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OhioBWC - Basics: (Policy library) - File

OWAH Policy PS

Policy Name:

Orders, Waivers, Appeals and Hearings

Policy #:

CP-15-01

Code/Rule Reference:

O.R.C 4123.511, 4121.36, 4121.35, 4123.57, 4123.512, 4123.511 and 4123.522

O.A.C 4123-6-16, 4121-3-09, 4123-3-18, 4121-3-30, 4123-3-09, 4123-3-36 and 4123-3-32

Effective Date:

11/14/2016

Approved:

Rick Percy, Chief of Operational Policy, Analytics & Compliance (Signature on File)

Origin:

Claims Policy

Supersedes:

Policy # CP-15-01, effective 09/12/2014

History:

Rev. 09/12/2014; New 11/08/2013

Review date:

09/12/2019

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that BWC publishes and/or executes orders, waivers and appeals in compliance with law and administrative rules.

 

II. APPLICABILITY

 

This policy applies to all BWC staff.

 

III. DEFINITIONS

 

Appeal: a formal request to a higher authority requesting a change in or reconsideration of a decision.

Hearing: a meeting wherein the parties to a claim are afforded an opportunity to present evidence and be heard before the Industrial Commission (IC) of Ohio, the statutorily-mandated adjudicatory body for workers’ compensation issues.

Order: the written notification of a decision made by the BWC or the IC from the evidence gathered in a claim.

Parties to a claim:  Injured Worker (IW), IW representative, employer, employer representative and BWC.

Waiver: a document or formal statement signed by parties to a claim giving up their appeal rights to orders issued by BWC and the IC.  The waiver does not affect any past or future orders pertaining to the claim file; only the order currently being waived.

 

IV. POLICY

  1. It is BWC’s policy to process and publish BWC orders and waivers, process appeals, and perfect IC Orders in accordance with legally-mandated timeframes.

 

B.    A BWC Order is required for all initial determinations and subsequent determinations in claims in which BWC has jurisdiction.

 

  1. Types of BWC Orders:

1.    Initial Allowance Order 

a.    Published when granting the initial allowance of a claim for payment of medical benefits and/or compensation.

                                      i.        For a medical only claim, this order shall address claim allowance and the payment of medical benefits.

                                     ii.        For a lost time claim, this order shall address claim allowance, the payment of medical benefits and payment of compensation.

b.    The following issues may also be addressed:

                                      i.        Setting of the full weekly wage (FWW) and average weekly wage (AWW);

                                     ii.        Temporary Total Compensation (TT);

                                    iii.        First seven days of lost time;

                                   iv.        Non-complying employers (no coverage);

                                    v.        Scheduled Loss Compensation Awards (loss of use, amputation, loss of vision, and loss of hearing);

                                   vi.        Salary Continuation.

2.    Initial Auto Adjudication Allowance Order

a.    Published systematically by the claims management system when an initial claim meets a set of criteria that causes the claims management system to automatically generate this allowance order;

b.    The claim status is systematically updated to “Allow.”

3.    Initial Denial Order – Published when denying an initial allowance of a claim.

4.    BWC Abate Order – Published to notify the dependent that the claim application has been abated by the death of the claimant.

5.    Subsequent Allowance Order

a.    Published when granting a request for action (written or verbal) after the initial claim determination or when issues are identified after the initial allowance of the claim;

b.    Is only available for accident and occupational disease claims;

c.    BWC does not have jurisdiction to deny a subsequent request per the Crabtree court decision except for requests for medical treatment (via Alternative Dispute Resolution Order), lump sum advancement, medication reimbursement and travel reimbursement (via Miscellaneous Order.) State ex rel. Crabtree v. BWC (1994), 71 Ohio St.3d 504.

6.    BWC Death Allow  Order 

a.    Published to grant death benefits and apportion benefits between dependents, either as the initial decision in the claim or as a subsequent decision on an existing claim;

b.    Published to reapportion death benefits between dependents and to award accrued compensation in claims where death benefits have been allowed.

7.    BWC Death Denial Order - Published to communicate BWC’s decision to deny death benefits, either as the initial decision in the claim or as a subsequent decision in an existing claim

8.    BWC Alternative Dispute Resolution Order – Published to communicate the determination of medical disputes.

9.    BWC DWRF (Disabled Workers’ Relief Fund) Order

a.    Published to communicate a decision on the IW’s entitlement to DWRF benefits.

b.    Types of issues that may be addressed in the BWC DWRF Order are:

i.      Entitlement to DWRF;

ii.     Non-entitlement to DWRF;

iii.    Social Security Disability Rate;

iv.   Permanent Total Disability (PTD) Declared Rate;

v.    Adjustment for increase or decrease in the DWRF Rate;

vi.   Overpayment of DWRF Benefits;

vii.  Stopping DWRF.

10.  BWC Tentative Order (TO) – Published to either grant or deny an initial determination or subsequent increase of percentage of permanent partial disability.

 

D.   Waivers

1.    Who can waive:

a.    IW/Claimant and/or IW/Claimant representative;

b.    Employer and/or Employer representative;

c.    BWC.

2.    The third party administrator (TPA) or other non-lawyer legally cannot independently waive proper notice of hearing or waive the right to appeal on behalf of any party. They may submit a waiver but the waiver shall indicate they are doing so at the direction of the employer and not at the independent discretion of the TPA.

3.    How to waive:

a.    Waiver of Appeal Period (C-108);

b.    Letter that contains all elements of the C-108;

c.    Online at ohiobwc.com or ohioic.com.

4.    How to submit waiver:

a.    Fax;

b.    Scanned and emailed;

c.    USPS.

5.    Parties to the claim must waive in writing in order to release payment prior to the expiration of an appeal period. If the award relates to compensation only, no waiver is required from the IW.

6.    When all parties agree to waive the appeal rights on an order, the appeal period automatically expires.

7.    The waiver does not affect any past or future orders pertaining to the claim.

 

E.    Appeals to BWC Orders

1.    Who can appeal: A party to the claim who disagrees with the BWC Order may appeal the decision to the IC, thereby asking that a hearing be held to further evaluate the merits of the claim.

2.    How to Appeal:

a.    Notice of Appeal (IC-12) form;

b.    On a letter that contains all elements of the IC-12;

c.    Online at www.ic.state.oh.us through the Industrial Commission Online Network (I.C.O.N.);

d.    All appeals shall be in writing.

3.    The appeal periods for BWC Orders are:

a.    Tentative Orders - The objection (appeal) period expires twenty (20) days from the printing of the TO;

b.    All other orders - 14 days after the date of receipt of the Order.

4.    Appeal timeline considerations:

a.    Faxes not received by the IC or the BWC during core business hours shall be considered received and filed on the next business day (core business hours are from 8:00 a.m. to 5:00 p.m.);

b.    When an appeal is received at BWC, BWC sends appeal to IC and images supporting documentation for review;

c.    If evidence is submitted after an appeal is filed and the appeal is not withdrawn, BWC no longer has jurisdiction. The documentation shall be imaged and the IC shall obtain all claim information through a systematic transfer of information prior to the IC hearing.

F.    BWC will not perfect a court order or an IC Court Unit memo until it receives the signed order or memo.

 


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