Policy and Procedure Name:
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Permanent Total Disability (PTD) and Disabled Workers’
Relief Fund (DWRF) for Self-Insured Claims
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Policy #:
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CP-16-03.3
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Code/Rule Reference:
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R.C. 4123.411
through 4123.417;
4123.58;
4123.62
O.A.C. 4123-3-31;
4123-3-34
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Effective Date:
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11/17/21
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-16-03, effective 04/20/2015 and Procedure #
CP-16-03-PR.1, effective 05/06/2019
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History:
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Previous versions of this policy are available upon
request
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Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Disabled Workers’ Relief Fund (DWRF)
DWRF Eligibility Amount
Permanent Total Disability (PTD)
Split PTD
Statutory PTD
IV. POLICY
A. SI PTD
B. DWRF
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Applications for
Compensation for PTD in SI Covered Claims
C. Statutory PTD
D. Claim Assignment
E. Collaboration with the
TPA/SI Employer
F. Annual Contact in SI
PTD Claims
G. DWRF Annual Processing
H. Billing and Claims
Information Inquiries
I. Settlements
The purpose of this policy is to ensure BWC calculates and
pays Disabled Workers’ Relief Fund (DWRF) benefits in compliance with the Ohio
Revised Code and the Ohio Administrative Code when Permanent Total Disability
(PTD) is granted in a covered self-insured (SI) claim.
This policy applies to all claims services staff.
Disabled
Workers’ Relief Fund (DWRF): A fund, separate from the state
fund, established to provide supplemental benefits to injured workers who are
receiving PTD compensation when the total of the PTD compensation plus the
social security disability (SSD) benefit is less than the DWRF eligibility
amount.
DWRF
Eligibility Amount: The threshold amount, adjusted annually
based on the consumer price index, used to determine an IW’s eligibility for
DWRF benefits and established by the BWC DWRF Unit and BWC’s Actuarial
Department.
Permanent
Total Disability (PTD): Compensation granted to an injured
worker for the duration of his/her life when the Industrial Commission of Ohio
(IC) determines that the injured worker is unable to perform any sustained remunerative
employment or is statutory PTD as defined in R.C. 4123.58.
Split PTD:
PTD compensation allocated by the IC to more than one claim for an injured
worker. The percentage for each claim is used to calculate the amount payable
per claim.
Statutory
PTD: PTD compensation payable based on the loss or loss of
use of both hands or both arms, or both feet or both legs, or both eyes, or of
any two thereof.
1. It is the
policy of BWC to expeditiously process PTD matters in SI claims to help ensure
applications are processed timely and awards are paid promptly by SI employers.
2. When a
covered SI claim is granted PTD, it is the policy of BWC to work with the SI
employer to secure the PTD payment rate.
1. It is the
policy of BWC to use the PTD rate paid by the SI employer to determine if the injured
worker (IW) is eligible for DWRF benefits.
2. BWC shall
proactively determine if the IW is eligible to receive DWRF benefits when PTD
is granted. No application is necessary.
3. DWRF
Payments in SI Claims
a. BWC will
bill SI employers for DWRF paid in all SI claims.
b. BWC will
also bill employers in claims that were previously SF, when the employer was SF
and is now SI.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Shall
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. Claims
services staff shall review the Application for Compensation for Permanent
Total Disability (IC-2) or Agreement As To Award for Permanent Total
Disability (IC-22) imaged in a claim file to determine if the application
for PTD was filed with BWC or the IC.
a. If the
application was filed with the IC and the imaged document contains an IC date
stamp, claims services staff shall:
i. Create
a case in the claim; and
ii. Update
the case issue to hearing.
b. If the
application does not have an IC date stamp, claims services staff shall:
i. Create
a case and select the event titled “Referred to the IC”;
ii. Complete
a notice of referral (NOR) to notify the IC that an IC-2 or IC-22 application
has been filed; and
iii. Update the
case issue to “Hearing”.
2. Upon
receipt of an IC-2 or IC-22, claims services staff must:
a. Send the Self-insuring
Employer Notice and Request for Information for Permanent Total Benefits
Application (C-268) to the SI employer to verify IW demographics and claim
information; and
b. Set a work
item for 14 days for return of the C-268 from the SI employer.
i. If
the C-268 is received, make updates as appropriate to the claims management
system.
ii. If
the C-268 is not received, call the SI employer to request the completed form
or send a second request.
iii. If there
is no response to the second request, file an Self Insured Complaint Form (SI-28).
1. If an IW
files a Motion for Statutory PTD, claims services staff shall forward the
request to the IC for processing via a NOR.
2. Claims
servives staff shall:
a. Send the C-268
to the SI employer to verify IW demographics and claim information; and
b. Set a work
item for 14 days for return of the C-268 from the SI employer.
3. If the completed
C-268:
a. Is
received, claims services staff shall make updates as appropriate to the claims
management system.
b. Is not
received or is missing information, claims services staff shall call the SI
employer to request the completed form, or send a second request.
c. If
there is no response to the second request, claims services staff shall file an
SI-28.
4. If an SI
employer files an IC-22 in response to the Motion for Stat-PTD benefits filed
by the IW, claims services staff shall forward it to the IC for processing via
a NOR.
5. Upon
receipt of an IC Tentative Order (TO) for statutory PTD, the assigned PTD/DWRF
CSS must verify that the order:
a. Includes
the PTD start date; and
b. Limits the
retroactive payment, if any, to no more than two years before the request for
statutory PTD.
c. If
the TO does not contain the required information, the PTD/DWRF CSS shall:
i. Contact
the parties to the claim and their representatives to discuss the error; and,
ii. Document
which party is going to request a corrected TO.
1. Upon
receipt of an IC order granting PTD, claims services staff shall enter the
claim’s information on the PTD Reassignment SharePoint site.
2. If the SI
employer settles the DWRF liability, the claim remains assigned to the SI
PTD/DWRF CSS.
3. If the SI
employer settles the DWRF liability and the PTD indemnity, the claim is
reassigned to the assigned claims assistant (CA).
1. Upon the
granting of PTD benefits in an SI claim, the PTD/DWRF CSS shall collaborate
with the TPA/SI employer as needed.
2. Initial
steps when PTD is granted:
a. The SI PTD/DWRF
CSS shall:
i. Send
the Self-Insuring Employer Notice and Request for Information for Injured
Worker Who Has Been Granted PTD Benefits (C-269), which provides
notification to the SI employer of the DWRF rate to be paid by BWC based on the
AWW information the SI employer previously provided and the Social Security
(SS) information BWC has on file; and
ii. Set
a work item for 14 days for return of the C-269 from the SI employer.
b. If the C-269:
i. Is
received, the SI PTD/DWRF CSS shall make updates as appropriate to the claims
management system.
ii. Is
not received, the PTD/DWRF CSS shall call the SI employer to request the
completed form, or send a second request.
c. The SI
PTD/DWRF CSS must work with the SI employer to resolve any discrepancies, if
necessary.
3. Ongoing
management of the claim(s):
a. If the SI PTD/DWRF
CSS receives any SS crossmatch work items that indicate, after review, that the
PTD rate should be updated, the PTD/DWRF CSS must contact the SI employer
regarding the SS change.
b. The SI PTD/DWRF
CSS will send the SI employer an updated PTD rate calculation worksheet along
with the effective date of the change.
c. The SI
PTD/DWRF CSS shall contact the SI employer if notification of the IW’s death is
received.
1. When the
annual contact work item is posted in the claim, the SI PTD/DWRF CSS shall
contact the SI employer or their designee annually via the “DWRF Annual Contact
– SI Insured” letter (found in the claims management system) to request:
a. The AWW,
if not previously submitted;
b. The PTD declared
and paid rates; and
c. Any
LSAs or other offsets affecting the rate.
2. The SI
PTD/DWRF CSS shall document in claim notes all efforts to obtain information
from an SI employer or their designee.
3. If the SI
employer or their designee fails to respond to the first letter:
a. The SI
PTD/DWRF CSS shall send a second letter requesting the information.
b. If there
is no response to the second letter, the SI PTD/DWRF CSS must make an attempt
to contact the SI employer or their designee by phone or email.
c. If
the phone or email contact is not successful, the SI PTD/DWRF CSS shall file an
SI-28 documenting that the SI employer or their designee has not been
responsive to BWC’s request for information. The notification shall include:
i. Dates
that the letters were sent; and
ii. Information
regarding phone calls or emails, including date and person contacted.
d. The SI PTD/DWRF
CSS shall work with the SI auditors to obtain contact information for the
employer if necessary.
4. When the
response is received, the SI PTD/DWRF CSS shall work with the SI employer or
designee to resolve any discrepancies if information previously reported has
changed. If necessary, the SI PTD/DWRF CSS shall staff the issue with the PTD/DWRF
Injury Management Supervisor (PTD/DWRF IMS).
5. Once the
discrepancy has been resolved, the SI PTD/DWRF CSS shall image a copy of the
revised PTD rate calculation worksheet indicating the change in the PTD
declared rate.
6. If any
changes occur, the SI PTD/DWRF CSS must make the appropriate updates in the
system.
7. The SI
PTD/DWRF CSS must build a PTD-SI plan based on the PTD rate calculation
worksheet.
8. If DWRF is
impacted due to the change, the SI PTD/DWRF CSS must issue a DWRF order addressing
the new rate.
1. The SI PTD/DWRF
CSS must issue a DWRF order during the DWRF annual process when an IW becomes
newly entitled to DWRF benefits.
2. Please see
the PTD/DWRF training document for detailed information regarding the SI DWRF
annual process procedures.
1. If the
PTD/DWRF CSS receives an inquiry from an SI employer about a DWRF billing, the
PTD/DWRF CSS shall inform the SI employer that the billing information can be
found on www.bwc.ohio.gov.
2. Excess
Carrier Requests
a.
Excess Carriers may periodically request information regarding a SI
backrupt claim by emailing Excessinsurance@bwc.state.oh.us.
The request may include:
i. The
amount of medical benefits and compensation payments;
ii. Authorizations;
and
iii. Invoices.
b. If the
request is claims related, the SI department will contact the PTD/DWRF CSS to
respond. The PTD/DWRF CSS must respond to these requests as soon as possible,
as a delay in response may result in BWC becoming permanently responsible for
the payment of the claim.
c. The
PTD/DWRF CSS or PTD/DWRF IMS must forward all email inquiries they receive
directly to Excessinsurance@bwc.state.oh.us
for review and assignment.
1. When the SI
PTD/DWRF CSS receives notification from the Industrial Commission that a SI
settlement has been approved, the PTD/DWRF CSS shall update the claim to the
appropriate settled status (e.g., settled medical, settled indemnity, settled
both).
2. If the PTD
indemnity or both the medical and indemnity are settled, the PTD/DWRF CSS must
stop DWRF payments.