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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 their 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 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 will refer to the Standard
Claim File Documentation and Altered Documents policy and
procedure for claim note and documentation requirements; and
2.
Must
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 will not terminate TT based upon the filing of the IC-2 and will
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 will 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 must
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 will 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 must 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 must 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) 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 must 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 must 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 will 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 must enter the
claim on the PTD Reassignment SharePoint site.
a. State-fund (SF)
claims will 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 CSS.
c. Self-Insured
(SI) claims, will 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 will remain assigned to the Special Claims CSS specified for
processing those claims.
2.
The
PTD IMS may reassign a claim back to the appropriate service office if the
indemnity benefits in the claim are settled.