Receive Workers’ Compensation Check
(C-230) has been submitted prior to the initial payment. For additional
information, refer to the Authorization
to Receive a Workers’ Compensation Payment policy.
d. PTD payments,
both accrued in the past and scheduled biweekly into the future, are subject to
weekly family support withholding.
i. Accrued
PTD payments are not subject to lump sum processing for child support.
ii. Refer to
the Family
Support and Attorney Fees Paid Pursuant to Deductions of Child Support from
Lump Sum Payments policy for additional information
e. PTD payments are
subject to collection of overpayments. Refer to the Adjustment
of Overpaid Compensation policy for additional information.
f. IWs
may receive a Lump Sum Advancement (LSA) from future PTD compensation. For
additional information, refer to the Lump
Sum Advancement policy.
2. Declared Rate
Calculation
a. No type of
retirement benefit will be considered when calculating the PTD declared rate.
b. BWC shall not
recalculate the PTD declared rate when the SSD increases. It is the policy of
BWC to recalculate the PTD declared rate only when:
i. The
AWW in the claim changes;
ii. The SSD
weekly rate decreases to a rate lower than the original PTD declared rate;
iii. The IW begins
receiving SSD; or
iv. The IW stops receiving
SSD.
c. External
customers may access the PTD Rate Calculation Worksheet on BWC’s website in the
“Tools for Authorized Representatives” offering.
3. Statutory PTD
a. IWs who are
statutorily PTD may return to work and continue to receive PTD compensation.
b. In claims other
than the IW’s statutory PTD claim, it is the policy of BWC to pay:
i. TT
or LM, as appropriate; and
ii. WL or LMWL,
as appropriate so long as the wage loss is caused by conditions other than
those which are the basis for statutory PTD.
4. Multiple Claims
a. When the IC
orders PTD paid in more than one claim, it is the policy of BWC to calculate
the PTD rate for each claim individually.
b. BWC shall then apply
the split percentage ordered by the IC to determine the declared rate for each
claim.
5. Incarceration
a. It is the policy
of BWC to refer the issue of PTD suspension to the IC when the IW is
incarcerated.
b. For additional
information, refer to the Incarceration
policy.
1. It is the policy
of BWC to use the IW’s PTD declared rate to proactively determine if the IW is
eligible to receive DWRF benefits when PTD is granted in both SF and SI claims.
No application is necessary.
2. It is the policy
of BWC to consider Social Security Administration (SSA) benefits in the
calculation of DWRF benefits as follows:
a. SSD benefits are
included in the calculation of DWRF benefits.
b. SSR benefits are
not included in the calculation of DWRF benefits.
c. Widow’s
benefits or other benefits received by the IW under another person’s SSN are
not considered in the calculation of DWRF benefits.
3. It is BWC’s
policy to issue an order to provide notice of the decision regarding DWRF when:
a. The initial
evaluation is complete; and
b. Anytime DWRF
benefits change.
4. DWRF Re-Evaluation
a. BWC must
re-evaluate DWRF eligibility and payment rate for IWs receiving PTD when:
i. The
PTD rate is changed;
ii. The IW
begins receiving SSD benefits;
iii. The IW’s
SSD-DWRF weekly rate changes;
iv. The IW stops receiving
SSD benefits; or
v. The DWRF
eligibility amount changes, usually January 1 each year.
b. BWC shall not honor
a C-230 for any DWRF payment or for any other request for fees associated with
assisting the IW in receiving DWRF benefits.
5. LSAs
a. An IW may not
receive an LSA from future DWRF benefits.
b. For additional
information, refer to the Lump
Sum Advancement policy.
6. Lump Sum
Settlements (LSS)
a. When calculating
a settlement of a claim, if DWRF is being paid in the claim, the DWRF
settlement amount will be calculated separately.
b. For additional
detail, please reference the BWC’s Lump
Sum Settlement policy.
7. Family Support
a. DWRF benefits
are not compensation, but rather a supplemental award, and therefore are not
subject to family support order withholding.
b. BWC shall not
withhold any amount from DWRF benefits for family support orders.
8. DWRF
Overpayments
a. If an
overpayment of DWRF is identified, it is the policy of BWC to refer the claim
to the IC to determine if the:
i. IW
is overpaid; and
ii. Overpayment
will be collected from the IW.
b. If the DWRF
overpayment is to be collected, it is the policy of BWC to only collect from
future DWRF increases, according to Adjudications
Before the Ohio Industrial Commission, Memo S2 – Overpayment Policy.
9. DWRF Payments in
SI Claims
a. BWC will bill SI
employers for DWRF paid in all SI claims.
a. BWC will also
bill employers in claims that were previously SF, when the employer was SF and
is now SI.
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. Claims services
support staff shall manually request a current social security crossmatch in
the claims management system when:
a. There is not a
crossmatch record which has been verified within the last month; and
b. A claim for the
IW is listed on the PTD hearing docket provided by the IC.
2. After PTD is
granted, the PTD/DWRF CSS must:
a. Update any
non-verified responses from the crossmatch which indicates that the BWC and SSA
data does not match; or
b. Resolve any
conflicting information, such as date of birth, on a verified record.
3. The PTD/DWRF CSS
must enter a note to document the outcome of the review of the verified
information from the crossmatch.
4. If the IW does
not have an SSN or the SSN cannot be verified with the crossmatch, the PTD/DWRF
CSS must attempt to verify social security status with the IW prior to making
payment. The PTD/DWRF IMS must perform an override to make payments if the SSN
cannot be verified.
5. PTD/DWRF staff
will receive a work item and enter a retirement date for the IW in the claims
management system when:
a. The crossmatch
indicates that the IW is receiving SSR; or
b. The IW reaches
full retirement age as determined by SSA.
1. The following
information must be available to calculate the PTD declared rate:
a. The IW’s average
weekly wage (AWW). For some IWs, their AWW is zero (see the Wages
policy for further information);
b. The PTD without
SSD maximum rate for the year of the injury or occupational disease (commonly
referred to as PTD max, this amount is equal to the statewide average weekly
wage [SAWW] for the year of injury or occupational disease);
c. The PTD
with SSD maximum rate for the year of the injury or occupational disease
(commonly referred to as PTD offset, this amount is equal to two-thirds of the
SAWW for the year of injury or occupational disease);
d. The PTD minimum
rate for the year of the injury or occupational disease (commonly referred to
as the PTD min, this amount is equal to one-half of the SAWW for the year of
injury or occupational disease); and,
e. A current
verified social security crossmatch record (i.e., verified within the last 30
days), which includes the amount of SSD received by the IW.
2. For claims with
dates of injury prior to 1/1/1976, the PTD/DWRF CSS shall verify social
security crossmatch information for SSD only for the calculation of DWRF
benefits. There are no impacts to the PTD calculation for these claims.
3. For claims with
dates of injury on or after 1/1/1976, the PTD/DWRF CSS shall review claims
notes for a note regarding information received in the SSA crossmatch.
4. The PTD/DWRF CSS
must use the SSD amount received by the IW on the PTD begin date for the
calculation of the initial PTD declared rate.
5. Calculating the
PTD Declared Rate
a. The PTD/DWRF CSS
shall calculate the PTD declared rate by combining the SSD-PTD weekly rate with
the WWCA.
b. If the AWW is below
the PTD minimum rate, the AWW is the PTD declared rate; or
c. If the AWW
is above the PTD minimum rate, but 2/3 of the AWW is under the PTD minimum
rate, the PTD minimum rate is the PTD declared rate; or
d. If 2/3 of the
AWW is above the PTD minimum rate, but below PTD with SSD maximum, 2/3 of the
AWW is the PTD declared rate; or
e. If 2/3 of the
AWW is above the PTD with SSD maximum rate, SSD benefits must be considered to
determine the PTD rate.
i. If
the total of the SSD weekly rate and the WWCA is above the SAWW for the DOI,
the PTD declared rate is the PTD with SSD maximum rate for the DOI; or
ii. If the
total of the SSD weekly rate and the WWCA is below the SAWW but greater than or
equal to 2/3 of the SAWW, the PTD declared rate is 2/3 of the AWW, not to
exceed the WWCA.
6. The PTD/DWRF CSS
shall complete PTD Rate Calculation Worksheets, found on the PTD/DWRF CSS job
site in COR, and image them into the claim.
a. A worksheet
shall be completed using SSD rate in effect on the PTD start date (if IW is not
receiving SSD the PTD/DWRF CSS would then enter $0 as the rate.)
b. Subsequently, if
any of the following changes occur to the SSD rate, a new worksheet shall be
completed:
i. IW
is granted SSD;
ii. The IW’s
SSD rate decreases; or
iii. The IW SSD
payments end.
1. DWRF Eligibility
Determination
a. The PTD/DWRF CSS
must determine DWRF eligibility for every IW who is granted PTD compensation.
b. The PTD/DWRF CSS
must issue an order regarding the IW’s eligibility for DWRF in every claim
where PTD is granted. The order shall include:
i. BWC’s
decision to find the IW eligible or ineligible for DWRF;
ii. The DWRF
weekly rate if the IW is found to be eligible; and
iii. BWC’s decision
regarding any back period of eligibility and any rate changes.
2. DWRF Calculation
a. The PTD/DWRF CSS
must calculate DWRF benefits as follows:
i. Add
the total PTD declared rate to the weekly SSD-DWRF rate.
ii. Compare
the total of 2(a)(i). above to the DWRF eligibility amount. If the total is
less than the DWRF eligibility amount, the IW is entitled to DWRF benefits.
iii. If the IW is
entitled to DWRF benefits, the DWRF rate is the lesser of the following
calculations:
a) The DWRF
eligibility amount minus the total PTD declared rate; or
b) The DWRF
eligibility amount minus the weekly SSD-DWRF rate.
b. For example:
i. The
DWRF eligibility amount for the current year is $350.
ii. The IW’s
PTD declared rate is $100 per week and SSD-DWRF rate is $150 per week.
iii. The two rates
combined equal $250, which is below the DWRF eligibility amount for the current
year, so the IW is eligible for DWRF benefits.
iv. To calculate the DWRF
weekly rate the following comparison is made:
a) $350 (DWRF
eligibility amount) - $100 (PTD declare rate) = $250; and
b) $350 (DWRF
eligibility amount) - $150 (SSD DWRF rate) = $200.
v. The DWRF
rate is the lesser of the two, or $200.
c. If PTD is
split across multiple claims, the DWRF amount is allocated across claims based
on the split PTD percentages. For example:
i. The
IC has split PTD across three claims, allocating 20% in claim one, 30% in claim
two and 50% in claim three; and
ii. The DWRF
amount for the IW is $200 per week; then
iii. BWC shall pay
$40 in claim one ($200 times 20%); $60 in claim two ($200 times 30%) and $100
in claim three ($200 times 50%).
d. If the IW is
incarcerated but is eligible to receive DWRF benefits, the SSD amount the IW
would be receiving, but for the incarceration, is used in the calculation of
DWRF benefits.
1. Payment and
Apportionment of PTD
a. The PTD/DWRF CSS
will pay PTD upon receipt of the SHO hearing order granting PTD as follows:
i. Payment
cannot be made until BWC receives the order from the IC.
ii. If an IW
representative contacts BWC requesting payment of PTD and the IC order has not
been received by BWC, the PTD/DWRF CSS shall contact the IC to request a copy
of the order.
iii. Upon receipt of
a tentative order from the IC, the PTD/DWRF CSS shall release the PTD payment:
a) Immediately upon
receipt of a waiver of the objection period from the employer of record; or
b) At the end of
the 14-day (plus four for mailing) objection period for non-statutory PTD; or
c) At the end of
the 30-day (plus four for mailing) objection period for statutory PTD; or
d) If an objection
is filed, payment is held until receipt of an SHO hearing order granting PTD.
iv. Upon receipt of the IC
order addressing an Agreement as to Award for Permanent Total Disability (IC-22),
the PTD DWRF CSS shall release the PTD payment.
b. The PTD/DWRF CSS
must apportion PTD benefits across claims if ordered to do so by the IC (split
PTD).
2. PTD Payment
Begin and End Dates
a. PTD payments
shall begin on the date ordered by the IC.
b. The initial PTD
payment end date is built to end on the IW’s 90th birthday.
i. The
PTD/DWRF CSS shall use the “Age 90 Calc” tab of the PTD calculation worksheet
on COR to determine the end date that should be entered in the claims
management system.
ii. Except for
black lung and marine fund claims, the PTD/DWRF CSS shall not end the PTD
payment plan in November, December, or January of any year.
3. Wage Replacement
and Other Compensation
a. The PTD/DWRF CSS
must deduct any wage replacement or %PP compensation paid on or after the PTD
begin date from the PTD payment if the IC order indicates that PTD is to be
paid less previously paid compensation.
i. The
PTD/DWRF CSS must void any wage replacement paid on or after the PTD begin date
and absorb the resulting overpayment from the PTD payments.
ii. If the
weekly rate of the wage replacement is higher than the PTD rate, the PTD/DWRF
CSS must process the remaining overpayment as directed in the Overpayment
of Compensation policy and procedure.
b. The PTD/DWRF CSS
must not void a %PP award paid on or after the PTD begin date. The PTD/DWRF CSS
shall:
i. Calculate
the offset; and
ii. Refer to
the PTD/DWRF training material on COR for additional information.
c. The
PTD/DWRF CSS must staff with a BWC attorney if TT or %PP compensation was
previously paid over the same period for which PTD is now ordered and the IC
order does not indicate that previously paid compensation must be deducted.
4. Black Lung and
Marine Fund Claims
a. Black lung and
marine fund claims shall be paid as ordered by the Department of Labor.
b. The Black
Lung/Marine Fund CSS must pay PTD at the rate ordered by the Department of
Labor.
c. The Black
Lung/Marine Fund CSS must build payments for black lung and marine fund claims
to end on December 31, pending notice from the Department of Labor of the rate
for the next year.
5. Honoring a C-230
a. The PTD/DWRF CSS
must honor a properly completed C-230 for the initial payment of PTD.
b. See the Authorization
to Receive a Workers’ Compensation Payment policy for additional
information.
6. Family Support
Withholding
a. The PTD/DWRF CSS
must implement weekly withholding orders for family support for all PTD
payments.
b. The initial
payment of accrued PTD is not subject to lump sum processing for family support
but is subject to weekly withholding orders.
c. See the Family
Support and Attorney Fees Paid Pursuant to Deductions of Child Support from
Lump Sum Payments policy and procedure for additional information.
7. Overpayments: The
PTD/DWRF CSS must ensure that overpayments are collected from PTD as directed
in the Adjustment
of Overpaid Compensation and Overpayment
of Compensation policies and procedures.
8. Settlements
a. The PTD/DWRF CSS
must continue to pay PTD and/or DWRF during processing of a Settlement
Agreement and Application for Approval of Settlement Agreement (C-240) up
to the date the BWC Approval of Settlement letter is mailed.
b. See the Lump
Sum Settlement policy and procedure for additional information
regarding processing of C-240s.
9. SSN
Discrepancies
a. If the IW does
not have a valid SSN, the PTD/DWRF CSS must perform a thorough investigation of
the SSN/SSN discrepancy.
b. If the IW does
not have a valid SSN, but the discrepancy is resolved prior to an EBT card
being sent, the PTD/DWRF CSS must notify:
i. The
PTD/DWRF IMS to override the SSN; and
ii. Benefits
Payable to Block the issuance of an EBT card and issue a paper warrant.
c. If the IW
does not have a valid SSN, but the discrepancy is resolved after an EBT card was
sent, the PTD/DWRF CSS must notify:
i. The
PTD/DWRF IMS to override the SSN; and
ii. Benefits
Payable to Block the EBT card and issue a paper warrant.
d. The PTD/DWRF CSS
continues process as normal if the SSN is valid and the discrepancies are
resolved.
10. Paying DWRF
a. Once the IW is
determined to be eligible to receive DWRF benefits, the PTD/DWRF CSS shall:
i. First
build the PTD benefit plan in the claims management system; and
ii. Then build
the DWRF benefit plan in the claims management system.
b. The PTD/DWRF CSS
shall then release the PTD and DWRF payment.
11. PTD/DWRF Payment Adjustments:
For specific direction on processing PTD/DWRF payment adjustments, please
reference the PTD/DWRF training manual on the COR PTD and DWRF policy page.
1. The PTD/DWRF CSS
must complete a review of the PTD rate calculation for potential changes when:
a. The AWW in the
claim is modified;
b. The IW begins
receiving SSD after the PTD begin date;
c. The SSD
rate decreases to an amount less than the IW was receiving on the PTD begin
date;
d. The IW is no
longer receiving SSD; or
e. When the PTD
start date changes.
2. The PTD rate is
not recalculated if the SSD rate increases.
3. If the review
indicates a change in the PTD declared rate:
a. The PTD/DWRF CSS
must issue an order for the new PTD declared rate.
b. The order must include:
i. The
begin date for the new rate;
ii. A
statement that previously paid compensation will be adjusted, if appropriate;
and
a) That the
adjustment will result in additional payment to the IW; or
b) That the
adjustment will result in an overpayment which will be established by a
separate order.
4. Before
recalculating the PTD declared rate, the PTD/DWRF CSS must make certain that
the wages were not set based on the earnings for the 52 weeks prior to the date
of disability. In some claims PTD payments are done in this manner based on
the State ex rel. Price v. Cent. Serv., Inc. court decision.
a. Wages in Price
claims are set based on the earnings for the 52 weeks prior to the date of
disability.
b. The maximum and
minimum PTD rates are based on the date of disability.
c. If the
PTD/DWRF CSS believes the claim is a Price claim, the PTD/DWRF CSS
shall:
i. Staff
the claim with a BWC attorney; and
ii. If the
claim is found to be a Price claim, update the adjustment.
1. The PTD/DWRF CSS
must re-evaluate the IW’s eligibility for DWRF and/or the rate of DWRF payment
when:
a. The PTD declared
rate changes; or
b. The amount of
SSD received by the IW changes outside of a yearly increase in SSD received by
all SSD recipients.
2. The claims
management system re-evaluates all IWs receiving PTD when there is a change in
SSD rate for all persons receiving SSD benefits, usually beginning January 1 of
each year (annual processing). See Section V.J of this procedure for more
information.
3. The PTD/DWRF CSS
shall use $0 as the SSD to recalculate DWRF if:
a. The IW requests
that the DWRF be recalculated because SSD is being paid at $0 due to the
collection of an overpayment by SSA;
b. The IW provides
proof that the overpayment of SSD occurred during a time in which SSD & PTD
were paid simultaneously, thereby artificially depressing the DWRF amounts; and
c. SSD is
$0.00 (including if the IW is receiving SS benefits, but it is a retirement
benefit).
4. The PTD/DWRF CSS
shall staff claims where DWRF must be recalculated with the PTD/DWRF IMS.
5. A DWRF order
shall be issued:
a. By the PTD/DWRF
CSS if the evaluation results in a DWRF rate change, other than for annual
processing; or
b. By the claims
management system during annual processing.
6. The PTD/DWRF CSS
must create a case and complete a NOR to the IC if an overpayment of DWRF
benefits has been identified.
a. Upon receipt of
the IC order, the PTD/DWRF CSS must modify the compensation as directed by the
IC.
b. If the IC order
indicates that an overpayment is not to be collected from the IW, the PTD/DWRF
CSS must request that the overpayment be removed from the claim.
1. The PTD/DWRF CSS
must terminate PTD benefits only upon:
a. The death of the
IW; or
b. The receipt of
an order from the IC terminating PTD benefits.
2. Upon the death
of the IW the PTD/DWRF CSS shall:
a. First reduce the
DWRF payment plan, if applicable;
b. Then reduce the
PTD payment plan to equal the date of death;
c. Then enter
the date of death in the claim;
d. Determine if
accrued compensation is payable (see the Accrued
Compensation policy and procedure). If, after the investigation process
is complete, the PTD/DWRF CSS determines that accrued compensation:
i. Is
payable:
a) Issue an order
which includes both the accrued PTD and DWRF; and
b) Pay the accrued
PTD and DWRF when the award becomes payable.
ii. Is not
payable, it is not necessary to issue an order to stop PTD due to the IW’s death.
3. The PTD/DWRF CSS
must make a referral to the Special Investigations Unit (SIU) if the IW reports
working while receiving PTD.
a. PTD compensation
will continue until direction is received from the SIU.
b. An IC order must
be received prior to suspending or terminating PTD payments.
4. The PTD/DWRF CSS
must follow the Incarceration
policy and procedure if BWC receives notice that an IW receiving PTD benefits
is incarcerated.
5. The PTD/DWRF CSS
shall not terminate or withhold PTD and/or DWRF benefits due to the IW’s
failure to respond to an annual contact letter.
6. The PTD/DWRF CSS
may withhold PTD and/or DWRF benefits if the IW is paid via paper warrant and
more than two consecutive warrants are returned to BWC as undeliverable due to
a bad address.
a. The PTD/DWRF CSS
must complete a thorough investigation to attempt to identify a new address for
the IW.
b. The PTD/DWRF CSS
must staff with the PTD/DWRF IMS prior to withholding benefits.
1. The claims
management system will create a work item once a year for each IW receiving PTD
and/or DWRF benefits.
2. Upon receipt of
the annual contact work item, the PTD/DWRF CSS shall send the PTD annual
contact letter to the IW.
a. If it is
documented in notes that contact has been made with the IW in the last year, no
annual contact letter is necessary if the IW answered the following questions:
i. Is
the address we have on file correct?
ii. What is
the best phone number to use to contact you?
iii. Have you worked
anywhere since you were found to be PTD?
a) If yes, was the
work part time, full time or volunteer?
b) If yes, what is
the name, address and/or phone number of the company or organization you worked
for?
b. If there is no
response is received from the first letter, the PTD/DWRF CSS must attempt a
second letter.
c. If there no
response to the second letter, the PTD/DWRF CSS must attempt to contact the IW
by phone.
d. The PTD/DWRF CSS
must complete the SIU referral form found on the PTD policy page in COR if
unable to contact the IW after two letters and a phone contact.
i. The
CSS shall:
a) Document the
dates of any notes regarding attempted contact with the IW;
b) Document the
date of imaged copies of any returned mail;
c) Document the
dates of the annual contact letters; and
d) Document
attempts to find a new address for the IW, if appropriate.
ii. The
PTD/DWRF CSS shall not withhold PTD benefits based on the lack of response by
the IW to the annual contact letter.
iii. Requests from
SIU to place the PTD/DWRF benefits on hold shall be staffed with the PTD/DWRF
IMS.
e. Upon receipt of a
returned annual contact letter, contact with the IW, or staffing with
SIU/Legal, if necessary, the PTD/DWRF CSS must:
i. Rename
the returned letter if necessary;
ii. Update the
IWs name and/or phone number if necessary;
iii. Update the
document turnaround timeframe;
iv. Make a referral to SIU
if the IW indicates that they have worked since the PTD begin date;
v. Extend any
payment plans that end in November, December, or January of any year to end in
a different month that occurs sometime after the IW’s ninetieth birthday;
vi. Extend any plans that
will end in the next 12 months to at least the IW’s ninetieth birthday, but
still not ending in November, December, or January of any year;
vii. Extend any plans for IWs who
are over 90 to at least the IW’s one hundredth birthday, but still not ending
in November, December, or January of any year; and
viii. Review the SSA information making
certain the IW has not changed to SSR due to early retirement or reached full
retirement and make the appropriate updates, if necessary.
1. The claims management
system will re-evaluate the eligibility and rate of DWRF compensation for every
IW in the claims processing system with an ongoing PTD payment plan when the DWRF
eligibility amount changes.
2. The PTD/DWRF CSS
must comply with processing restrictions for annual processing as identified by
the claims services division (usually in November and December of each year).
3. The PTD/DWRF
CSSs must complete the necessary review and clean-up of claims prior to annual
processing, based on the pre-annual processing reports.
4. The claims management
system generates annual processing orders when:
a. The DWRF rate
for the IW will change;
b. The IW becomes
newly entitled to DWRF;
c. The IW is
no longer entitled to DWRF.
5. Neither the
PTD/DWRF CSS nor the system shall issue an annual processing order when the
IW’s DWRF benefit is increased but no additional payment is made to the IW
because the increase will be withheld to reduce an overpayment in DWRF benefits.
1. Upon receipt of
a C-240, the PTD claim shall be reassigned.
a. The work items
associated with the claim will automatically reassign to the assigned LSS CSS.
b. The LSS CSS
shall coordinate with the PTD/DWRF CSS regarding events in the claim that may
impact the PTD rate.
2. The DWRF portion
of any settlement is calculated and paid independent of other compensation
included in the settlement.
3. LSS CSS may
approve settlement of DWRF benefits with the proper authority without settling
the associated PTD.
4. See the Lump
Sum Settlement policy and procedure for additional information.
1. The PTD/DWRF CSS
must build an LSA offset for the reduction of any LSA paid from future PTD.
2. The PTD/DWRF CSS
shall not modify the PTD declared rate when an LSA is granted.
3. No LSA shall be
granted from future DWRF payments.
4. Additional
information regarding LSAs can be found in the Lump
Sum Advancement policy and procedure.
1. Excess Carriers
may periodically request information regarding a SI bankrupt claim by emailing Excessinsurance@bwc.state.oh.us.
The request may include:
a. The amount of
medical benefits and compensation payments;
b. Authorizations;
and
c. Invoices.
2. If the request
is claims related, the SI department will contact the PTD/DWRF CSS to respond.
The PTD/DWRF CSS must respond to these requests as soon as possible, as a delay
in response may result in BWC becoming permanently responsible for the payment
of the claim.
3. The PTD/DWRF CSS
or PTD/DWRF IMS must forward all email inquiries they receive directly to Excessinsurance@bwc.state.oh.us
for review and assignment.
1. TT
a. Claims services
staff shall not pay TT in the same claim as PTD.
b. Claims services
staff may pay TT in a claim other than the PTD claim when an IW is found to be
statutorily PTD and continues to work. See Section V.O of this procedure for
more information.
2. LM
a. Claims services
staff shall not pay LM in the same claim as non-statutory PTD has been ordered.
b. Claims services
staff may pay LM in lieu of PTD in a claim for an IW who was found to be
statutorily PTD. See Section V.O of this procedure for more information.
3. %PP
a. The PTD/DWRF CSS
shall deduct %PP from PTD paid in the same claim and over the same period.
b. Claims services
staff shall not pay %PP in a claim once PTD is granted.
4. WL and LMWL
a. Claims services
staff shall not pay WL or LMWL in any claim for an IW receiving non-statutory
PTD.
b. For IWs who are
statutorily PTD, claims services staff may pay WL or LMWL in a claim other than
the statutory PTD claim, when the wage loss in the different claim is a result
of conditions other than those that were the basis for the finding of statutory
PTD. See Section V.O of this procedure for more information.
5. Claims services
staff shall pay scheduled loss compensation, including facial disfigurement,
concurrently with PTD in the same or another claim, if appropriate.
6. The PTD/DWRF CSS
shall pay violation of specific safety rule (VSSR) awards concurrently with PTD
if appropriate.
7. See the specific
policy and procedure for each of these compensation types for more information.
1. The PTD/DWRF CSS
shall not offset statutory PTD benefits for payments the IW receives for
disability benefits from an employer.
2. The PTD/DWRF CSS
shall not pay TT, WL, or LMWL in the same claim in which statutory PTD benefits
are being paid.
3. The PTD/DWRF CSS
shall suspend PTD and pay LM compensation if the IW enters a vocational
rehabilitation plan in a PTD claim and chooses to receive LM.