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Policy
and Procedure Name:
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Permanent
Total Disability (PTD) and Disabled Workers’ Relief Fund
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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
Disabled Workers’ Relief Fund
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
– Disabled Workers’ Relief Fund (SSD-Disabled Workers’ Relief Fund)
Weekly Social Security Disability Rate
– PTD (SSD-PTD)
Weekly Worker’s Compensation Amount
(WWCA)
IV. POLICY
A. PTD Awards
B. Disabled
Workers’ Relief Fund Awards
V. PROCEDURE
A. General Claim
Note and Documentation Requirements
B. SSA Crossmatch
C. PTD Declared
Rate
D. Determining
Disabled Workers’ Relief Fund Eligibility and Rates
E. Paying PTD and
Disabled Workers’ Relief Fund
F. Re-calculating
the PTD Declared Rate
G. Re-Evaluating
Disabled Workers’ Relief Fund Eligibility and Rates
H. Terminating/Suspending
PTD
I. PTD Annual
Review
J. Disabled
Workers’ Relief Fund Annual Processing
K. PTD/ Disabled
Workers’ Relief Fund and LSS
L. PTD/ Disabled
Workers’ Relief Fund 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 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: 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
Disabled Workers’ Relief Fund eligibility amount.
Disabled Workers’
Relief Fund Eligibility Amount: The threshold
amount, adjusted annually based on the consumer price index, used to determine
an IW’s eligibility for Disabled Workers’ Relief Fund benefits and established
by the BWC Disabled Workers’ Relief Fund 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 their life when the Ohio Industrial Commission (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 Disabled Workers’ Relief
Fund 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 Disabled Workers’ Relief Fund. 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 Disabled Workers’ Relief Fund
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 – Disabled Workers’ Relief Fund (SSD-Disabled Workers’ Relief
Fund): The SSD
amount used for calculation of Disabled Workers’ Relief Fund 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:
·
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
·
If
the AWW is less than the PTD minimum rate, the AWW is the WWCA; or,
·
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
·
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 Check 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 will 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 will 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 Disabled Workers’ Relief Fund 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 Disabled Workers’ Relief Fund benefits as follows:
a. SSD benefits
are included in the calculation of Disabled Workers’ Relief Fund benefits.
b. SSR benefits
are not included in the calculation of Disabled Workers’ Relief Fund benefits.
c. Widow’s
benefits or other benefits received by the IW under another person’s SSN are
not considered in the calculation of Disabled Workers’ Relief Fund benefits.
3. It is BWC’s
policy to issue an order to provide notice of the decision regarding Disabled
Workers’ Relief Fund when:
a. The initial
evaluation is complete; and
b. Anytime Disabled
Workers’ Relief Fund benefits change.
4. Disabled
Workers’ Relief Fund Re-Evaluation
a. BWC must
re-evaluate Disabled Workers’ Relief Fund 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-Disabled
Workers’ Relief Fund weekly rate changes;
iv. The IW stops
receiving SSD benefits; or
v. The Disabled Workers’
Relief Fund eligibility amount changes, usually January 1 each year.
b. BWC will not honor
a C-230 for any Disabled Workers’ Relief Fund payment or for any other request
for fees associated with assisting the IW in receiving Disabled Workers’ Relief
Fund benefits.
5. LSAs
a. An IW may not
receive an LSA from future Disabled Workers’ Relief Fund 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 Disabled Workers’ Relief Fund is being
paid in the claim, the Disabled Workers’ Relief Fund settlement amount will be
calculated separately.
b. For additional
detail, please reference the BWC’s Lump Sum
Settlement
policy.
7. Family Support
a. Disabled
Workers’ Relief Fund benefits are not compensation, but rather a supplemental
award, and therefore are not subject to family support order withholding.
b. BWC will not
withhold any amount from Disabled Workers’ Relief Fund benefits for family
support orders.
8. Disabled
Workers’ Relief Fund
Overpayments
a. If an
overpayment of Disabled Workers’ Relief Fund benefits 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 Disabled
Workers’ Relief Fund overpayment is to be collected, it is the policy of BWC to
only collect from future Disabled Workers’ Relief Fund benefits increases,
according to Adjudications
Before the Ohio Industrial Commission, Memo S2 – Overpayments.
9. Disabled
Workers’ Relief Fund Payments in SI Claims
a. BWC will bill
SI employers for Disabled Workers’ Relief Fund benefits paid in all SI claims.
b. BWC will also
bill employers in claims that were previously SF, when the employer was SF and
is now SI.
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. Claims services
support staff will 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 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 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 CSS
must attempt to verify social security status with the IW prior to making
payment. The PTD IMS must perform an override to make payments if the SSN
cannot be verified.
5. PTD 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 CSS will verify social security
crossmatch information for SSD only for the calculation of Disabled Workers’
Relief Fund 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 CSS will review claims notes for
a note regarding information received in the SSA crossmatch.
4. The PTD 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 CSS will
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 CSS will
complete PTD Rate Calculation Worksheets, found on the PTD CSS job site in COR,
and image them into the claim.
a. A worksheet will
be completed using SSD rate in effect on the PTD start date (if IW is not
receiving SSD the PTD CSS would then enter $0 as the rate.)
b. Subsequently,
if any of the following changes occur to the SSD rate, a new worksheet will be
completed:
i.
IW
is granted SSD;
ii. The IW’s SSD
rate decreases; or
iii. The IW SSD
payments end.
1. Disabled
Workers’ Relief Fund Eligibility Determination
a. The PTD CSS
must determine Disabled Workers’ Relief Fund eligibility for every IW who is
granted PTD compensation.
b. The PTD CSS
must issue an order regarding the IW’s eligibility for Disabled Workers’ Relief
Fund benefits in every claim where PTD is granted. The order must include:
i.
BWC’s
decision to find the IW eligible or ineligible for Disabled Workers’ Relief
Fund benefits;
ii. The Disabled
Workers’ Relief Fund 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. Disabled
Workers’ Relief Fund Rate Calculation
a. The PTD CSS must
calculate Disabled
Workers’ Relief Fund
benefits as follows:
i.
Add
the total PTD declared rate to the weekly SSD-Disabled Workers’ Relief Fund rate.
ii. Compare the
total of Section V.D.2.a.i immediately above to the Disabled Workers’
Relief Fund
eligibility amount. If the total is less than the Disabled
Workers’ Relief Fund
eligibility amount, the IW is entitled to Disabled Workers’ Relief Fund benefits.
iii. If the IW is
entitled to Disabled
Workers’ Relief Fund
benefits, the Disabled
Workers’ Relief Fund
rate is the lesser of the following calculations:
a) The Disabled
Workers’ Relief Fund
eligibility amount minus the total PTD declared rate; or
b) The Disabled
Workers’ Relief Fund
eligibility amount minus the weekly SSD-Disabled Workers’ Relief Fund rate.
b. For example:
i.
The
Disabled
Workers’ Relief Fund
eligibility amount for the current year is $350.
ii. The IW’s PTD
declared rate is $100 per week and SSD-Disabled Workers’ Relief Fund rate is $150
per week.
iii. The two rates
combined equal $250, which is below the Disabled Workers’ Relief Fund eligibility
amount for the current year, so the IW is eligible for Disabled
Workers’ Relief Fund
benefits.
iv. To calculate
the Disabled
Workers’ Relief Fund
weekly rate the following comparison is made:
a) $350 (Disabled
Workers’ Relief Fund
eligibility amount) - $100 (PTD declare rate) = $250; and
b) $350 (Disabled
Workers’ Relief Fund
eligibility amount) - $150 (SSD-Disabled Workers’ Relief Fund rate) = $200.
v. The Disabled
Workers’ Relief Fund
rate is the lesser of the two, or $200.
c. If PTD is split
across multiple claims, the Disabled Workers’ Relief Fund benefit 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 Disabled
Workers’ Relief Fund benefit amount for the IW is $200 per week; then
iii. BWC will 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 Disabled Workers’ Relief Fund benefits,
the SSD amount the IW would be receiving, but for the incarceration, is used in
the calculation of Disabled Workers’ Relief Fund benefits.
1. Payment and
Apportionment of PTD
a. The PTD 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 CSS will contact the IC to request a copy of the
order.
iii. Upon receipt of
a tentative order from the IC, the PTD CSS will 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 CSS will release the PTD payment.
b. The PTD 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 will
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 CSS will 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 CSS must not end the PTD payment
plan in November, December, or January of any year.
3. Wage
Replacement and Other Compensation
a. The PTD 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 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 CSS must
process the remaining overpayment as directed in the Overpayment of
Compensation
policy and procedure.
b. The PTD CSS
must not void a %PP award paid on or after the PTD begin date. The PTD CSS will:
i.
Calculate
the offset; and
ii. Refer to the
PTD/ Disabled Workers’ Relief Fund training material for additional information.
c. The PTD 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 must 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 CSS
must honor a properly completed C-230 for the initial payment of PTD.
b. See the Authorization
to Receive a Workers’ Compensation Check policy for additional
information.
6. Family Support
Withholding
a. The PTD 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 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 CSS
must continue to pay PTD and/or Disabled Workers’ Relief Fund benefits 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 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 CSS must notify:
i.
The
PTD 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 CSS must notify:
i.
The
PTD IMS to override the SSN; and
ii. Benefits
Payable to Block the EBT card and issue a paper warrant.
d. The PTD CSS
continues process as normal if the SSN is valid and the discrepancies are
resolved.
10. Paying Disabled
Workers’ Relief Fund Benefits
a. Once the IW is
determined to be eligible to receive Disabled Workers’ Relief Fund benefits,
the PTD CSS will:
i.
First
build the PTD benefit plan in the claims management system; and
ii. Then build the Disabled
Workers’ Relief Fund benefit plan in the claims management system.
b. The PTD CSS will
then release the PTD and Disabled Workers’ Relief Fund payment.
11. PTD/Disabled
Workers’ Relief Fund Payment Adjustments: For specific direction on processing
PTD/Disabled Workers’ Relief Fund payment adjustments, please reference the
PTD/Disabled Workers’ Relief Fund training manual.
1. The PTD 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 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 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 CSS
believes the claim is a Price claim, the PTD CSS must:
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 CSS
must re-evaluate the IW’s eligibility for Disabled Workers’ Relief Fund benefits
and/or the rate of Disabled Workers’ Relief Fund 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 CSS must
use $0 as the SSD to recalculate the Disabled Workers’ Relief Fund rate if:
a. The IW requests
that the Disabled Workers’ Relief Fund rate 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 Disabled Workers’
Relief Fund amounts; and
c. SSD is $0.00
(including if the IW is receiving SS benefits, but it is a retirement benefit).
4. The PTD CSS must
staff claims where Disabled Workers’ Relief Fund benefits must be recalculated
with the PTD IMS.
5. A Disabled
Workers’ Relief Fund order will be issued:
a. By the PTD CSS
if the evaluation results in a Disabled Workers’ Relief Fund rate change, other
than for annual processing; or
b. By the claims
management system during annual processing.
6. The PTD CSS
must create a case and complete a NOR to the IC if an overpayment of Disabled
Workers’ Relief Fund benefits has been identified.
a. Upon receipt of
the IC order, the PTD 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 CSS
must request that the overpayment be removed from the claim.
1. The PTD 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 CSS must:
a. First reduce
the Disabled Workers’ Relief Fund 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
CSS determines that accrued compensation:
i.
Is
payable:
a) Issue an order
which includes both the accrued PTD and Disabled Workers’ Relief Fund benefits;
and
b) Pay the accrued
PTD and Disabled Workers’ Relief Fund benefits 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 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 CSS
must follow the Incarceration policy and
procedure if BWC receives notice that an IW receiving PTD benefits is
incarcerated.
5. The PTD CSS must
not terminate or withhold PTD and/or Disabled Workers’ Relief Fund benefits due
to the IW’s failure to respond to an annual contact letter.
6. The PTD CSS may
withhold PTD and/or Disabled Workers’ Relief Fund 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 CSS
must complete a thorough investigation to attempt to identify a new address for
the IW.
b. The PTD CSS
must staff with the PTD 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 Disabled Workers’ Relief Fund benefits.
2. Upon receipt of
the annual contact work item, the PTD CSS must 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 CSS must attempt a second
letter.
c. If there no
response to the second letter, the PTD CSS must attempt to contact the IW by
phone.
d. The PTD 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 will document:
a) The dates of
any notes regarding attempted contact with the IW;
b) The date of
imaged copies of any returned mail;
c) The dates of
the annual contact letters; and
d) Attempts to
find a new address for the IW, if appropriate.
ii. The PTD CSS must
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/ Disabled Workers’ Relief Fund benefits on hold must be
staffed with the PTD IMS.
e. Upon receipt of
a returned annual contact letter, contact with the IW, or staffing with
SIU/Legal, if necessary, the PTD 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 90th birthday;
vi. Extend any
plans that will end in the next 12 months to at least the IW’s 90th 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 Disabled Workers’ Relief
Fund compensation for every IW in the claims processing system with an ongoing
PTD payment plan when the Disabled Workers’ Relief Fund eligibility amount
changes.
2. The PTD 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 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 Disabled
Workers’ Relief Fund rate for the IW will change;
b. The IW becomes
newly entitled to Disabled Workers’ Relief Fund benefits; or
c. The IW is no
longer entitled to Disabled Workers’ Relief Fund benefits.
5. Neither the PTD
CSS nor the system will issue an annual processing order when the IW’s Disabled
Workers’ Relief Fund benefit is increased but no additional payment is made to
the IW because the increase will be withheld to reduce an overpayment in Disabled
Workers’ Relief Fund benefits.
1. Upon receipt of
a C-240, the PTD claim will be reassigned.
a. The work items
associated with the claim will automatically reassign to the assigned LSS CSS.
b. The LSS CSS will
coordinate with the PTD CSS regarding events in the claim that may impact the
PTD rate.
2. The Disabled
Workers’ Relief Fund portion of any settlement is calculated and paid
independent of other compensation included in the settlement.
3. LSS CSS may
approve settlement of Disabled Workers’ Relief Fund 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 CSS
must build an LSA offset for the reduction of any LSA paid from future PTD.
2. The PTD CSS must
not modify the PTD declared rate when an LSA is granted.
3. No LSA will be
granted from future Disabled Workers’ Relief Fund 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 CSS to respond. The
PTD 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 CSS or
PTD 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 will 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 will 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 CSS will
deduct %PP from PTD paid in the same claim and over the same period.
b. Claims services
staff will not pay %PP in a claim once PTD is granted.
4. WL and LMWL
a. Claims services
staff will 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 will pay scheduled loss compensation, including facial disfigurement,
concurrently with PTD in the same or another claim, if appropriate.
6. The PTD CSS will
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 CSS will
not offset statutory PTD benefits for payments the IW receives for disability
benefits from an employer.
2. The PTD CSS will
not pay TT, WL, or LMWL in the same claim in which statutory PTD benefits are
being paid.
3. The PTD CSS will
suspend PTD and pay LM compensation if the IW enters a vocational
rehabilitation plan in a PTD claim and chooses to receive LM.