Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Causal Relationship (Causality)
Claimant
Common Law Marriage
Death Benefits
Dependent
Emergency Management Worker
Guardian
Legal Presumption
Natural Parent
Partial Dependent
Prospective Dependent
Whole Dependent
IV. POLICY
A. Notice of Death
B. Filing an Application
for Death Benefits
C. Funeral and Medical
Expenses
D. Statute of Limitations
E. Eligibility for Death
Benefits
F. Level of Dependency:
Whole, Partial and Prospective
G. Death Benefits Rates and
Apportionment
H. Claimant Annual Contact
I. Claimant Status
Change(s) and Reapportionment
J. Family Support
K. Overpayments
L. Scheduled Loss
Compensation
M. Claimant Incarceration
N. Lump Sum Advancement
and Lump Sum Settlement
V. PROCEDURE
A. Standard Claim File
Documentation
B. Processing a Notice of
Death
C. Processing an
Application for Death Benefits
D. Establishing Level of
Dependency and Documentation Requirements
E. Determination of the
Claim and Death Benefits
F. Claimant Annual Contact
G. Dependency Status
Changes and Reapportionment
H. Overpayments
I. Lump Sum Advancement
and Lump Sum Settlement of Death Benefits
The purpose of this policy is to ensure that BWC processes a
notice of death of an injured worker (decedent) and requests for death benefits
and payment of medical and funeral expenses consistently, appropriately, and in
compliance with law.
This policy applies to BWC Claims Services staff.
Causal Relationship (Causality): Medical and legal concepts are
both necessary to establish a compensable death claim:
·
A medical concept describing a relationship between the
condition(s) and the industrial accident or occupational disease and death; and
·
A legal concept that establishes a relationship between the
employment and accident or occupational disease that led to the death of a decedent.
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).
Common Law Marriage: A marriage
relationship created by agreement and cohabitation rather than by ceremony.
Ohio law recognizes these marriages only if
established in Ohio prior to October 10, 1991, or if
established after that date in another state or nation that recognizes the
validity of common law marriages, consistent with the laws of that state or
nation.
Death Benefits: Benefits payable pursuant
to R.C. 4123.59 and R.C. 4123.60 to a dependent of an injured worker who has
died as a result of an injury or occupational disease received in the course
of, and arising out of, the injured worker’s employment.
Dependent: A member of the family of the
decedent, for example a surviving spouse or a blood relative, such as child,
step-child, 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.
Emergency Management Worker: An individual
who has registered for service pursuant to R.C. 5502.34, in connection with the
development, maintenance, and operation of any state or local emergency
management agency authorized by law, and who has met the minimum requirements
of R.C. 4123.031 to 4123.037, or who has been registered as an emergency
management worker pursuant to R.C. 5502.34 during a disaster or emergency.
Guardian: Any person appointed by the
probate court to have the care and management of the person, the estate, or
both of an incompetent or minor person.
Legal Presumption: A conclusion based upon
a particular set of facts, combined with established laws, logic or reasoning.
Natural Parent: The legally recognized
parent of a child, whether biological or adoptive.
Partial Dependent: A claimant who has
received some financial support from the decedent and they are unable to
support themselves.
Prospective Dependent: A member of the
family of the decedent, for example a surviving spouse or a blood relative,
such as child, step-child, parent or other blood relative not found to be a
whole or partial claimant, but whose circumstances clearly indicate a need for
potential financial support and there is evidence of an intention or commitment
of the decedent to provide such financial support.
Whole Dependent: A claimant that is
presumed or found to have relied on the decedent for financial support, to a
greater degree than a partial or prospective claimant (e.g., a surviving spouse
and minor children are presumed wholly dependent).
1. When a decedent
dies as the result of a work-related injury or occupational disease, a notice of
death may be initiated via:
a. A First
Report of Injury, Occupational Disease or Death (FROI);
b. An
Application for Death Benefits and/or Funeral Expenses (C-5);
c. An Application
for Accrued Compensation (C-6);
d. A Motion
(C-86);
e. Telephone
notification;
f. In
person notification;
g. Online through
the BWC website;
h. Email
notification; or
i. Any
other electronic or written communication.
2. BWC shall
request supporting documentation and when necessary, obtain a written notice of
death.
1. The claimant,
when filing for death benefits, must submit to BWC:
a. A C-5; and
b. For new claims:
i. A FROI;
and
ii. Supporting
documentation to establish a causal relationship
for death benefits.
c. For existing
claims, supporting documentation to establish a causal
relationship for death benefits.
2. If the claimant
has an authorized representative (e.g., legal counsel), the claimant must file
an appropriate authorization with BWC.
a. Any
authorization made by the decedent expires upon their death and is not
applicable to the claimant.
b. See the Authorized
Representatives policy for further information.
1. In addition to
the death benefits discussed above, an application may be made for
reimbursement of, or payment for:
a. Medical, nurse,
hospital services, and medicine related to the decedent’s work-related injury
or occupational disease; and
b. Funeral expenses
up to the maximum allowed by law.
2. An individual or
provider that incurred the expense and making the application must provide
supporting documentation such as an invoice or receipt.
3. In addition to
funeral expenses, BWC may pay for related exceptional transportation costs;
e.g., returning the body of the decedent when the death occurs outside the area
where the decedent lived.
D. Statute of Limitations
1. Applying for
Death Benefits with a Date of Injury Prior to 09/29/2017:
a. An Application
for death benefits, except emergency management workers, where the decedent’s
death is due to a work-related injury must be filed within two years from the
date of death.
b. An application
for death benefits for an emergency management worker employed by the state or
a political subdivision, who dies in the performance of their duties as an
emergency management worker, must be filed:
i. Within
one year of the date of the death; or
ii. If the
emergency management worker filed an injury claim within one year of an injury,
and the emergency management worker subsequently dies from that injury, within
six months after the date of death.
2. Applying for
Death Benefits with a Date of Death On or After 09/29/2017:
a. An application
for death benefits, including emergency management workers, employed by the
state or a political subdivision, where the decedent’s death is due to a
work-related injury must be filed within one year from the date of death.
b. If the emergency
management worker filed an injury claim within one year of an injury, and the
emergency management worker subsequently dies from that injury, the application
for death benefits must be filed within six months after the date of death.
3. Death due to an
occupational disease claim occurring:
a. Before Sept. 28th,
2021 must be filed within two years after death.
b. On or after
Sept. 28th, 2021 must be filed within one year after death.
4. See the Jurisdiction
policy for further information.
1. To be eligible
for death benefits:
a. The claimant
must be a dependent;
b. An application
must be made within the required time frames described above; and
c. The death
must have occurred in the course of and arising out of the decedent’s
employment.
2. To be eligible
for funeral expenses only:
a.
Must establish a compensable claim under the law; and
b. Provide a copy
of the funeral bill invoice.
3. To be eligible
for medical services:
a. Must establish a
compensable claim under the law; and
b. Provide a copy
of the medical bill invoice to the MCO for payment.
4. The status of
the decedent as an undocumented worker or public work-relief employee does not
by itself negate the decedent’s dependents from eligibility for death benefits.
1. BWC shall, based
on the evidence and circumstances at the time of the decedent’s death, identify
a dependency level as whole, partial or prospective.
2. The time of
death is a snapshot of the circumstances to establish dependency.
3. The following
are presumed to be a whole dependent:
a. The surviving
spouse:
i. Lives
with the decedent at the time of death; or
ii. Lives
separately from the decedent due to the decedent’s aggression.
b. A child of the
decedent living with the decedent at the time of death and for whom the
decedent was contributing more than 50% of the child’s financial support, or
for whose maintenance the decedent was legally responsible; and the child is:
i. Under
the age of 18;
ii. 18 years
old but less than 25 years old and pursuing a full-time educational program
while enrolled in an accredited educational institution and program; or
iii. 18 years old or
older and physically or mentally incapacitated from earning.
c. An unborn
child, when born and with proof of paternity, is eligible for death benefits
beginning on the date of birth of the child.
4. It is a legal
presumption that there is sufficient dependency to entitle a surviving natural
parent(s), share and share alike, with whom the decedent was living at the time
of the decedent's death, to a total minimum award of three thousand dollars.
5. There may be a
combination of dependency (whole, partial and prospective) in a claim.
1. The weekly rate for
death benefits for a whole dependent is 66 2/3% of the decedent’s average
weekly wage (AWW); but:
a. The weekly rate
shall not exceed the statewide average weekly wage for the year of death; and
b. The weekly rate
shall not be less than 50% of the statewide average weekly wage (SAWW) for the
year of death.
2. The weekly rate
for a partial dependent is 66 2/3% of the decedent’s AWW; but:
a. The weekly rate
shall not exceed the SAWW for the year of death; and
b. There is no
minimum weekly rate.
3. The benefit for
a prospective dependent is based on the amount of support that was received or
expected to be received from the decedent; and
a. The award for
all prospective dependents (excluding natural parents deemed prospective
dependents) shall not exceed a total amount of three thousand dollars.
b. Natural parents
determined to be prospective dependents shall receive a minimum total award of three
thousand dollars.
4. For an IW who is
receiving total disability compensation at the time of death, the claimant’s
rate of benefits that is based upon the IW’s AWW will not be subject to the
SAWW minimum and maximum rates for the year of injury. The claimant’s rate
will be subject to the SAWW minimum and maximum rates for the decedent’s year
of death.
5. Apportioning
Death Benefits Among Dependents
a. When there are
two or more whole or partial dependents eligible for death benefits, BWC will
apportion the amount of the benefit among the whole and partial dependents
equitably, considering the circumstances of each particular case.
i. If
there is at least one whole dependent, the one benefit, as calculated based on
the whole dependent, shall be apportioned among the whole and partial
dependents.
ii. Payment of
benefits to any prospective dependent(s) does not factor into the benefits paid
or apportioned among whole and partial dependents.
b. An award to
natural parents living with the decedent at the time of death that are
determined to be prospective dependents shall be equally apportioned.
c. If there
is more than one prospective dependent (excluding natural parents) the award to
the prospective dependents will be apportioned among the prospective dependents
as BWC determines equitable.
1. A claimant is
required to immediately notify BWC when there is a change to their dependency
status (e.g., surviving spouse remarries, a child stops attending a full-time
educational program, a claimant’s death).
2. BWC shall send
an annual contact letter to the claimant to verify continuing eligibility. A
claimant is required to:
a. Complete and
sign the letter acknowledging and verifying the information in the letter; and
b. Return the
signed letter and any required documentation. A scanned, or faxed copy of the
completed and signed letter will fulfill the signature requirement.
c. If the
annual contact letter is not returned, BWC may suspend benefits until continued
eligibility is verified.
3. In addition to
an annual contact letter, a claimant/student receiving benefits is required to
submit to BWC, for each educational period (e.g., semester, quarter):
a. Proof of
continued enrollment in a full-time educational program (e.g., class
registration); and
b. Proof of
participation in, and completion of the previous educational period for which
benefits were received (e.g., a grade report).
4. The failure of a
claimant to respond to an annual contact letter or submit the required
documentation, including the documentation required from a student for each
educational period, may result in the suspension of the claimant’s benefits.
1.
When a whole or partial dependent’s status changes and benefits were
originally apportioned by BWC shall reapportion the benefit among the active
dependents and issue an order with the reapportioned rates to each of the
impacted dependents.
2. When benefits
were originally apportioned by the Industrial Commission (IC), a status change
of a dependent and potential reapportionment shall be referred to the IC.
3. Death benefits
will be reapportioned when:
a. Benefits were
awarded and apportioned to one or more dependents and subsequently an
additional dependent is identified and awarded benefits; or
b. A whole or
partial dependent’s eligibility status changes.
1. BWC shall deduct
any family support that the claimant is ordered to pay from the claimant’s
death benefits.
2. See the Family
Support Orders and Attorney Fees Paid Pursuant to Deductions of Child Support
from Lump Sum Payments policy.
1. If the decedent
has an existing overpayment, the overpayment does not carry over to the
claimant’s death claim benefits.
2. If the claimant
has an existing overpayment, the overpayment shall be recouped from the
claimant’s death benefits.
3. Overpayments
shall be processed consistent with the Overpayments
policy.
1. BWC shall consider upon application a
request for scheduled loss compensation, in accordance with the Scheduled Loss Compensation policy.
2. When scheduled loss compensation awards
are granted or paying but there remains an amount unpaid prior to the
decedent’s date of death, BWC shall pay in accordance with the Scheduled Loss Compensation and Accrued Compensation policies.
3. When scheduled loss compensation awards
are granted before or after death, and there is scheduled loss compensation
payable after the date of death, BWC shall pay in accordance with the Scheduled Loss Compensation policy.
1. BWC shall
terminate benefits to a claimant effective the date of incarceration and may
resume benefits upon release of the claimant, if the claimant is otherwise
eligible.
2. See the Incarceration
policy for further information.
1. Upon remarriage
of the surviving spouse, BWC shall pay a two-year lump sum award minus any
previous lump sum advancement or overpayment.
2. A request for a
lump sum advancement shall be processed consistent with the Lump
Sum Advancement policy.
3. A claimant is
eligible to file an application for death benefits when a decedent’s claim was
previously settled or denied.
4. A claimant may
seek to settle a death claim consistent with the Lump
Sum Settlement policy.
1. BWC staff shall
refer to the Standard
Claim File Documentation and Altered Documents policy for claim note
requirements; and
2. Shall follow any
other specific instructions for claim notes included in this procedure.
1. No Existing
Claim
a. Claims services
staff shall recognize that only a claimant may have a compensable death claim,
not an employer or MCO. An employer, MCO, or provider may file a FROI
or other documentation as notice that an employee has died.
b. When claims
services staff receives a notice of death of an employee and there is no
existing claim, claims services staff shall:
i. Assign
a claim number;
ii. Assign the
claim to the appropriate team:
a) Survivor
Benefits team;
b) Stat OD team;
c) SI Bankrupt team.
iii. Contact the
employer to obtain contact information for any next of kin;
iv. Take any other
reasonable steps to identify the decedent’s next of kin, as necessary; and
v. Send an
“Initial Contact Letter-No Claim” to the family of the decedent.
a) The letter shall
be sent to a next of kin, if one has been identified.
b) If a next of kin
has not been identified, the letter shall be sent to the decedent’s last known
address.
c. If an
application for death benefits is not received within 28 days from the date of
the “Initial Contact Letter-No Claim” claims services staff shall:
i. Issue
the “No Claim Filed” letter to the employer, MCO and potential claimant(s), if
any were identified; and
ii. Place the
claim in “dismissed” status in the claims management system.
d. If an
application for death benefits is subsequently filed, claims services staff
shall:
i. Place
the claim in “pending” status; and
ii. Process,
determine and manage the claim consistent with this policy.
2. Application for
Death Benefits: When an application for death benefits or the payment of
medical or funeral expenses is filed where there is no existing claim, claims
services staff shall:
a. Assign a claim
number; and
b. Ensure the claim
is assigned to the appropriate team or claims services staff member.
3. Existing
Claim
a. When claims
services staff receive notice of the death of an injured worker in an existing
claim, claims services staff shall:
i. Verify
the death through a Social Security cross match, a death certificate, a
published obituary, a police report or other reliable means;
ii. Update the
claim with the validated date of death;
iii. Discontinue any
ongoing compensation;
iv. Abate pending
applications consistent with the Abatement
policy; and
v. Determine
any accrued compensation consistent with the Accrued
Compensation policy.
b. If claims
services staff receive a verbal request for death benefits, claims services
staff shall:
i. Provide
the claimant with a C-5 and request
that the claimant returns it as soon as possible; or
ii. If the
request is for medical or funeral expenses only, request that the claimant
submit a written request (which may be a C-5) with an
appropriate invoice or receipt.
c. If claims
services staff receives a written request for death benefits, claims services
staff shall reassign the claim to the appropriate team or claims services staff
member. In general:
i. If
the request is made in an existing claim assigned to the Self-Insured Bankrupt team,
is a special handling claim or is a self-insuring claim, the claim will remain
with the team or self-insuring employer handling the claim.
ii. All other state-fund
death claims shall be assigned to the centralized Survivor Benefits team and an
email sent to the injury management supervisor (IMS) for the centralized
Survivor Benefits team.
d. BWC management may
make assignment exceptions on a case-by-case basis or based on operational
need. Claims services staff shall consult with their supervisor or the IMS for
the Survivor Benefits team for direction when in doubt as to the appropriate
assignment of a death claim.
e. If resolving
pending matters in an existing claim will significantly delay reassigning the
claim to the Survivor Benefits team (after a request for death benefits is
received), the IMS of the team assigned the existing claim and the Survivor
Benefits team IMS shall consult and agree upon a plan to resolve the pending
matters and begin processing the death benefits request in a timely and
efficient manner.
f. If
an application for death benefits is made in a settled claim or in a claim
where the statute of limitations has expired, claims services staff shall:
i. Reopen
the claim;
ii. Update the
status reason to “Accepted”; and
iii. Update the
nature of injury category to “Death”.
g. Claims services
staff shall address authorized representative issues consistent with the Authorized
Representatives policy.
4. If, after the
filing of a death claim, another claimant is identified and/or comes forward,
claims services staff shall:
a. Advise the
subsequent claimant that he/she needs to file a C-5 or other
written application for death benefits;
b. Once the
application is received, ensure it is imaged and made part of the existing
death claim;
c. Send the
new claimant an “Initial Contact” letter; and
d. Continue the
process of determining compensability and dependency consistent with this
policy.
5. Parties to the
Death Claim
a. Claims services
staff shall ensure all parties to the claim are entered as:
i. A
customer in the claims management system; and
ii. A
participant to the claim.
a) The surviving
spouse is identified as the “Beneficiary”;
b) All other
claimants are identified as “Dependent”.
6. Prior to adding
a customer, claims services staff shall conduct a thorough customer search to
determine if the claimant has previously been entered into the claims
management system as a customer.
1. Public
Employment Risk Reduction Program (PERRP) Referrals
a. If the claim
involves a public employer, claims services staff shall send a notification to
the PERRP unit via the “BWC PERRP Fatality” mailbox and copy the IMS. The
notification shall contain:
i. The
claim number;
ii. The date
of death;
iii. The decedent’s
name;
iv. The employer’s name;
and
v. The
employer’s policy number.
b. Claims services
staff shall enter a claim note indicating notification was sent to the PERRP.
2. Gathering
Information and Documentation and Making Initial Contacts
a. Issuing the
Initial Contact Letter(s) to the Claimant(s):
i. When
a death claim has been filed by a claimant(s), within seven days claims
services staff shall send the claimant(s) the “Initial Contact” letter
informing the claimant(s) of:
a) The claim
number;
b) The name and
contact information of the assigned claims service specialist (CSS);
c) The right to
seek legal counsel; and
d) Any information
or documentation needed from the claimant to make a determination for death
benefits.
ii. If not already
filed by the claimant, claims services staff shall send a C-5 with the
initial contact letter for the claimant to complete and return.
iii. When a death
claim has been filed by a claimant(s), within seven days claims services staff
shall send the employer notice of the request for death benefits.
b. As applicable to
the claim, claims services staff shall request the following documentation from
the agency or service provider that created the document:
i. The
death certificate;
ii. Police
reports;
iii. Emergency
service reports;
iv. Hospital records;
v. Coroner’s
report;
vi. Autopsy and toxicology
reports; and
vii. Any other relevant records
and reports necessary to make a determination for death benefits.
c. Claims
services staff shall use any correspondence and/or forms identified for
specific requests for documentation, available in the claims management system
and/or available on the Claims Online Resource (COR).
d. As available,
claims services staff shall obtain from the Internet or other resources:
i. The
decedent’s obituary or other published notification of death;
ii. Any news stories
related to the decedent’s death;
iii. Any other
readily available, relevant information to assist with making a determination
in the claim; and
iv. Claims services staff,
when appropriate, may repeat steps above V.C.2.d.i.-iii.
e. Employer
Contact: Within a reasonable time, claims services staff shall contact the
employer by telephone and:
i. Provide
the claim number and claims services staff’s name, mailing address, telephone
number, fax number and email address; and
ii. Request
the following information, as applicable:
a) Description of
the accident and the accident report;
b) Names, addresses
and telephone numbers of the surviving spouse and/or other potential claimant(s)
or other contacts the employer is aware of;
c) Earnings
information for the decedent for the 52 weeks prior to the date of death;
d) Names and
contact information of any witnesses;
e) Names and
contact information for any investigating authority and related reports; and
f) Any
Occupational Safety & Health Administration reports or other related
investigation reports.
f. Claimant
Contact: Within a reasonable time, claims services staff shall contact the
claimant(s) by telephone (this verbal request shall not substitute for an
initial contact letter) and:
i. Provide
the claim number and claims services staff’s name, mailing address, telephone
number, fax number and email address; and
ii. As
appropriate, request the following information/documentation from the claimant:
a) Names and
addresses of the surviving spouse and children;
b) If no surviving
spouse or children, the names and addresses of the decedent’s relatives who
lived with the decedent at the time of death;
c) Earnings
information of the decedent for one year prior to death (including multiple
employers);
d) The marriage
license of the decedent and the surviving spouse;
e) If the decedent
or surviving spouse was previously married, a copy of the divorce decree or
separation agreements;
f) Birth certificates
of children of the decedent;
g) Social security
numbers of claimants; and
h) Additional
medical records and/or a list of medical providers, as may be relevant to the
claim.
g. Managed Care
Organization (MCO) Contact: Within a reasonable time, claims services staff
shall contact the MCO by telephone and:
i. Provide
the claim number and claims services staff’s name, mailing address, telephone
number, fax number and email address; and
ii. Request
the following information, as applicable:
a) Medical records
relating to the death of the decedent;
b) Medical history
of the decedent;
c) Records of
hospitalizations;
d) Other medical
information that may be relevant in making a determination for compensability
of the claim.
h. Claims services
staff shall identify, conduct interviews and obtain written statements, as
needed of any other witnesses or individuals that may have information
pertinent to the claim.
3. Claims services
staff may consult with a BWC attorney, the Special Investigation Unit or a
medical services specialist (MSS) for assistance obtaining documentation, as
needed.
1. Claims services
staff shall verify, for any individual claiming to be a claimant that:
a. The individual
is a member of the family of the decedent; and
b. The individual
relied on the decedent, in whole or in part, for financial support or meets the
criteria for presumed dependency.
2. Surviving Spouse
a. The surviving
spouse was living with the decedent at the time of death; or
b. The reason the surviving
spouse was not living with the decedent was due to decedent’s aggression.
3. Claims services
staff shall verify the surviving spouse and dependency through:
a. A marriage
certificate establishing a valid marriage; and
b. Divorce decrees
or death certificates from any former spouse(s) of the decedent or the
decedent’s surviving spouse; and
c. Proof of
residence with the decedent at the time of death (e.g., personal check with
both names and same address, death certificate with decedent’s address and
funeral home bill addressed to surviving spouse with address), or if the
surviving spouse was not living with the decedent at the time of death:
i. Evidence
showing that the separation was due to the decedent’s aggression (e.g., police
reports, court records);
ii. Evidence
of dependency if the spouse and decedent were not living together at the time
of death; or
iii. The decedent and
surviving spouse separation was intended to be temporary (e.g., temporarily
living separately due to job transfer or one spouse living with and caring for
a family member).
a) Example 1: The
surviving spouse lives in Cincinnati, Ohio. The decedent, at the time of death
was working in Youngstown, Ohio. The surviving spouse states that the decedent
was working a temporary assignment of approximately six months in Youngstown
and living in an extended-stay hotel. Documentation that would help establish
that the separation was temporary includes, but is not limited to:
i) A
personal check, bank statement, or lease agreement that shows the names of both
the surviving spouse and the decedent at the same address;
ii) The
employer’s statement verifying the decedent was working a temporary assignment;
iii) The employer’s written
policy or other document explaining the living arrangements during the work
assignment;
iv) If the decedent was
paying for lodging directly, receipts for the lodging.
b) Example 2: The
surviving spouse indicates she has been living in her parents’ home for the
three months prior to the decedent’s death. She states her mother is terminally
ill and she has been caring for her, but her intention was to eventually return
to the home she previously shared with the decedent. Documentation that would
help establish that there was an intent to cohabitate in the future includes
but is not limited to:
i) A
personal check, bank statement, or lease agreement that shows the names of both
the surviving spouse and the decedent at the same address;
ii) A
statement from the mother’s doctor or other medical record verifying the
mother’s condition;
iii) The obituary of the
decedent that lists the surviving spouse;
iv) Personnel records from
the employer that lists the surviving spouse and his/her address;
v) Emails, letters
or other communications that indicate the decedent and surviving spouse’s
continuing relationship and/or expectation of living together again in the
future.
d. If the surviving
spouse claims a common law marriage established after October 10, 1991,
evidence that shows the common law marriage was established in compliance with
the laws of the state or nation in which they were cohabitating.
e. If the surviving
spouse claims a common law marriage established in Ohio, supporting evidence
must be produced showing that the marriage was established prior to October 10,
1991; supporting documentation needs to show that:
i. The
couple represented themselves to their community as married (e.g., the
surviving spouse listed as spouse on personnel records, shared bank accounts,
other business records showing the decedent and surviving spouse used the same
last name);
ii. The couple
was treated by their community as husband and wife (e.g., mail addressed to the
decedent and surviving spouse as a couple or Mr. and Mrs.);
iii. The couple
cohabitated;
iv. The couple had the
legal capacity to enter into the marriage (e.g., if the decedent or surviving
spouse was previously married, a divorce degree or a death certificate of the
previous spouse); and
v. Legal
finding of common law marriage through any legal proceeding prior to the
decedent’s death.
f. A
surviving spouse who does not qualify as a whole dependent, may qualify as a
partial or prospective dependent if the surviving spouse provides documentation
showing some support from the decedent.
4. Dependent
Children
a. Claims services
staff shall presume a child of the decedent is a whole dependent when:
i. The
child is under the age of 18;
ii. The child
is under the age of 25 and pursuing a full-time educational program while
enrolled in an accredited educational institution and program;
iii. The child is 18
years old or older, living with the decedent at the time of death, and has a
physical or mental condition that prevents the child from generating earnings;
and
iv. The decedent was
contributing more than one-half of the support for the child or was legally
responsible for the maintenance of the child at the time of decedent’s death.
v. A step
child may be a dependent if the decedent is married to the surviving
spouse/mother of the step child and providing more than one-half support and in
addition, the other biological parent of the step child is not contributing to
the child’s support.
b. Claims services
staff shall obtain the birth certificate of any biological or adopted child of
the decedent’s for which benefits are being requested, in addition to
documentation that may be required based on the child’s circumstances as
described in sections V.D.4.c.-k. immediately below.
c. Child 18
but less than 25 years old, pursuing a full-time educational program in an
accredited educational institution at the time of death:
i. Claims
services staff shall require supporting documentation, such as:
a) Class registration
or schedule;
b) Report of grades
for completed courses;
c) Proof of payment
of fees and/or tuition;
d) School
transcript;
e) Letter of
acceptance into an educational institution; and/or
f) Proof of
the school’s accreditation.
ii. Claims
services staff may request more than one type or source of documentation as is
reasonably necessary to establish the child is pursuing a full-time educational
program in an accredited educational institution and program at the time of the
decedent’s death.
iii. Claims services
staff shall ensure the documentation adequately identifies the child, the
educational institution and the time period the information addresses (e.g.,
year and semester).
iv. Claims services staff
shall ensure documentation received is reasonably reliable and accurate (e.g.,
appears printed from a school website, contains the school’s letterhead).
v. Claims
services staff may supplement the documentation with information readily
available on the Internet (e.g., academic calendar to establish dates of
educational periods, such as semester beginning and ending dates, school
information regarding accreditation, information on what constitutes full-time
attendance).
vi. Claims services staff
shall continue paying death benefits during a break, providing the break does
not last longer than one grading period during any academic year (semester,
quarter, etc.).
vii. Claims services staff shall
only consider grades to the extent they may indicate the child is not attending
classes, withdrawn or otherwise not pursuing a full-time program.
viii. Claims services staff may refer
potentially fraudulent requests for death benefits to the Special
Investigations Unit for further investigation.
d. Adult
dependent(s) 18 years old or older with a mental or physical condition that
prevents the adult dependent from generating earnings:
i. Claims
services staff shall require medical documentation verifying the adult
dependent’s mental or physical disability, including the anticipated duration
of the condition that prevents the adult dependent from generating earnings.
ii. Claims
services staff may request more than one type or source of documentation as is
reasonably necessary to establish the adult dependent is physically or mentally
incapacitated from earning.
iii. Claims services
staff shall not disqualify an adult dependent otherwise qualifying as a
dependent under this provision due to the adult dependent working in a
sheltered workshop, if the adult dependent does not earn more than two thousand
dollars in any calendar quarter.
iv. Claims services staff
may refer potentially fraudulent requests for death benefits to the Special
Investigations Unit for further investigation.
e. If the child is
adopted, claims services staff shall require:
i. A
birth certificate listing the decedent as the child’s parent;
ii. A copy of
the court documents establishing the adoption; or
iii. If the adoption
is not finalized at the time of the decedent’s death, legal documentation or
other evidence establishing the level of support that was being provided by the
decedent.
f. If
the decedent and the child’s other parent were never married, claims services
staff shall require:
i. A
birth certificate listing the decedent as the child’s parent or other
documentation showing the decedent is the biological parent of the child (e.g.,
court ordered child support, paternity test, etc.); and
ii. An
affidavit or other evidence that confirms the child has not been adopted by
another.
g. If the child is
living with the decedent’s ex-spouse, claims services staff shall require an
affidavit confirming the child has not been adopted by another.
h. If the decedent
is alleged to be the parent of an unborn child, and the mother is not the
decedent’s spouse, once the child is born claims services staff shall require
documentation verifying the decedent is the biological parent.
i. A
stepchild is not presumed to be a whole dependent, but documentation may be
submitted which supports a determination that the stepchild is a whole,
partial, or prospective dependent, based on the circumstances and level of
support the decedent was providing the stepchild. In addition to the
documentation described in this section and V.E.
below, evidence necessary to make this determination includes:
i. Documentation
of the marriage of the decedent and natural parent;
ii. Documentation
showing the stepchild was living with the decedent at the time of the
decedent’s death;
iii. Documentation
showing that the decedent was financially supporting the stepchild at the time
of the decedent’s death; and
iv. Documentation showing
that the other biological parent is not paying child support and providing any
financial support to the stepchild.
j. Guardians
i. If
the decedent’s minor child is living with the surviving parent, claims services
staff shall verify (verbally or in writing) that the surviving parent is the
guardian of a decedent’s minor child and no further documentation shall be
routinely required.
ii. If a
claimant has a court appointed guardian, claims services staff shall request
from the guardian or whatever source necessary a copy of the court documents
appointing the guardian.
iii. If a minor child
does not have a guardian (a surviving parent or court appointed guardian),
claims services staff shall withhold benefits until a guardian is appointed, or
until BWC receives a court order directing it to pay benefits.
k. Claims
services staff shall require any other additional documentation as may be
necessary based on the circumstances.
5. Other Potential
Whole Dependents: Any family member living with the decedent at the time of
death may be determined to be a whole dependent if claims services staff
obtains evidence that shows the decedent was responsible for at least half of
the family member’s support.
6. Partial
Dependents: Claims services staff shall verify partial dependents with
documentation showing:
a. The claimant was
a family member of the decedent.
b. The claimant was
living with the decedent at the time of death; and
c. The
decedent provided the claimant some financial support for living expenses
(e.g., payment of rent or mortgage, medical bills, groceries, utilities).
7. Prospective
Dependents: Claims services staff may identify a prospective dependent when:
a. The claimant was
a family member of the decedent;
b. The prospective claimant
was living with the decedent at the time of death; and
c. There are
circumstances that clearly indicate a financial need on the part of the
claimant and that the decedent intended to provide some support. (e.g., bank
statements showing past payment of utilities or other living expenses of the
claimant, affidavits from claimant, other family members or friends).
8. Surviving
Natural Parent
a. Claims services
staff shall verify the natural parent of the decedent with the decedent’s birth
certificate.
b. Claims services
staff may determine the natural parent living with the decedent at the time of
death is a whole or partial claimant.
c. If claims
services staff determine that the natural parent living with the decedent at
the time of death is not a whole or partial claimant, claims services staff
shall presume the natural parent is a prospective claimant and shall make a
minimum award of $3,000 as required by law.
9. Claims services
staff shall consider a presumption of dependency to be rebuttable. Claims
services staff shall determine when a claimant is a dependent and the level of
dependency in accordance with the facts of each particular claim.
E.
Determination of the Claim and Death Benefits
1. Determination of
the Claim
a. Claims services
staff shall review the documentation in the claim.
b. Claims staffing
i. For
claims assigned to the Survivor Benefits team, a formal multi-disciplinary
staffing shall occur, prior to issuing an order.
ii. The death
benefits formal staffing shall include the following team members:
a) The IMS;
b) An MSS;
c) A representative
from Claims Policy;
d) A legal
representative from the Legal Services Division;
e) Claims services
staff assigned to the claim; and
f) Other
staff as needed based on the issue(s) in a claim.
iii. To expedite
claim determinations, each staffing team member shall, to the extent reasonably
possible, review the claim prior to the scheduled staffing.
iv. The multi-disciplinary
staffing shall address matters related to determining the claim and as needed,
matters related to dependency.
v. Members of
the staffing team shall provide input and assistance based on the member’s
respective area of expertise.
vi. When the staffing team
identifies the need for additional information or documentation, the IMS may schedule
an additional staffing or discuss the issue through email, as necessary.
c. When
determined necessary to clarify the cause of death and the relatedness to the
injury or occupational disease, claims services staff shall request a physician
file review.
i. The
MSS shall assist with identifying when a referral is appropriate and making the
referral, consistent with the Independent
Medical Exams and Physician File Reviews policy.
ii. The MSS
and BWC attorney shall collaborate as necessary, in preparing the appropriate
questions to be addressed by the physician completing the file review.
d. The determination
of a death claim shall be made by claims services staff and the IMS based on
all the evidence in the claim. The evidence in the claim must prove each
element of compensability.
e. Claims services
staff shall issue the initial claim determination by order.
f. Claims
services staff shall address the order to the selected claimant, with a copy to
any other claimants, the employer and any authorized representatives.
i. If
the claim is allowed, the order shall include the following, as applicable:
a) A brief statement
of the reason for and the evidence supporting the decision;
b) A listing of the
claimant(s) including name, date of birth, the determined level of dependency
(whole, partial or prospective) and the period of payment;
c) If there is
evidence available, the average weekly wage, or the minimum or maximum rate
used to calculate the weekly benefit;
d) The weekly
benefit and the apportionment;
e) The effect of
remarriage of the surviving spouse and the limitations/requirements for
continuing benefits for children;
f) Funeral
expenses payable; and
g) Any other
related issue(s).
ii. If the
claim is denied the order shall include a brief statement of the reason for and
the evidence supporting the denial.
g. In an existing
claim claims services staff shall:
i. Change
the claim type from “accident” or “OD” to “death” if the claim is allowed; or
ii. Keep the
claim type as accident or OD if the claim is denied.
h. For purposes of
processing in the claims management system only, when a new claim is allowed,
claims services staff shall enter “allowed” conditions supported by the
evidence.
i. If a
request for death benefits is withdrawn by the claimant, claims services staff
shall dismiss the claim.
2. Funeral Expenses
a. Claims services
staff shall award verified funeral expenses in an allowed claim up to a maximum
allowed by law.
i. Prior
to issuing any payment for funeral expenses, claims services staff shall verify
the amount of the balance or payment in full of the funeral expenses. Payment
shall be made directly to the individual that made payment and/or to the unpaid
service provider.
ii. Funeral
costs deducted from the proceeds of an insurance policy shall typically be
reimbursed to the beneficiary of the insurance policy.
iii. Claims services
staff shall consult with the IMS and BWC attorney if there is any question
regarding reimbursable/payable funeral expenses.
b. In addition to
standard funeral expenses, claims services staff may pay exceptional costs
related to the transportation of the decedent’s body. Examples:
i. The
decedent died outside his/her state of residence while seeking BWC approved
medical treatment for an allowed condition;
ii. The
decedent died while working far enough away from the decedent’s residence to
incur exceptional costs to transport the decedent’s body.
iii. The
determination of reimbursement or payment of exceptional costs related to the
transportation of the decedent’s body shall be made by claims services staff,
the IMS and the BWC attorney, when necessary.
3. Medical Expenses
a. Medical expenses
related to the decedent’s death are submitted to the MCO and processed pursuant
to standard procedure for medical bill payments
b. See the MCO
Policy Reference Guide for further information.
4. Payment of Death
Benefits
a. Benefits to a
claimant(s) shall begin the day after the death of the decedent and continue
until the claimant’s status changes and benefits terminate.
b. Benefits to an
unborn child begin the day the child is born.
c. Benefits
to a claimant with a guardian shall be payable to the claimant, consistent with
the Custody,
Guardianship, Power of Attorney and Incapacitation policy.
d. Whole Dependent
Benefit Rates
i. Claims
services staff shall calculate the benefit for a whole dependent(s) at 66 2/3%
of the decedent’s average weekly wage.
ii. The weekly
rate shall not exceed the statewide average weekly wage for the year of death
or be less than 50 percent of the statewide average weekly wage for the year of
death.
e. Partial
Dependent Benefit Rates
i. Claims
services staff shall calculate the benefit for a partial dependent(s) at 66
2/3% of the decedent’s average weekly wage.
ii. The weekly
rate shall not exceed the statewide average weekly wage for the year of death.
iii. There is no
minimum weekly rate
f. Prospective
Dependent Benefit Rates
i. Claims
services staff shall calculate the benefit for a prospective dependent based on
the amount of support that was received or expected to be received from the
decedent, but the award for all prospective dependents (excluding natural
parents deemed prospective dependents) shall not exceed a total amount of
$3,000.
ii. The
minimum benefit claims services staff shall award to a natural parent(s) living
with the decedent at the time of death and determined to be a prospective
dependent(s) is a total of $3,000.
iii. Claims services
staff shall calculate the benefit for a prospective dependent(s) separate from
the amount of the benefit apportioned among the whole and partial dependents.
5. Apportioning
Death Benefits Among Claimants
a. When there are
two or more whole and/or partial dependents, claims services staff shall
apportion the one benefit among all the eligible dependents fairly, considering
the circumstances of each particular case.
i. If
there is at least one whole dependent, claims services staff shall apportion
the one benefit, as calculated based on the whole dependent, among the whole
and partial dependent(s).
ii. Claims
services staff shall not factor a prospective dependent and the prospective
dependent’s benefit award into the benefit apportioned among the whole and/or
partial dependent(s).
iii. Claims services
staff shall utilize “Guidelines for Apportioning Death benefits Among
Dependents” available on COR.
b. Claims services
staff shall apportion an award to natural parents, living with the decedent at
the time of death determined to be prospective dependents, equally.
c. If there
is more than one prospective dependent, excluding a natural parent(s), claims
services staff shall apportion the award fairly among the prospective
dependents.
d. Claims services
staff shall staff unusual cases with an IMS, BWC attorney and/or the Survivor
Benefits team for guidance,
6. Family Support:
If there is a family support order against a dependent, claims services staff
shall refer to the Family
Support Orders and Attorney Fees Paid Pursuant to Deductions of Child Support
from Lump Sum Payments policy.
1. Annual Contact
a. Claims services
staff shall confirm the status of the surviving spouse and/or other
dependent(s) receiving benefits, no less than once every 12 months, to verify
that:
i. The
address is still correct;
ii. The
dependent(s) has not died;
iii. The dependent is
not incarcerated, or has not been incarcerated during the past 12 months; and
iv. There has otherwise
been no change in dependency status affecting eligibility to receive benefits.
b. Claims services
staff shall use an annual contact letter (available in the claims management
system and/or on COR).
c. The annual
contact letter shall ask the dependent (or recipient of the letter) whether:
i. The
address is still correct;
ii. The
dependent(s) has died;
iii. The dependent is
incarcerated, or has been incarcerated during the past 12 months; and
iv. There has otherwise
been any change in dependency status affecting eligibility to receive benefits.
d. The dependent
shall be required to:
i. Sign
the letter acknowledging and verifying the information provided in the letter;
and
ii. Return the
signed letter and any required documentation to BWC within a stated period of
time. A scanned or faxed copy of the signed letter will fulfill the signature
requirement.
2. Additional
Claimant-Specific Requirements: In addition to the requirements described
immediately above, claims services staff shall take the following steps based
on the circumstances of the claimant:
a. Minor Child with
Guardian: The annual contact letter sent to the listed guardian of a dependent
child under the age of 18 shall verify:
i. The
guardianship is still active; and
ii. The
correct guardian is identified.
b. Surviving Spouse:
The annual contact letter sent to the surviving spouse shall verify that the
surviving spouse has not remarried.
c. Child
Reaching Age 18: Claims services staff shall send a letter to a child who will
be turning age 18 to notify the child he/she is subject to the termination of their
benefits and explaining under what conditions benefits may continue.
d. Child Pursuing a
Full-time Educational Program
i. Every
educational period (e.g., semester, quarter) claims services staff shall
communicate via letter, email or text and require the child to provide:
a) Proof of
continued enrollment in a full-time educational program (e.g., class
registration); and
b) Proof of
participation in and completion of the previous educational period, if
applicable (e.g., a grade report).
ii. Claims
services staff shall continue to send and require the child to sign and return
an annual contact letter.
e. An adult
dependent over the age of 18 with a mental or physical condition that prevents
the adult dependent from generating earnings.
i. Temporary
incapacity: If the original medical documentation indicates the adult
dependent’s incapacitating condition is temporary, claims services staff shall
request updated medical information as deemed appropriate, but no less than
annually.
ii. Permanent
incapacity: When the claim documentation (e.g., the original benefits order)
indicates the adult dependent has a permanent mental or physical incapacity:
a) Claims services staff
shall review the claim to ensure the claim contains the supporting medical
documentation and to determine if there is any reason to believe the
incapacitating condition could have changed.
b) If the medical
documentation in the claim is adequate to support the ongoing permanent
incapacitation, claims services staff shall not request updated medical
documentation.
c) If there is
inadequate medical documentation in the claim to support permanent
incapacitation or there is otherwise reason to request updated documentation
claims services staff:
i) Shall
staff the issue with the IMS; and
ii) If the IMS
approves requesting updated medical documentation, document in claim notes the
reason for the additional medical documentation and that the IMS has approved
the request.
iii. Claims services
staff may refer any potentially fraudulent requests to the Special
Investigations Unit for further investigation.
f. Claims
services staff may request additional documentation from a dependent at any
time to verify continuing eligibility status as is reasonably necessary.
3. Non-Response to
a Contact and/or Information Request: If the dependent(s) does not respond
and/or provide required documentation within the time period required by BWC
via letter or other form of communication, claims services staff shall:
a. Take reasonable
steps to locate and contact the dependent, which may include but is not limited
to:
i. Sending
a second letter to the dependent;
ii. Telephoning
the dependent at the last known phone number;
iii. Contacting any
attorney of record for that dependent;
iv. Reviewing information
in any other workers’ compensation claim the dependent may have for contact
information or an employer or attorney of record;
v. Using the
internet to find:
a) Another phone
number and/or address;
b) Any information
indicating the dependent has died; or
c) Any other
information that may help locate and contact the dependent; and
d) Consulting
and/or referring the issue to the Special investigations Unit for further
investigation into the status of the dependent.
b. Suspend benefits
when reasonable attempts to establish contact and verify the dependent’s
ongoing dependency status have been unsuccessful.
i. Claims
services staff shall not suspend benefits prior to staffing with the IMS, and
BWC attorney if necessary.
ii. If
determined appropriate following staffing, claims services staff shall:
a) Suspend benefits
to the non-responsive dependent only, beginning the next available benefit
period. (Any other dependents shall continue to receive his/her regular benefit
amount); and
b) 30 days
following the date the benefits are first suspended, issue an order terminating
benefits to the non-responsive dependent and reapportion. See Orders,
Waivers, Appeals and Hearings policy for further information.
1. When a whole or
partial dependent’s status changes and benefits were originally apportioned by
BWC, claims services staff shall reapportion the benefit among the active
dependents and issue an order with the reapportioned rates to each of the
impacted dependents.
2. When benefits
were originally apportioned by the IC, a status change of a dependent and
potential reapportionment shall be referred to the IC.
3. Dependency
status changing events include but are not limited to:
a. Remarriage of a
surviving spouse:
i. Upon
remarriage of the surviving spouse, claims services staff shall award two years
of compensation to the surviving spouse in a lump sum payment, using the date
of remarriage as the payment begin and end date. No further compensation shall
be paid to the surviving spouse.
ii. Claims
services staff shall calculate the award using the rate the surviving spouse
was receiving at the time of the remarriage. For example:
a) Surviving spouse
weekly rate at time of remarriage: $400.00
b) Two years = 104
weeks
c) $400.00 × 104=
$41,600 Total Award
iii. Claims services
staff shall deduct the remaining balance of any lump sum advancement still in
effect at the time of remarriage from the two-year lump sum award, consistent
with the Lump
Sum Advancement policy.
b. Death of a
Claimant: Claims services staff shall terminate benefits to a claimant upon
death and reapportion the benefit among the remaining active claimants.
c. Child
Reaches 18 Years of Age
i. Claims
services staff shall terminate benefits to a child on the day prior to the
child’s 18th birthday, unless the child is enrolled in a full-time
educational program at an accredited educational institution and program,
including high school; or qualifies as an incapacitated child unable to earn
wages.
ii. If
benefits are terminated at age 18 and the child later enrolls in a full-time
educational program at an accredited educational institution and program, benefits
shall be awarded (if otherwise qualified), and reapportioned, if multiple
dependents are receiving benefits. Such award and reapportionment shall be
effective the first day of classes, until the day prior to the child’s
twenty-fifth birthday or until the child stops attending school.
d. Child Reaches 25
Years of Age or Stops/Starts Attending School
i. Claims
services staff shall terminate benefits for a dependent child that has been
enrolled in a full-time educational institution and program:
a) The day prior to
the child’s twenty-fifth birthday; or
b) When he or she
stops attending the accredited educational institution and program full-time,
whichever comes first.
ii. Benefits
terminated prior to the child’s twenty-fifth birthday may be reinstated if the
child starts attending school again and is otherwise eligible, effective the
first day of classes.
e. Mental or
Physical Incapacity Ends
i. Claims
services staff shall staff a claim with the BWC attorney if evidence indicates
that the adult dependent is receiving earnings and/or the condition that caused
the mental or physical incapacity has resolved to determine if benefits should
discontinue or otherwise change.
ii. Claims
services staff shall issue a BWC order or notice of referral to the IC
indicating whether the benefits are being terminated or reduced and language
that there is no longer evidence of a physical or mental incapacity that
prevents the adult dependent from generating earnings.
f. Claimant
is Incarcerated or Released from Incarceration
i. Claims
services staff shall terminate benefits to a claimant effective the date of
incarceration and may resume benefits upon release of the claimant, if the
claimant is otherwise eligible.
ii. See the Incarceration
policy for further information.
1. Claims services
staff shall process consistent with the Overpayment of Compensation policy
when:
a. There is an
overpayment of death benefits; or
b. The claimant has
a separate workers’ compensation claim in which there is an overpayment.
2. Claims services
staff shall refer to and follow the Overpayment
of Compensation policy.
1. Claims services
staff shall approve or deny a request for a lump sum advancement on death
benefits consistent with the Lump
Sum Advancement policy.
2. Claims services
staff shall refer a request for lump sum settlement to the appropriate LSS team
for processing.
3. The LSS team may
settle a death claim consistent with the Lump
Sum Settlement policy.