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Policy and Procedure Name:
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Pre-Permanent Total Disability (PTD)
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Policy #:
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CP-16-03.1
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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
Permanent Total Disability (PTD)
Split PTD
Statutory PTD
IV. POLICY
A. Applications for PTD
B. Statutory PTD
C. IC Orders
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Applications for PTD
C. Temporary Total (TT)
Compensation Pending PTD Decision
D. Percentage of Permanent
Partial (%PP) or Increase of %PP Pending PTD Decision
E. Additional Allowance
Pending PTD Decision
F. Lump Sum Settlements
(LSS) Pending PTD Decision
G. Statutory PTD
H. Claim Assignment
The purpose of this policy is to ensure that appropriate
updates are made when an application for permanent total disability (PTD) is
filed and that proper actions are taken on other applications filed while the
PTD application is pending
This policy applies to all claims services staff.
Permanent Total
Disability (PTD): Compensation granted to an injured
worker (IW) for the duration of his/her life when the Industrial Commission of
Ohio (IC) determines that the IW 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 IW. 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.
When an application for PTD is pending with the Industrial Commission of
Ohio (IC), it is the policy of BWC to ensure all claim information is current.
2.
While the PTD application is pending, it is the policy of BWC to address
all incoming applications.
3.
When an Application Filed for Compensation for Permanent Total
Disability (IC-2) is received, a thorough review of the claim is completed
to ensure:
a. The IC is
properly informed of all the allowed and denied conditions in the claim(s); and
b. If
applicable, all outstanding wage and compensation issues are addressed prior to
the claim being reassigned to the PTD team.
1.
It is the policy of BWC, when appropriate, to proactively refer a claim
to the IC for statutory PTD when the injured worker (IW) has lost by amputation
or loss of use:
a. Both hands
or both arms;
b. Both feet
or both legs;
c. Both
eyes; or
d. Of any two
thereof.
2.
IWs who have been found to be statutorily PTD may return to work and
continue to receive PTD compensation.
1.
When an IW’s PTD is medically obvious, a staff hearing officer (SHO) may
grant PTD without a hearing for statutory or non-statutory PTD.
2.
The staff hearing officer (SHO) must conduct a hearing in order to grant
or deny PTD when the application is not medically obvious or when an objection
has been filed to a Tentative Order (TO).
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 must follow these procedures for state funded and
self-insuring bankrupt claims when an application is filed for PTD.
2.
Claims services staff must review IC-2 applications imaged in a claim
file to determine if the application for PTD was filed with BWC or the IC.
3.
If the application does not have an IC date stamp, claims services staff
must complete a Notice of Referral (NOR) to notify the IC that an IC-2
application has been filed.
4.
For all IC-2 applications, claims services staff must:
a. Create a
legal case and under the issue tab select event title: “Referred to the IC”;
b. Select the
appropriate case issue status (e.g. statutory or non-statutory);
c. Update
the case issue status to “Hearing”; and
d. Enter the
PCN number when received from the IC.
5.
Upon receipt of an IC-2 application in a state fund claim, claims
services staff must review the claim(s) to ensure:
a. The
conditions allowed by BWC or IC order are correctly updated in the claim;
b. Wages were
set correctly, and the appropriate wage order was published;
c. If
applicable, all overpayments were declared and are absorbing correctly; and
d. All IW
demographic information in the claim is current (e.g. IW address is current, no
recent returned mail).
1.
Claims services staff shall not terminate TT based upon the filing of
the IC-2 and shall continue payment of TT.
2.
When BWC receives a MEDCO-14 form or equivalent from the treating
provider indicating that the IW has reached maximum medical improvement (MMI),
claims services staff is not required to wait for a decision on the IC-2.
Claims services staff shall terminate TT as of the MMI date on the BWC order.
3.
If the evidence on file is from a provider other than the treating
provider who indicates the IW has reached MMI, claims services staff may send
the MMI issue to the IC while the IC-2 is still under consideration.
4.
Claims services staff may schedule extent of disability exams and
process findings that the IW has reached MMI.
5.
If the IC-2 is dismissed or the IC finds the IW is not PTD, claims services
staff shall review the issue with the local BWC attorney to determine if any of
the evidence from the IC-2/IC exam for PTD could be used as a basis for an IC
referral on the issue of MMI.
1.
Claims services staff shall process an Application for Determination
or Increase of Percentage of Permanent Partial Disability (C-92) filed
prior to the IC-2 filing date.
2.
If the C-92 and IC-2 are filed on the same day, claims services staff
must use the receipt time stamp to determine which application was filed first.
3.
Claims services staff shall not process a C-92 that is filed after an
IC-2 until the processing on the IC-2 is complete, as detailed in the Percentage of Permanent Partial Disability or Increase of
Permanent Partial Disability Compensation policy and procedure.
4.
See the Percentage of Permanent Partial Disability or Increase of
Permanent Partial Disability Compensation policy and procedure for additional information regarding %PP.
1.
When a request for allowance of additional conditions is received,
claims services staff must:
a. Process
any requests filed prior to the filing of the IC-2;
b. Suspend
any requests filed after the filing of IC-2;
c. Set
a reminder to follow-up on the request once a decision has been made regarding
PTD; and
d. Process
the request once the IC decision regarding PTD becomes final, regardless of the
IC’s decision to allow or deny PTD.
2.
See the Additional Allowance policy and procedure for
additional information.
1.
The LSS CSS shall process any Settlement Agreement and Application
for Approval of Settlement Agreement (C-240), regardless of the filing
date.
2.
See the Lump Sum Settlement (LSS)LSS policy and
procedure for additional information regarding PTD and LSS.
1.
Eligibility Determination
a. Claims
services staff must review the claim to determine if the IW may be eligible for
statutory PTD when a BWC or IC order has awarded an IW loss by amputation or
loss of use of the body parts as described in policy Section IV.B.
b. For claims
with dates of injury on or after 08/25/06:
i. BWC
may refer a claim to the IC for the finding of statutory PTD when BWC or the IC
has granted the loss by final order.
ii. The
loss or loss of use of a single limb does not constitute the loss of two body
parts for purposes of determining statutory PTD. For example, the loss of the
arm does not constitute the loss of the hand and the loss of the arm.
c. For
claims with dates of injury prior to 8/25/06, the loss or loss of use of a
single limb constitutes the loss of two separate entities of the limb (e.g.,
the loss of the arm constitutes the loss of the hand and the loss of the arm).
d. BWC shall
refer requests for statutory PTD filed by the IW or the IW’s attorney to the IC
for determination.
e. The
standard for total loss of vision for statutory PTD is greater than the
standard for scheduled loss (State ex rel. Szatkowski v. Indus. Comm).
i. For
example, an IW may receive scheduled loss for 100% loss of vision but have some
vision with correction. Vision with correction may negate the IW’s eligibility
for statutory PTD.
ii. Claims
services staff shall consult with a BWC attorney for questions regarding loss
of vision and possible eligibility for statutory PTD.
2.
Referral for Statutory PTD Determination
a. Claims
services staff must complete a NOR if the IW meets the eligibility criteria
listed above, or the IW files a Motion requesting statutory PTD.
b. Upon
completion of the NOR, claims services staff shall create a legal case with a
case status issue of “Statutory PTD”.
i. Under
the issue tab, select event title: “Referred to the IC”;
ii. Select
case issue status: “Statutory”;
iii. Update the
case issue status to “Hearing”; and
iv. Enter the PCN
number when received from the IC.
3.
Reassignment After Determination of Statutory PTD – Upon receipt of an
IC TO for statutory PTD, the assigned claims services staff must immediately send
the claim to the appropriate PTD team via the PTD reassignment SharePoint site.
1.
Immediately upon receipt of an IC order granting PTD, claims services
staff shall enter the claim on the PTD Reassignment SharePoint site.
a. State-fund
(SF) claims shall be assigned as follows:
i. SF
claims previously assigned to a service office will be assigned to the
appropriate PTD team.
ii. SF
claims assigned to Special Claims (COEMP, RIC and PWRE) are assigned to the
Dayton PTD team.
b. When PTD compensation
has been allocated by the IC to more than one claim for an IW (Split PTD), and
all claims are SF, the claims will be assigned to the same PTD/DWRF CSS.
c. Self-Insured
(SI) claims, shall be assigned to the Dayton PTD team as follows:
i. All
SI covered and bankrupt claims; and
ii. All
split PTDs that involve SF and SI covered or bankrupt claims.
d. Black Lung
and Marine Fund claims shall remain assigned to the Special Claims CSS
specified for processing those claims.
2.
The PTD/DWRF IMS may reassign a claim back to the appropriate service
office if the indemnity benefits in the claim are settled.