|
Policy and Procedure Name:
|
Scheduled Loss Compensation
|
|
Policy #:
|
CP-19-01
|
|
Code/Rule Reference:
|
R.C. 4123.57
(B)
O.A.C. 4123-3-09;
4123-3-15 (C); 4123-3-16 and 4123-3-37
|
|
Effective Date:
|
02/15/2022
|
|
Approved:
|
Ann M. Shannon, Chief of Claims Policy and Support
|
|
Origin:
|
Claims Policy
|
|
Supersedes:
|
Policy # CP-19-01, effective 10/02/2015 and Procedure #
CP-19-01.PR1, effective 05/06/2019
|
|
History:
|
Previous versions of this policy are available upon
request
|
Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Amputation
Ankylosis
Claimant
Corrective eye surgery
Dependent
Enucleation
Loss of hearing
Loss of use
Loss of vision
IV. POLICY
A. General Information for
Scheduled Loss Compensation
B. Eligibility for
Scheduled Loss Compensation
C. Amputations
D. Loss of Use, including
Ankylosis
E. Loss of Vision
F. Loss of Hearing
G. Payment of Scheduled
Loss Compensation Award
H. Death of an Injured
Worker
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Scheduled Loss Compensation
C. Reviewing and
Processing the Scheduled Loss Compensation Request
D. Physician File Review
(PFR) or Independent Medical Examination (IME)
E. Issuing a Decision for
Scheduled Loss Compensation
F. Payment of Scheduled
Loss Compensation Award
G. Ohio Industrial
Commission Orders on Scheduled Loss Compensation
H. Self-Insured Claims
The purpose of this policy is to ensure that BWC processes an
application for scheduled loss compensation and pays the allowed award in
weekly installments, according to the schedule provided in R.C. 4123.57(B).
This policy applies to Claims Services and Legal Division
staff.
Amputation:
To cut or remove a limb or body part from the body.
Ankylosis:
Total stiffness of or contractures due to scars or injuries that may cause
joints to be useless because they cannot move.
Claimant:
One who asserts a right, demand or claim for workers’ compensation benefits.
For purposes of this policy, “claimant” typically refers to the surviving
spouse, other dependents or a provider that is seeking reimbursement or payment
for services pertaining to the decedent’s death (e.g., a funeral home).
Corrective
eye surgery: For purposes of this policy, addresses the visual
problems, but not a wholly equal substitute for the natural lens. In addition,
corrective eye surgery is not necessarily a permanent solution as there can be
future problems with the implant. (e.g., corneal lens implants.)
Dependent:
A member of the family of the decedent, for example a surviving spouse or a
blood relative, such as child, stepchild, parent or other blood relative who
relied on the decedent, in whole or in part, for financial support as provided
by law. A dependent is not a fiancé(e), live-in significant other, or a foster
child, etc.
Enucleation:
To remove the eye without removing the muscles that control the eye.
Loss of
hearing: For purposes of this policy, a permanent and total
incapability of receiving auditory input (sound).
Loss of use:
A body part is useless for all practical intents and purposes to the extent
that it was amputated. Severance is not required as defined in the statute.
Loss of
vision: For the purposes of this policy, the loss of uncorrected
vision which is the percentage of vision acuity actually lost as a result of
the injury or occupational disease.
1. A scheduled loss
compensation award may also be called Permanent Partial (PP) or a Paragraph B
award because it is filed under RC 4123.57(B). To be consistent, BWC shall use
the language “scheduled loss compensation.”
2. It is the policy
of BWC that an injured worker is not entitled to receive a scheduled loss
compensation award and a percentage of permanent partial disability
compensation (%PP) award for the same part of body without applying an offset
between the two awards.
3.
It is the policy of BWC to deduct a previously paid %PP award granted
for the same part of body for which a scheduled loss compensation award will be
granted. State ex rel. Maurer v. Industrial Commission of Ohio (1989),
47 Ohio St.3d 62.
4. It is the policy
of BWC that an injured worker may receive a %PP award and a scheduled loss
compensation award concurrently in the same claim or different claims only when
the parts of body are different.
5. It is the policy
of BWC that if the loss of use of a body part produces a residual impairment
beyond the scheduled loss, an injured worker may receive a %PP for the
additional residual impairment.
6.
It is the policy of BWC to deduct a previously paid Temporary Partial
compensation award granted for the same part of body for which a scheduled loss
compensation award will be granted.
7. It is the policy
of BWC that it may consider a Lump Sum Advancement (LSA) request on a scheduled
loss compensation award for an injured worker but not for any other claimant,
including a dependent in a claim for death benefits.
8. For claims with
a date of injury prior to August 25, 2006, statutory permanent total disability
(PTD) may be awarded when an injured worker has a total loss of, or a loss of
use of, an entire limb. State ex rel. Thomas v. Industrial Commission of
Ohio (2002), 97 Ohio St.3d 37.
B. Eligibility for
Scheduled Loss Compensation
1. An application
for scheduled loss compensation may be made any time during the life of a
claim.
2. The injured
worker or claimant shall provide supporting medical documentation from a
physician that demonstrates that the loss is:
a. Permanent; and
b. The result of a
work-related injury.
3. The application
for scheduled loss compensation shall be made on a Motion (C-86), or its
equivalent, and include:
a. Specific part of
body, type and extent of loss (e.g., severance, ankylosis, or how for all
practical intents and purposes there is a loss of use that is being requested);
and
b. Specific
supporting medical evidence documenting the part of body, type and extent of
loss, with additional information as follows:
i. For
an amputation, the physician must provide a clear and accurate description of
the point of amputation.
ii. For loss
of vision:
a)
The medical documentation is from an ophthalmologist, except when
the loss of vision is based on psychiatric factors;
b) The medical
documentation supports the loss of vision in one or both eyes;
c) Includes the
injured worker’s pre-injury uncorrected vision;
d) Includes the
injured worker’s post-injury uncorrected vision;
e)
The medical documentation must demonstrate at least a twenty-five
percent loss of uncorrected vision post-injury.
iii. For loss of
hearing:
a) The medical
documentation is from an ear, nose, and throat (ENT) physician
(otolaryngologist) except when the loss of hearing is based on psychiatric
factors; and
b) The medical
documentation demonstrates that the loss of hearing in one or both ears is
total.
4. BWC may request
additional medical evidence as necessary.
C. Amputations
1. An injured worker is
entitled to a scheduled loss compensation award when they sustain a loss of a
body part that is the result of severance, and reattachment of the same body
part has not been successful (functional).
a. If the same
severed body part is reattached, an award will not be given when medical
documentation supports that the reattachment was successful (functional). State
ex rel. Welker v. Industrial Commission of Ohio (2001), 91 Ohio St.3d 98.
b. The injured
worker may request an amputation award if the reattachment subsequently becomes
unsuccessful and has to be removed.
2. An injured
worker may be entitled to a scheduled loss compensation award even if they
receive a prosthetic device to replace the amputated body part. However, the
use of an orthotic device may not necessarily equate to a functional loss of
use.
3. When there is an
increase in the scheduled loss compensation due to an additional amputation
(below knee amputation revised to above knee amputation), the scheduled loss
compensation award is paid but the previously paid award is deducted from the
amount.
4. Fingers,
hands, and/or arms
a. The loss of
one-third or distal phalange of any finger other than the first finger (i.e.,
the thumb) is considered equal to the loss of one-third of the finger. The
amputation must be at or near the joint. The loss of the finger near the
proximal interphalangeal (PIP) joint is equal to the loss of two-thirds of the
finger.
b. The loss of a
second, or distal, phalange of the thumb is considered equal to the loss of
one-half of such thumb; the loss of more than one-half of the thumb is
considered equal to the loss of the whole thumb.
c. The
scheduled loss compensation award for the loss of two or more fingers by
amputation or ankylosis cannot exceed the amount for the loss of a hand. The
injured worker cannot combine the loss of parts of four fingers to equal the
total loss of two fingers, for purposes of qualifying for a total loss of hand
award. State ex rel. Honda of America MFG., Inc. v. Industrial Commission of
Ohio, 183 Ohio App.3d 732 (2009).
d. If a loss of the
arm is payable, the injured worker is not entitled to an additional award for
loss of the hand. The award for the arm includes the award for the hand.
e. If the injured
worker’s thumb is amputated and replaced with the great toe, BWC will only pay
for the amputation of the toe. There is no award for the loss of the thumb. State
ex rel. Mast v. Indus. Comm., 193 Ohio App.3d 650, 2011-Ohio-2865.
f. Amputation
of the hand and arm below the elbow joint is considered equal to the loss of
the hand. If the amputation is at the elbow, a determination must be made
regarding the functionality of the elbow before determining if the injured
worker is eligible for the loss of the hand or loss of the entire arm.
g. Amputation above
the elbow will result in an award for the loss of the arm. A scheduled loss
compensation award cannot be granted for partial loss of the arm.
5. Toes, feet,
and/or legs
a. Loss of the
great toe up to the interphalangeal joint is equal to one-half loss of the
great toe; loss beyond the interphalangeal joint is equal to the loss of the
great toe. For other toes, a loss of two-thirds of the toe is required for a
scheduled loss compensation award to be granted. No partial loss award is
granted for toes other than the great toe.
b. When there is an
increase in the scheduled loss compensation due to an additional amputation,
the amputation is paid less the previously paid amount.
c. If a loss
of the leg is payable, the injured worker is not entitled to an additional
award for loss of the foot. The award for the leg includes the award for the
foot.
d. Amputation above
the ankle, but below the knee, an injured worker should receive a loss of the
foot. Amputation above the knee an injured worker should receive a loss of the
leg. State ex rel. McLean v. Industrial Commission of Ohio (1986), 25
Ohio St.3d 90.
D. Loss of Use, Including
Ankylosis
1. Permanent
impairment of a body part without severance may entitle the injured worker to
an award.
2. First finger (i.e., thumb)
and other fingers
a. First finger may
have a:
i. Loss
of use for 1/2 of the first finger; or
ii. Total
loss of use for entire first finger.
b. Due to the
uniqueness of the first finger, the loss of use of the interphalangeal joint, (the
joint between the distal and proximal phalanges) is considered equal to the
loss of one-half of the first finger. State ex rel. Riter v. Industrial
Commission of Ohio (2001), 91 Ohio St.3d 89. Riter v IC does not
apply to amputations of the first finger unless ankylosis of the first finger
accompanies the first finger amputation.
c. Loss of
use of the metacarpophalangeal joint between the proximal phalanx and
metacarpal bone is usually considered equal to the total loss of use of the
whole first finger.
d. Other fingers,
second through fifth, may have a loss of use for:
i. 1/3
of the finger; or
ii. 2/3
of the finger; or
iii. Total
loss of use for entire finger.
3. The loss of more than the
distal and middle phalanges (including loss of the PIP joint) is equal to total
loss of the finger. Awards shall not exceed 175 weeks, which is the number of
weeks payable for the total loss of the hand.
4. When there is an increase in
the scheduled loss compensation due to an additional loss of use, the loss of
use is paid less the previously paid award for the same body part.
1. A loss of vision
award is based on the injured worker’s post injury vision prior to correction
by glasses, contacts, corneal transplants, or surgical intervention. Kroger
v. Stover (1987), 31 Ohio St.3d 229.
a. If an injured
worker has an eye injury that will heal without surgery, the scheduled loss
compensation award will not be determined until the healing process is
completed.
b. If an injured
worker requires corrective surgery as a result of the injury, the scheduled
loss compensation award is determined based on the condition prior to surgical
correction and healing.
2.
The minimum award for each eye is twenty-five percent loss of
uncorrected vision. Although at least a twenty-five percent loss of uncorrected
vision is required to receive a loss of vision scheduled loss compensation
award, the injured worker may have loss of vision of less than twenty-five
percent granted as an allowed condition in the claim.
3. The percentage
needed for loss of vision is the percent of vision loss, not the percentage of
whole person impairment (WPI).
4. When the injured
worker has permanently lost an eye due to enucleation, they are entitled to
total loss of vision for that eye.
5. The loss of
vision for traumatic cataract is based on the injured worker’s post injury
vision prior to correction by glasses, contacts, or surgical intervention.
a. Cataracts that
develop due to prolonged usage of medications, advancing age or other
conditions are not considered traumatic.
b. Cataracts that
develop due to prolonged usage of medication may be considered for additional
allowance as a flow-through condition as a known side effect of treatment for
another allowed condition. It is important that the treatment for the other
condition must be generally accepted as causing or associated with the
development of cataracts.
1. Scheduled loss
compensation for loss of hearing shall be awarded only when the injured worker
has permanent and total loss of hearing in one or both ears as a result of a
work-related injury.
2. An injured
worker may have loss of hearing allowed in a claim, but not be eligible for a
scheduled loss compensation award if the loss of hearing is partial.
G.
Payment of Scheduled Loss Compensation Award
1. It is BWCs
policy when paying a scheduled loss award in a lump sum to reduce it to net
present value. Refer to the Lump Sum Advancement policy.
2. It is BWCs
policy to pay multiple scheduled loss compensation awards for multiple body
parts consecutively, not concurrently. This is consistent with case law. State
ex rel. Swallow v. Industrial Commission of Ohio (1988), 36 Ohio St.3d 55.
3.
The date of injury will determine the rate payable for the scheduled
loss compensation award. A date of injury:
a. On or after November 3, 1989, compensation is payable per
week to the injured worker at one hundred percent of the statewide average
weekly wage (SAWW) for the date of injury, regardless of the injured worker’s
average weekly wage (AWW), according to R.C. 4123.62(C).
b. On August 22, 1986, through November 2, 1989, compensation is payable at sixty-six and two-thirds
percent of the injured worker’s AWW at the time of the injury multiplied by the
number of weeks, not to exceed a maximum of the SAWW for the date of injury and
no less than 40% of the SAWW for the date of injury.
c. On December
2, 1975, through August 21, 1986, compensation is payable at sixty-six and
two-thirds percent of the injured worker’s average weekly wage (AWW) at the
time of the injury multiplied by the number of weeks, not to exceed a maximum
of 50% of the statewide average weekly wage (SAWW) for the date of injury and
no less than 25% of the SAWW for the date of injury.
d. Prior to
December 2, 1975, consult with the BWC Legal Division to determine the proper
rate of payment in effect on the date of injury.
1. When a scheduled
loss compensation award(s) is granted and/or paying but there remains an amount
unpaid prior to the injured worker’s date of death, BWC shall:
a. Pay scheduled
loss compensation payable through the date of death, in accordance with the Accrued
Compensation policy and procedure.
b. Pay in this
order:
i. The
surviving spouse, if one exists; or
ii. Other
dependent; or
iii. If no surviving
spouse or other dependent exists, the estate of the IW; or
iv. If no estate exists,
another person, including an adult child of the IW, who shows proof of payment
of medical bills or funeral expenses for the IW, up to the amount of the bill
provided but not to exceed the accrued compensation amount payable.
v. Accrued
compensation may be apportioned between the surviving spouse and other
dependents, when appropriate.
2. When scheduled
loss compensation award is granted before or after death, and there is
scheduled loss compensation payable after the date of death, BWC:
a. May grant a
scheduled loss compensation award as accrued compensation when an injured
worker’s surviving spouse or other dependent files an application for an
amputation or loss of use.
b. Shall pay, upon
application, an unpaid scheduled loss compensation award for the period after
the injured worker’s date of death in biweekly payments to the surviving spouse
or other dependent.
c. Shall pay,
if granted:
i. To
the surviving spouse if one exists; or
ii. If no
surviving spouse exists, to another dependent.
d. Shall not grant
a lump sum advancement against an unpaid scheduled loss compensation payment to
a surviving spouse or other dependent.
3. BWC recognizes
that an estate is entitled to the accrued compensation of a scheduled loss
compensation award but is not entitled to the unpaid balance or ongoing
payments into the future of the scheduled loss compensation award. Estates are
not entitled to the ongoing remainder of the balance because an estate cannot
be a dependent. State ex rel. Liposchak v. Indus. Comm., 90 Ohio St.3d
276, 2000-Ohio-73; State ex rel. Estate of Sziraki v. Admr., Bur. of
Workers’ Comp., 137 Ohio St.3d 201, 2013-Ohio-4007.
4. BWC shall not
pay a scheduled loss compensation award after the death of the decedent’s
surviving spouse or dependent.
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 included in this
procedure.
1. Claims services
staff may identify an injured worker who appears to be eligible for a scheduled
loss compensation award and may notify the injured worker that they may file
for a scheduled loss compensation award, and BWC will process the request.
Note: BWC cannot guarantee any particular outcome for the motion as there are
complex legal, medical and factual issues that may impact the ultimate
eligibility for an award.
2. Claims services
staff shall process a C-86 or its
equivalent requesting scheduled loss compensation anytime during the life of a
claim for one or more of the following:
a. Amputation;
b. Loss of use;
c. Loss of
vision;
d. Loss of hearing.
1. Claims services
staff shall ensure the C-86 or its
equivalent meets the eligibility
requirements of this policy.
2. If claims
services staff is unsure the C-86 or its
equivalent meets the eligibility requirements the application may be reviewed
with the supervisor and a BWC attorney.
3. Claims services
staff shall:
a. Upon receipt of
the scheduled loss compensation request, provide notice to the employer of
record or employer representative.
b. Make a telephone
call to the employer or employer’s representative.
i. Document
the attempt/contact made in claim notes for each party.
ii. Set a work
item for three business days, not including the date the telephone call was
placed. (e.g., call placed on Thursday, left a message. Set a work item for three
business days – Friday, Monday, Tuesday – claims staff can continue processing
application on Wednesday.)
c. If there
is no response or a returned call, staff shall send notice by letter (Insured
Due Process) via fax, email or mail to the applicable party:
i. Document
action taken in claim notes for each party.
ii. Set a work
item as follows:
a) Three full
business days to respond if the letter is sent by fax or email; or
b) Seven full
business days to respond if the letter is sent by mail.
4. Continue
reviewing the scheduled loss compensation request after sufficient notice has
been provided or when work item(s) has expired with no response.
5. Claim services
staff shall process the scheduled loss compensation request as long as it is
feasible that an allowed condition in the claim could result in a scheduled
loss.
6. If medical documentation
is insufficient to support the request or additional evidence is necessary,
claims services staff must request the applicable evidence from the injured
worker, claimant, authorized representative, MCO, or provider.
a. Make a telephone
call to all applicable parties.
i. Document
the attempt/contact made in claim notes for each party.
ii. Set a work
item for three business days, not including the date the telephone call was
placed. (e.g., call placed on Thursday, left a message. Set a work item for three
business days – Friday, Monday, Tuesday – claims staff can continue processing
application on Wednesday.)
b. If there is no
response or a returned call, staff shall send notice by letter via fax, email
or mail to the applicable party.
i. Document
action taken in claim notes for each party.
ii. Set a work
item as follows:
a) Three full
business days to respond if the letter is sent by fax or email; or
b) Seven full
business days to respond if the letter is sent by mail.
c. Continue
reviewing request after requesting the insufficient or additional medical
documentation or when work item(s) has expired with no response.
7. Claims services
staff shall review the injured workers or claimants’ medical evidence and staff
the next course of action with the supervisor and BWC attorney, which may be
one of the following:
a. Evidence
supports the request; the CSS shall staff the request with a supervisor and BWC
attorney prior to issuing a determination consistent with Section E of this procedure; or
b. Evidence does
not clearly support the request, or the date of loss is not clearly indicated,
in which case the CSS may discuss the evidence with a nurse prior to staffing
with a supervisor and BWC attorney to determine if a physician file review or
independent medical examination may be necessary.
c. Issue a
BWC Miscellaneous order to dismiss if there is a lack of evidence on file to
support the request.
1. Claims services
staff does not need to do a PFR or IME if eligibility requirements and
sufficient proof of a scheduled loss compensation award is submitted.
2. Claims services
staff may schedule a PFR or IME when there is an outstanding issue(s) and shall
consult with their supervisor to determine which, a PFR or IME, is appropriate.
Examples:
a. An outstanding
issue(s) regarding the request; or
b. A question on the
onset of the date of loss.
3. If an injured
worker has previously been granted a %PP award for the same body part, claims
staff shall send for a PFR or IME and use the specific question requesting the DEP
physician to explain what portion of the %PP award is encompassed by the
scheduled loss and what portion of the %PP might be due to residual effects.
4. Claims services staff
shall discuss with the nurse situations where it is alleged that the loss of
vision or loss of hearing is based on psychiatric factors to determine what
medical specialty to consult to appropriately address the issue.
5. For a unique or
unusual fact pattern, claims services staff must work with the nurse and BWC
attorney to add specific questions to the standard scheduled loss compensation
questions.
6. Claims services staff
shall refer to the Independent
Medical Exams (IME) and Physician File Reviews (PFR) policy on Claims
On-line Resources (COR) for the specific questions to use.
E. Issuing a
Decision for Scheduled Loss Compensation
1. Claims services
staff is required to staff all scheduled loss compensation
requests with a supervisor and BWC attorney prior to publication of the order
addressing the award. Claims services staff must enter a required claim note
with the specific note title: SL CSS Staffed with IMS, Legal.
2. Claims services
staff shall use the date of injury, not the date of amputation or actual loss
of use, when determining the rate at which the award will be paid.
3. Claims services
staff shall use the following dates to begin the scheduled loss compensation
award:
a. The date of
amputation or actual loss of use date; or
b. For loss of use
by reason of ankylosis, the date the physician makes the diagnosis of the loss
of use; or
c. The date
of the loss as determined by the medical documentation from the physician or
the IME report.
4. Prior to issuing
the determination on the scheduled loss compensation request, claims services staff
shall build the scheduled loss compensation indemnity benefits plan and use the
Scheduled Impairment Awards window, as follows:
a. For an award in
a claim with a date of injury (DOI) prior to November 3, 1989, claims services
staff must:
i. Manually
calculate the award using the statutory formula in place at the time of the DOI;
and
ii. Build it
as a miscellaneous payment.
iii. Use the
compensation rate chart located on COR Home Page listed under Commonly Used
Documents or the schedule in R.C. 4123.57(B) when determining the number of
weeks payable for the loss of the applicable body part. Claims services staff
shall refer to Section IV.G.2.a for
the calculation.
b. For an award in
a claim with a date of injury on or after November 3, 1989, claims services
staff must enter in the claims management system as follows:
i. For
amputations, loss of use, and loss of hearing:
a) Select scheduled
loss;
b) Amputations,
loss of use, and loss of hearing are entered as a 100%;
c) Enter the
percentage (%) in the Scheduled Impairment Awards window.
ii. For loss
of vision:
a) Select scheduled
loss –vision;
b) Enter the
percentage (%) of loss cited in the medical documentation in the Scheduled
Impairment Awards window.
c. Claims
Services staff shall not schedule the award; just build it in the claims
management system so the correct dates and amounts appear in the BWC Order.
5. Claims services
staff shall issue a decision on a scheduled loss compensation request as
follows:
a. A BWC Subsequent
order if allowing the request for scheduled loss compensation in its entirety
as requested and employer is in agreement or did not respond to notice; or
b. A BWC Death
Subsequent order on a death claim if allowing the request for scheduled loss
compensation in its entirety as requested and employer is in agreement or did
not respond to notice; or
c. A notice
of referral to the Industrial Commission when there is a conflict, such as:
i. An
employer disagrees with the request for scheduled loss compensation;
ii. BWC’s
recommendation is to deny the request for scheduled loss compensation in its
entirety;
iii. BWC’s
recommendation is to allow in part and deny in part the request for scheduled
loss compensation.
6. Claims services
staff shall refer to the Notice
of Referral to the Industrial Commission policy for additional
information.
7. Claims services
staff shall use specific language when issuing a notice of referral to the IC
and staff with a BWC attorney for the language to use:
a. When a loss of
use of the interphalangeal joint (the joint between the distal and proximal
phalanges) is requested as total loss of the first finger (i.e., the thumb) as
discussed in Section IV.D.2.b.
b. When a request
for an amputation award is for a severed body part that was successfully
reattached, as discussed in Section IV.C.1.a.
c. For any
unique or unusual fact patterns.
8. Claims services
staff may, as needed, work with a BWC attorney for specific language for a BWC
Order or a notice of referral.
9. Claims services
staff shall pay an amputation or loss of use award less the previous paid award
when there is an increase in the scheduled loss compensation due to an
additional amputation or loss of use to the same area of the body.
a. Example: When
granting an increase from the loss of fingers to a loss of the hand, the loss
of the hand is granted less the weeks previously paid for the individual
fingers.
b. Example: When
granting an increase from the loss of the toes to a loss of the foot, the loss
of the foot is granted less the weeks previously paid for the individual toes.
10. Claims services staff shall
use the ‘previous impairment offset worksheet’ located on COR (Claims On-line
Resource) to calculate the amount to enter as an offset, under Indemnity
Payments > Adjustment tab > Adjustments drop-down > Add Adjustment.
11. Claims services staff must
address when a deduction will occur to the scheduled loss compensation award in
the BWC Order or in the notice of referral due to:
a. A previous %PP
award granted for the same part of body for which a scheduled loss compensation
award will be granted.
b. An overpayment.
c. Family
support.
12. When claims services staff
arrive at the dollar amount of the previously paid scheduled loss compensation
or %PP compensation that is attributed to the same body part as the scheduled
loss compensation award, the amount is entered as an offset, under Indemnity
Payments > Adjustment tab > Adjustments drop-down > Add Adjustment.
13. Claims services staff shall
choose the appropriate order insert to describe the situation where there will
be a reduction in the amount of scheduled loss compensation paid out due to
previous awards granted, such as previous scheduled loss compensation or %PP
awarded. The reduction of award shall be noted in the BWC order.
14. The claims services
supervisor is required to review and electronically approve (i.e., respond by
email) all correspondence orders granting scheduled loss compensation. Claims services
supervisor must enter a required claim note with the specific note title:
a. SL IMS Reviewed
Order – Approved (if order is correct); or
b. SL IMS Reviewed
Order – Returned (if order needs to be corrected).
1. Claims services
staff shall pay a scheduled loss compensation award at the expiration of the
appeal period.
2. Claims Services
staff shall pay all awards of scheduled loss compensation in weekly
installments in accordance with the schedule associated with the loss of the
applicable body part, unless ordered by the Industrial Commission to pay
differently.
3. Claims services
staff shall pay the scheduled loss compensation award based on the date of
injury and is payable at the rate defined in section, IV.G.3.
For a date of injury prior to December 2, 1975, staff shall send an email to BWC
Claims Policy Field Tech mailbox to work with BWC Legal Division to determine
the rate in effect for the date of injury.
4. Claims services
staff shall honor an Authorization
to Receive Workers Compensation Payment (C-230) filed
by the injured worker’s representative for payment of a scheduled loss
compensation award for the initial accrued lump sum payment (i.e., the first
check). Future payments shall be set up on scheduled weekly payments.
5. Deductions from
a scheduled loss compensation award
a. Family Support
i. Claims
services staff shall apply family support weekly deduction orders to scheduled
loss compensation awards that are being paid biweekly.
ii. Accrued
scheduled loss compensation awards are subject to hold for lump sum family
support processing. Claims services staff shall refer to the Family
Support policy for additional information regarding family support
obligations.
b. Overpayments
i. Claims
services staff may recoup overpayments from a scheduled loss compensation award
at forty percent. However, if fraudulent activity is determined, recoupment is
one hundred percent.
ii. Claims
services staff shall refer to the Overpayments
of Compensation and Adjustment
of Overpaid Compensation policies for additional information.
6. Claims services
staff shall pay multiple scheduled loss compensation awards for multiple body
parts consecutively, not concurrently, unless otherwise ordered.
7. Claims services
staff may pay a scheduled loss compensation award concurrently with:
a. Temporary total
disability compensation;
b. Wage loss
compensation;
c. Permanent
total disability
d. Statutory
permanent total disability;
e. Living
maintenance;
f. Living
maintenance wage loss;
g. Facial
disfigurement;
h. %PP;
i. Disabled
workers relief fund;
j. Death
benefits.
8. Claims services
staff may pay a scheduled loss compensation award for periods after the IW’s
date of death in biweekly payments to the widow(er) or other dependent unless
otherwise ordered.
9. Claims services
staff may consider a lump sum advancement on a scheduled loss compensation
award for an injured worker but not for any other claimant or dependent in a
death claim. Claims services staff shall refer to the Lump
Sum Advancement policy for additional information.
G. Ohio Industrial
Commission Orders on Scheduled Loss Compensation
1. Claims services
staff shall timely review an Industrial Commission order and if there is an
issue with the decision shall staff the order with the supervisor and BWC
attorney.
2. Claims services
staff shall staff all issues of concurrent payments or lump sum payments with BWC
Legal.
3. Claims services
staff shall perfect the order consistent with Orders,
Waivers, Appeals and Hearings policy unless the BWC attorney has
provided other direction.
1. Claims services
staff may receive the Agreement as to Compensation for Permanent Partial
Disability (IC-GC1)
form which is used in a self-insured claim when a self-insuring employer and
injured worker have entered into an agreement for compensation of permanent
partial disability or scheduled loss compensation.
2. Claims services
staff shall review the IC-GC1
to determine if:
a. The number of
weeks being paid corresponds with the medical documentation on file;
b. The number of
weeks payable is in accordance with the rate chart; and
c. The Waiver
of Notice of Hearing and Waiver of Right of Appeal section of the IC-GC1 is signed by
the self-insuring employer and injured worker with a copy sent to all parties.