OhioBWC - Basics: (Policy library) - File

Death Claims

Policy and Procedure Name:

Death Claims

Policy #:

CP-04-04

Code/Rule Reference:

R.C. 4127.03; R.C. 4123.031; R.C. 4123.032; R.C. 4123.59; R.C. 4123.60; R.C. 4123.66; O.A.C. 4123-3-07; O.A.C. 4123-5-13

Effective Date:

02/27/2020

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy (CP)

Supersedes:

Policy # CP-04-04, effective 09/29/17 and Procedure # CP-04-04.PR1, effective 09/29/17

History:

Previous versions of this policy are available upon request


 

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

 


 

I. POLICY PURPOSE

 

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.

 

II. APPLICABILITY

 

This policy applies to BWC Claims Services staff.

 

III. DEFINITIONS

 

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).

 

 

IV. POLICY

 

A.    Notice of Death

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.

 

B.    Filing an Application for Death Benefits

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.

 

C.   Funeral and Medical Expenses

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 shall be filed within two years after death.

4.    See the Jurisdiction policy for further information.

 

E.    Eligibility for Death Benefits

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.

 

F.    Level of Dependency: Whole, Partial and Prospective

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.

 

G.   Death Benefits Rates and Apportionment

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.

 

H.   Claimant Annual Contact

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.

 

I.      Claimant Status Change(s) and Reapportionment

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.

 

J.     Family Support

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.

 

K.    Overpayments

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.

 

L.    Scheduled Loss Compensation

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.

 

M.   Claimant Incarceration

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.

 

N.   Lump Sum Advancement and Lump Sum Settlement

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.

 

 

V. PROCEDURE

 

A.    Standard Claim File Documentation

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.

 

B.    Processing a Notice of Death

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.

 

C.   Processing an Application for Death Benefits

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.

 

D.   Establishing Level of Dependency and Documentation Requirements

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.

 

F.    Claimant Annual Contact

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.

 

G.   Dependency Status Changes and Reapportionment

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.

 

H.   Overpayments

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.

 

I.      Lump Sum Advancement and Lump Sum Settlement of Death Benefits

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.