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OhioBWC - Basics: (Policy library) - File

Policy Name:

OCCUPATIONAL DISEASE CLAIMS

Policy #:

CP-15-03

Code/Rule Reference:

R.C. 4123.01(F); 4123.511(B) (1); 4123.68

Industrial Commission (IC) Resolution R03-1-02 and R15-1-01.

Effective Date:

09/29/17

Approved:

Kevin R. Abrams, Chief Operating Officer

Origin:

Claims Policy (CP)

Supersedes:

05/24/17; Occupational Disease Claims policy CP-15-03 dated 06/10/16.

History:

New 06/10/16; Rev. 05/24/17

 

 

I.      POLICY PURPOSE

 

The purpose of this policy is to ensure that BWC determines and manages occupational disease claims appropriately and in compliance with applicable laws.

II.    APPLICABILITY

 

This policy applies to Claims Services staff.

III.   DEFINITIONS

Causal connection:  For purposes of this policy, determination that exposure to a hazardous substance at work produces a harmful effect, confirmed by medical diagnosis.

 

Date of disease:  For purposes of this policy, it is the latest event of one of the following:

       The date the injured worker first became aware through medical diagnosis that he/she was suffering from an occupational disease; or

       The date the injured worker first received medical treatment for the occupational disease; or

       The date the injured worker first quit work because of the occupational disease.

 

Injurious exposure:  Contact with a hazardous substance that either proximately causes the occupational disease, or augments or aggravates a pre-existing occupational disease.

 

Last injurious exposure:  The last point in time, and/or the last place where the injured worker was in contact with the hazardous substance, that caused or contributed to the occupational disease.

 

Non-scheduled occupational disease: A disease not specifically listed in R.C. 4123.68, but which otherwise meets the definition of a compensable occupational disease as defined in R.C. 4123.01.

 

Occupational Disease:  A disease contracted in the course of employment, where the employment is shown to create a risk of contracting the disease in greater degree and in a different manner from the general public. The disease’s causes and the characteristics of its manifestation must demonstrate a relationship to the work environment, or the condition of the employment environment must be shown to result in a hazard which distinguishes the employment in character from employment generally.

 

Risk:  For purposes of this policy, exposure to the chance of injury, loss, hazard or danger.

 

Scheduled occupational disease:  A disease listed in R.C. 4123.68 that an injured worker contracts in the course and scope of employment.

 

Standard Injury Claim: A claim involving a work-related accident, not an occupational disease.

 

Statutory occupational disease:  For purposes of this policy, a scheduled occupational disease that requires an independent medical examination prior to claim determination.

 

 

IV.  POLICY

 

A.    General policy statements

1.    An occupational disease claim may be scheduled or non-scheduled.  For consistency purposes, the policy shall use the language “occupational disease claim” to reference both.

2.    It is the policy of BWC that a pre-existing disease aggravated during employment is not compensable as an occupational disease claim. Brody v. Mihm, 72 Ohio St.3d 81 (1995).  One exception is when a pre-existing disease is aggravated or substantially aggravated by an injury.  This situation may be compensable as an injury claim.  Refer to Aggravation and Substantial Aggravation of a Pre-Existing Condition for additional information.  For example:

a.    An injured worker has an allowed occupational disease claim for right carpal tunnel.  The injured worker has surgery, returns to work and carpal tunnel syndrome has resolved.

b.    The same injured worker subsequently gets injured when a press comes down on the right hand and the pre-existing carpal tunnel syndrome is aggravated.  The claim may be allowed for an aggravation or substantial aggravation of a pre-existing disease.

3.    BWC will establish the date of disease using the information available at the time of claim filing. 

4.    BWC, during the initial investigation of claim, shall classify a claim as an occupational disease claim when it meets the criteria outlined in this policy.

5.    A claim that does not meet the requirements of an occupational disease may meet the requirement for a standard injury claim under the Compensable Injuries policy.

6.    A firefighter’s cancer claim that does not meet the presumption in Firefighters with Cancer Occupational Disease Claims policy may meet the requirement for an occupational disease claim as outlined in this policy.

7.    A statutory occupational disease claim is one of the following diseases specifically listed in R.C. 4123.68:

a.    Berylliosis;

b.    Any cardiovascular, pulmonary, or respiratory disease of a firefighter or police officer caused or induced by the cumulative effect of exposure to heat, smoke, toxic gases, chemical fumes and other toxic substances;

c.     Silicosis;

d.    Coal miners’ pneumoconiosis;

e.    Asbestosis; and

f.      Any other occupational disease of the respiratory tract resulting from injurious exposure to dust.

 

B.    Compensability for an occupational disease claim

1.    For timely filing, statute of limitations in an occupational disease claim, refer to the Jurisdiction policy.

2.    A claim meets the occupational disease definition and is compensable when supported by proof of the following:

a.    A work-related exposure to a hazardous substance;

b.    A harmful effect that is confirmed by medical diagnosis;

c.     A causal relationship between the work-related exposure and harmful effect that is confirmed by a medical diagnosis by a physician; and

d.    The conditions of employment created a greater risk to the injured worker than to the general public.

3.    BWC will consider the following in making a claim determination for occupational disease claims:

a.    Mechanism or agent causing the disease;

b.    Type of employment;

c.     Employment history;

d.    Medical documentation; and

e.    Any other pertinent information required or available.

 

C.   Supporting evidence for an occupational disease

1.    Medical Evidence

a.    An occupational disease requires sufficient medical documentation from a physician to substantiate and support the diagnosis of the alleged occupational disease. Medical documentation includes, but is not limited to:

i.      office notes;

ii.     examination reports;

iii.    diagnostic testing;

iv.   pathology reports. 

b.    BWC shall require a physician’s statement of causality that addresses the causal connection between the alleged occupational disease and the injured worker’s employment.

c.     BWC may seek additional medical evidence that exceeds the minimum evidence required or may obtain additional diagnostic testing, as necessary, to make an informed decision.

2.    Employment Information

a.    It is the policy of BWC to require a detailed and complete employment history which includes, but is not limited to, the following:

i.      Injured worker’s job title and job description(s);

ii.     Job specific information the injured worker utilized for a job that may include:

a)    Chemicals used;

b)    Hazardous substances;

c)    Specific tools;

d)    Job specific processes;

e)    Injured worker’s duration of exposure/use for each job specifically indicated in IV.C.2.a.-d. or as otherwise indicated by the injured worker as in for each employer; to which the injured worker was exposed and timeframe of exposure;

f)     Date of employment for each employer worked.

b.    BWC shall, for purposes of establishing the employer of record, determine:

i.      When the last injurious exposure occurred in an occupational disease claim; and

ii.     Where the last injurious exposure occurred.

 

D.   Statutory occupational disease claims

1.    BWC shall, before making an initial claim determination, refer the injured worker alleging an occupational disease listed in section IV.A.7.a.-f. of this policy to a qualified medical specialist for an independent medical examination (IME) for evaluation and recommendation with regard to:

a.    Diagnosis;

b.    Extent of disability; and/or

c.     Other medical questions concerning the claim.

2.    Concerning claims alleging an occupational disease in section IV.A.7.c.-f. of this policy and any claim filed for any asbestosis-related occupational disease, other than mesothelioma, the following evidence must be submitted prior to a referral for an IME, except in death claims:

a.    A written interpretation of:

i.      X-rays by a certified “B reader”; or

ii.     A high-resolution computed tomography (HRCT);

b.    Pulmonary function studies and interpretation by a licensed physician;

c.     An opinion of causal relationship by a licensed physician.

3.    BWC, as part of the statutory IME process, requires the Disability Evaluator Panel (DEP) physician who performs the IME to obtain an independent B-reader or HRCT.  Refer to Independent Medical Examinations and Physician File Reviews policy for additional information.

4.    In a statutory occupational disease claim, the initial claim determination order is issued no later than twenty-eight (28) days after receipt of the IME report by BWC.

5.    In cases of death due to occupational disease, BWC shall refer the claim to a qualified medical specialist for a physician file review (PFR).  Refer to the Death Claims policy for additional information.

6.    It is the policy of BWC to handle an alleged mesothelioma claim in the same manner as a statutory occupational disease claim except that BWC shall refer the claim for a PFR, not an IME, prior to the initial claim determination.

 

E.    Wages in an occupational disease claim

1.    BWC will not set wages in an occupational disease claim until a request for compensation is filed.

2.    BWC will use the date the injured worker first became disabled due to the occupational disease to establish wages in an occupational disease claim in accordance with the Wages policy.

 

F.    Compensation and medical benefits in an occupational disease claim

1.    Compensation

a.    It is the policy of BWC to establish the injured worker’s minimum and maximum compensation rate applicable to the claim based on the date of disease established at the time of filing.

b.    BWC may consider payment of temporary total compensation in an allowed occupational disease claim for a period up to six months prior to the date of disease. 

c.     Compensation may be granted in an occupational disease claim, with the following limitations:

i.      Claims for cardiovascular, pulmonary or respiratory disease for firefighters or police officers, silicosis, asbestosis, coal miners’ pneumoconiosis and any other occupational disease of the respiratory tract resulting from injurious exposure to dust, are limited to:

a)    Temporary Total Disability compensation;

b)    Permanent Total Disability compensation;

c)    Death Benefits;

d)    Change of Occupation.

ii.     Firefighters with cancer occupational disease claims that meet the presumption in the Firefighters with Cancer Occupational Disease Claims policy are limited to:

a)    Temporary Total Disability compensation;

b)    Working Wage Loss compensation;

c)    Permanent Total Disability compensation;

d)    Death Benefits.

iii.    BWC may process a request for percentage of permanent partial disability (%PP) in an occupational disease claim, except for the following diseases:

a)    Cardiovascular, pulmonary or respiratory disease for firefighters or police officers;

b)    Silicosis;

c)    Asbestosis;

d)    Coal miners’ pneumoconiosis;

e)    Any other occupational disease of the respiratory tract resulting from injurious exposure to dust; and

f)     Firefighters with cancer claims that meet the presumption in the Firefighters with Cancer Occupational Disease Claims policy.

iv.   For all other occupational disease claims, BWC may grant all other appropriate compensation under Ohio law.

 

2.    Medical Benefits - services provided for diagnostic exams and/or treatment may be paid for a period up to two years prior to the date of disease in an allowed occupational disease claim.

 

 

BWC staff may refer to the corresponding procedure for this policy entitled “PROCEDURE FOR OCCUPATIONAL DISEASE CLAIMS” for further guidance.


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