OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Abatement

Policy #:

CP-01-05

Code/Rule Reference:

O.A.C. 4123-5-21

Effective Date:

07/20/18

Approved:

Kevin R. Abrams, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

Policy #CP-01-05 and Procedure #CP-01-05 PR.1, effective 07/01/13

History:

Rev. 07/20/18; New 07/01/13

 

 

  I.          POLICY PURPOSE

 

The purpose of this policy is to ensure BWC properly abates a pending application(s) when the injured worker (hereafter the “decedent”) or other claimant dies.

 

II.          APPLICABILITY

 

This policy applies to claims services staff.

 

III.          DEFINITIONS

 

Abatement: To discontinue any further action on an application(s) pending in a claim at the time of the decedent’s or other claimant’s death.

 

Application: A form or other means of communicating to BWC the following:

1.      Requests: Communications requesting an initial or subsequent action be taken.

Examples:

a.   Application for Payment of Lump Sum Advancement (C-32);

b.   Request for Temporary Total Compensation (C-84);

c.   Motion (C-86).

2.      Authorizations: Communications that serve to grant permission.

Examples:

a.   A Power of Attorney;

b.   Claimant Authorized Representative (R-2);

c.   Authorization to Receive Workers’ Compensation Payment (C-230).

3.      Agreements: Communications that serve as a contract between the parties.

Examples:

a.   Settlement Agreement and Application for Approval of Settlement      Agreement (C-240);

b.   Rehabilitation Agreement (RH-1).

 

Claimant: One who asserts a right, demand or claim for workers’ compensation benefits.

 

IV.          POLICY

 

A.     It is the policy of BWC to abate an application(s) filed by a decedent or other claimant and pending in a claim when the decedent or other claimant dies with the following exceptions:

1.     An application(s) related to payment of medical services rendered as a result of a decedent’s allowed injury or occupational disease claim; and

2.     A Settlement Agreement and Application for Approval of Settlement Agreement (C-240) and/or an Amended Settlement Agreement and Release (C-241), if the decedent dies after issuance of the “LSS Approval” letter. See the Lump Sum Settlement policy and Accrued Compensation policy for further information.

 

B.     Abatement of an application(s) pending in a claim does not prohibit:

1.     Other claimants from filing an application(s) subsequent to the decedent’s death; see the Death Claims policy and Accrued Compensation policy for further information.

2.     The payment of approved medical services related to the decedent’s allowed injury or occupational disease claim.

 

V.          PROCEDURE

 

A.     BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim-note requirements and shall follow any other specific instructions included in this procedure.

 

B.     Abatement of a pending application(s): When claims services staff receive notice of the death of a decedent or other claimant:

1.     Claims services staff shall verify the death through a Social Security cross match, a death certificate, a published obituary, a police report or some other reliable means; and

2.     Discontinue action on an application(s) filed by the decedent or other claimant and pending at the time of the decedent’s or other claimant’s death, except for:

a.     An application(s) related to payment of medical services rendered as a result of the decedent’s allowed injury or occupational disease claim; and

b.     A Settlement Agreement and Application for Approval of Settlement Agreement (C-240) and/or an Amended Settlement Agreement and Release (C-241), when the decedent dies after issuance of the “LSS Approval” letter. See the Lump Sum Settlement policy for further information.

 

C.    Issuing the Abatement Order: Claims services staff shall issue an abatement order addressed to the surviving spouse, or if no surviving spouse exists, to another dependent or family member identified by claims services staff, as appropriate.

1.     The order shall indicate the specific application that has been abated based on the decedent’s death.

2.     Claims services staff may need to change the “Original Recipient” or add a “New Participant” in the claims management system.

3.     If claims services staff is unable to identify a surviving spouse, another dependent or family member, claims services staff shall use “Change Delivery Options” in the claims management system and address the order to “The family of…” and mail it to the decedent’s last known address.

4.     Claims services staff shall ensure a copy of the abatement order is sent to the decedent’s authorized representative, by adding the decedent’s representative as a recipient of the order.

a.     Claims services staff shall NOT immediately expire the decedent’s authorized representative upon notice of death.

b.     Refer to the Authorized Representatives policy and procedure for further information.

 

D.    Claims services staff shall:

1.     Process an application(s) filed subsequent to the death of the decedent. Claims services staff shall refer to the Accrued Compensation policy and/or the Death Claims policy for further information.

2.     Refer medical bills for approved medical services rendered as a result of the allowed injury or occupational disease claim to the MCO for processing.