|
Policy and Procedure Name:
|
Scheduled Loss Compensation
|
|
Policy #:
|
CP-19-01
|
|
Code/Rule Reference:
|
R.C. 4123.57
(B)
O.A.C. 4123-3-09;
4123-3-15 (C); 4123-3-16 and 4123-3-37
|
|
Effective Date:
|
02/15/2022
|
|
Approved:
|
Ann M. Shannon, Chief of Claims Policy and Support
|
|
Origin:
|
Claims Policy
|
|
Supersedes:
|
Policy # CP-19-01, effective 10/02/2015 and Procedure #
CP-19-01.PR1, effective 05/06/2019
|
|
History:
|
Previous versions of this policy are available upon
request
|
Table of Contents
I. POLICY
PURPOSE
II.
APPLICABILITY
III.
DEFINITIONS
Amputation
Ankylosis
Claimant
Corrective
Eye Surgery
Dependent
Enucleation
Loss of
Hearing
Loss of Use
Loss of
Vision
IV. POLICY
A. General Information for Scheduled Loss
Compensation
B. Eligibility for Scheduled Loss
Compensation
C. Amputations
D. Loss of Use, Including Ankylosis
E. Loss of Vision
F. Loss of Hearing
G. Payment of Scheduled Loss Compensation
Award
H. Death of an IW
V. PROCEDURE
A. General Claim Note and Documentation
Requirements
B. Scheduled Loss Compensation
C. Reviewing and Processing the Scheduled Loss
Compensation Request
D. Physician File Review (PFR) or Independent
Medical Examination (IME)
E. Issuing a Decision for Scheduled Loss
Compensation
F. Payment of Scheduled Loss Compensation
Award
G. IC Orders on Scheduled Loss Compensation
H. Self-Insured Claims
The purpose of this policy is to ensure that BWC processes an
application for scheduled loss compensation and pays the allowed award in
weekly installments, according to the schedule provided in R.C. 4123.57(B).
This policy applies to Claims Services and Legal Division
staff.
Amputation:
To cut or remove a limb or body part from the body.
Ankylosis:
Total stiffness of or contractures due to scars or injuries that may cause
joints to be useless because they cannot move.
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).
Corrective Eye
Surgery: For purposes of this policy, addresses the visual problems,
but not a wholly equal substitute for the natural lens. In addition, corrective
eye surgery is not necessarily a permanent solution as there can be future
problems with the implant. (e.g., corneal lens implants.)
Dependent:
A member of the family of the decedent, for example a surviving spouse or a
blood relative, such as child, stepchild, 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.
Enucleation:
To remove the eye without removing the muscles that control the eye.
Loss of Hearing:
For purposes of this policy, a permanent and total incapability of receiving
auditory input (sound).
Loss of Use:
A body part is useless for all practical intents and purposes to the extent
that it was amputated. Severance is not required as defined in the statute.
Loss of Vision:
For the purposes of this policy, the loss of uncorrected vision which is the
percentage of vision acuity actually lost as a result of the injury or
occupational disease.
1. A scheduled loss
compensation award may also be called Permanent Partial (PP) or a Paragraph B
award because it is filed under RC 4123.57(B). To be consistent, BWC shall use
the language “scheduled loss compensation.”
2. It is the policy
of BWC that an injured worker (IW) is not entitled to receive a scheduled loss
compensation award and a percentage of permanent partial disability
compensation (%PP) award for the same part of body without applying an offset
between the two awards.
3.
It is the policy of BWC to deduct a previously paid %PP award granted
for the same part of body for which a scheduled loss compensation award will be
granted. State ex rel. Maurer v. Industrial Commission of Ohio (1989),
47 Ohio St.3d 62.
4. It is the policy
of BWC that an IW may receive a %PP award and a scheduled loss compensation
award concurrently in the same claim or different claims only when the parts of
body are different.
5. It is the policy
of BWC that if the loss of use of a body part produces a residual impairment
beyond the scheduled loss, an IW may receive a %PP for the additional residual impairment.
6.
It is the policy of BWC to deduct a previously paid Temporary Partial
compensation award granted for the same part of body for which a scheduled loss
compensation award will be granted.
7. It is the policy
of BWC that it may consider a Lump Sum Advancement (LSA) request on a scheduled
loss compensation award for an IW but not for any other claimant, including a
dependent in a claim for death benefits.
8. For claims with
a date of injury (DOI) prior to August 25, 2006, statutory permanent total
disability (PTD) may be awarded when an IW has a total loss of, or a loss of
use of, an entire limb. State ex rel. Thomas v. Industrial Commission of
Ohio (2002), 97 Ohio St.3d 37.
B. Eligibility for
Scheduled Loss Compensation
1. An application
for scheduled loss compensation may be made any time during the life of a
claim.
2. The IW or
claimant shall provide supporting medical documentation from a physician that demonstrates
that the loss is:
a. Permanent; and
b. The result of a
work-related injury.
3. The application
for scheduled loss compensation shall be made on a Motion (C-86), or its
equivalent, and include:
a. Specific part of
body, type, and extent of loss (e.g., severance, ankylosis, or how for all
practical intents and purposes there is a loss of use that is being requested);
and
b. Specific
supporting medical evidence documenting the part of body, type, and extent of
loss, with additional information as follows:
i. For
an amputation, the physician must provide a clear and accurate description of
the point of amputation.
ii. For loss
of vision:
a)
The medical documentation is from an ophthalmologist, except when
the loss of vision is based on psychiatric factors;
b) The medical
documentation supports the loss of vision in one or both eyes;
c) Includes the IW’s
pre-injury uncorrected vision;
d) Includes the IW’s
post-injury uncorrected vision;
e)
The medical documentation must demonstrate at least a 25% loss of
uncorrected vision post-injury.
iii. For loss of
hearing:
a) The medical
documentation is from an ear, nose, and throat (ENT) physician
(otolaryngologist) except when the loss of hearing is based on psychiatric
factors; and
b) The medical
documentation demonstrates that the loss of hearing in one or both ears is
total.
4. BWC may request
additional medical evidence, as necessary.
C. Amputations
1. An IW is entitled to a
scheduled loss compensation award when they sustain a loss of a body part that
is the result of severance, and reattachment of the same body part has not been
successful (functional).
a. If the same
severed body part is reattached, an award will not be given when medical
documentation supports that the reattachment was successful (functional). State
ex rel. Welker v. Industrial Commission of Ohio (2001), 91 Ohio St.3d 98.
b. The IW may
request an amputation award if the reattachment subsequently becomes
unsuccessful and has to be removed.
2. An IW may be
entitled to a scheduled loss compensation award even if they receive a
prosthetic device to replace the amputated body part. However, the use of an
orthotic device may not necessarily equate to a functional loss of use.
3. When there is an
increase in the scheduled loss compensation due to an additional amputation
(below knee amputation revised to above knee amputation), the scheduled loss
compensation award is paid but the previously paid award is deducted from the
amount.
4. Fingers, hands,
and/or arms
a. The loss of 1/3
or distal phalange of any finger other than the first finger (i.e., the thumb)
is considered equal to the loss of 1/3 of the finger. The amputation must be at
or near the joint. The loss of the finger near the proximal interphalangeal
(PIP) joint is equal to the loss of 2/3 of the finger.
b. The loss of a second,
or distal, phalange of the thumb is considered equal to the loss of 1/2 of such
thumb; the loss of more than 1/2 of the thumb is considered equal to the loss
of the whole thumb.
c. The
scheduled loss compensation award for the loss of two or more fingers by
amputation or ankylosis cannot exceed the amount for the loss of a hand. The IW
cannot combine the loss of parts of four fingers to equal the total loss of two
fingers, for purposes of qualifying for a total loss of hand award. State ex
rel. Honda of America MFG., Inc. v. Industrial Commission of Ohio, 183 Ohio
App.3d 732 (2009).
d. If a loss of the
arm is payable, the IW is not entitled to an additional award for loss of the
hand. The award for the arm includes the award for the hand.
e. If the IW’s
thumb is amputated and replaced with the great toe, BWC will only pay for the
amputation of the toe. There is no award for the loss of the thumb. State ex
rel. Mast v. Indus. Comm., 193 Ohio App.3d 650, 2011-Ohio-2865.
f. Amputation
of the hand and arm below the elbow joint is considered equal to the loss of
the hand. If the amputation is at the elbow, a determination must be made
regarding the functionality of the elbow before determining if the IW is
eligible for the loss of the hand or loss of the entire arm.
g. Amputation above
the elbow will result in an award for the loss of the arm. A scheduled loss
compensation award cannot be granted for partial loss of the arm.
5. Toes, feet,
and/or legs
a. Loss of the
great toe up to the interphalangeal joint is equal to 1/2 loss of the great
toe; loss beyond the interphalangeal joint is equal to the loss of the great
toe. For other toes, a loss of 2/3 of the toe is required for a scheduled loss
compensation award to be granted. No partial loss award is granted for toes
other than the great toe.
b. When there is an
increase in the scheduled loss compensation due to an additional amputation,
the amputation is paid less the previously paid amount.
c. If a loss
of the leg is payable, the IW is not entitled to an additional award for loss
of the foot. The award for the leg includes the award for the foot.
d. Amputation above
the ankle, but below the knee, an IW should receive a loss of the foot. Amputation
above the knee an IW should receive a loss of the leg. State ex rel. McLean
v. Industrial Commission of Ohio (1986), 25 Ohio St.3d 90.
D. Loss of Use, Including
Ankylosis
1. Permanent
impairment of a body part without severance may entitle the IW to an award.
2. First finger (i.e., thumb)
and other fingers
a. First finger may
have a:
i. Loss
of use for 1/2 of the first finger; or
ii. Total
loss of use for entire first finger.
b. Due to the
uniqueness of the first finger, the loss of use of the interphalangeal joint, (the
joint between the distal and proximal phalanges) is considered equal to the
loss of one-half of the first finger. State ex rel. Riter v. Industrial
Commission of Ohio (2001), 91 Ohio St.3d 89. Riter v IC does not
apply to amputations of the first finger unless ankylosis of the first finger
accompanies the first finger amputation.
c. Loss of
use of the metacarpophalangeal joint between the proximal phalanx and
metacarpal bone is usually considered equal to the total loss of use of the
whole first finger.
d. Other fingers,
second through fifth, may have a loss of use for:
i. 1/3
of the finger; or
ii. 2/3
of the finger; or
iii. Total
loss of use for entire finger.
3. The loss of more than the
distal and middle phalanges (including loss of the PIP joint) is equal to total
loss of the finger. Awards shall not exceed 175 weeks, which is the number of
weeks payable for the total loss of the hand.
4. When there is an increase in
the scheduled loss compensation due to an additional loss of use, the loss of
use is paid less the previously paid award for the same body part.
1. A loss of vision
award is based on the IW’s post injury vision prior to correction by glasses,
contacts, corneal transplants, or surgical intervention. Kroger v. Stover
(1987), 31 Ohio St.3d 229.
a. If an IW has an
eye injury that will heal without surgery, the scheduled loss compensation
award will not be determined until the healing process is completed.
b. If an IW
requires corrective surgery as a result of the injury, the scheduled loss
compensation award is determined based on the condition prior to surgical
correction and healing.
2.
The minimum award for each eye is 25% loss of uncorrected vision. Although
at least a 25% loss of uncorrected vision is required to receive a loss of
vision scheduled loss compensation award, the IW may have loss of vision of
less than 25% granted as an allowed condition in the claim.
3. The percentage
needed for loss of vision is the percent of vision loss, not the percentage of
whole person impairment (WPI).
4. When the IW has
permanently lost an eye due to enucleation, they are entitled to total loss of
vision for that eye.
5. The loss of
vision for traumatic cataract is based on the IW’s post injury vision prior to
correction by glasses, contacts, or surgical intervention.
a. Cataracts that
develop due to prolonged usage of medications, advancing age or other
conditions are not considered traumatic.
b. Cataracts that
develop due to prolonged usage of medication may be considered for additional
allowance as a flow-through condition as a known side effect of treatment for
another allowed condition. It is important that the treatment for the other
condition must be generally accepted as causing or associated with the
development of cataracts.
1. Scheduled loss
compensation for loss of hearing shall be awarded only when the IW has
permanent and total loss of hearing in one or both ears as a result of a
work-related injury.
2. An IW may have
loss of hearing allowed in a claim, but not be eligible for a scheduled loss
compensation award if the loss of hearing is partial.
G.
Payment of Scheduled Loss Compensation Award
1. It is BWCs
policy when paying a scheduled loss award in a lump sum to reduce it to net
present value. Refer to the Lump Sum Advancement policy.
2. It is BWCs
policy to pay multiple scheduled loss compensation awards for multiple body
parts consecutively, not concurrently. This is consistent with case law. State
ex rel. Swallow v. Industrial Commission of Ohio (1988), 36 Ohio St.3d 55.
3.
The DOI will determine the rate payable for the scheduled loss
compensation award. A DOI:
a. On or after November 3, 1989, compensation is payable per
week to the IW at 100% of the statewide average weekly wage (SAWW) for the DOI,
regardless of the IW’s average weekly wage (AWW), according to R.C. 4123.62(C).
b. On August 22, 1986, through November 2, 1989, compensation is payable at 66 2/3% of the IW’s AWW at the
time of the injury multiplied by the number of weeks, not to exceed a maximum
of the SAWW for the DOI and no less than 40% of the SAWW for the DOI.
c. On December
2, 1975, through August 21, 1986, compensation is payable at 66 2/3% of the IW’s
AWW at the time of the injury multiplied by the number of weeks, not to exceed
a maximum of 50% of the SAWW for the DOI and no less than 25% of the SAWW for
the DOI.
d. Prior to
December 2, 1975, consult with the BWC Legal Division to determine the proper
rate of payment in effect on the DOI.
1. When a scheduled
loss compensation award(s) is granted and/or paying but there remains an amount
unpaid prior to the IW’s date of death, BWC shall:
a. Pay scheduled
loss compensation payable through the date of death, in accordance with the Accrued
Compensation policy and procedure.
b. Pay in this
order:
i. The
surviving spouse if one exists; or
ii. Other
dependent; or
iii. If no surviving
spouse or other dependent exists, the estate of the IW; or
iv. If no estate exists,
another person, including an adult child of the IW, who shows proof of payment
of medical bills or funeral expenses for the IW, up to the amount of the bill
provided but not to exceed the accrued compensation amount payable.
v. Accrued
compensation may be apportioned between the surviving spouse and other
dependents, when appropriate.
2. When scheduled
loss compensation award is granted before or after death, and there is
scheduled loss compensation payable after the date of death, BWC:
a. May grant a
scheduled loss compensation award as accrued compensation when an IW’s
surviving spouse or other dependent files an application for an amputation or
loss of use.
b. Shall pay, upon
application, an unpaid scheduled loss compensation award for the period after
the IW’s date of death in biweekly payments to the surviving spouse or other
dependent.
c. Shall pay,
if granted:
i. To
the surviving spouse if one exists; or
ii. If no
surviving spouse exists, to another dependent.
d. Shall not grant
a lump sum advancement against an unpaid scheduled loss compensation payment to
a surviving spouse or other dependent.
3. BWC recognizes
that an estate is entitled to the accrued compensation of a scheduled loss
compensation award but is not entitled to the unpaid balance or ongoing
payments into the future of the scheduled loss compensation award. Estates are
not entitled to the ongoing remainder of the balance because an estate cannot
be a dependent. State ex rel. Liposchak v. Indus. Comm., 90 Ohio St.3d
276, 2000-Ohio-73; State ex rel. Estate of Sziraki v. Admr., Bur. of
Workers’ Comp., 137 Ohio St.3d 201, 2013-Ohio-4007.
4. BWC shall not
pay a scheduled loss compensation award after the death of the decedent’s
surviving spouse or dependent.
1.
BWC
staff shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2.
Shall
follow any other specific instructions for claim notes included in this
procedure.
1. Claims Services
staff may identify an IW who appears to be eligible for a scheduled loss
compensation award and may notify the IW that they may file for a scheduled
loss compensation award, and BWC will process the request. Note: BWC cannot
guarantee any particular outcome for the motion as there are complex legal, medical,
and factual issues that may impact the ultimate eligibility for an award.
2. Claims Services
staff shall process a C-86 or its equivalent requesting scheduled loss
compensation anytime during the life of a claim for one or more of the
following:
a. Amputation;
b. Loss of use;
c. Loss of
vision;
d. Loss of hearing.
1. Claims Services
staff shall ensure the C-86 or its equivalent meets the eligibility
requirements of this policy.
2. If Claims
Services staff is unsure the C-86 or its equivalent meets the eligibility
requirements the application may be reviewed with the supervisor and a BWC
attorney.
3. Claims Services
staff shall:
a. Upon receipt of
the scheduled loss compensation request, provide notice to the employer of
record or employer representative.
b. Make a telephone
call to the employer or employer’s representative.
i. Document
the attempt/contact made in claim notes for each party.
ii. Set a work
item for three business days, not including the date the telephone call was
placed. (e.g., call placed on Thursday, left a message. Set a work item for three
business days – Friday, Monday, Tuesday – claims staff can continue processing
application on Wednesday.)
c. If there
is no response or a returned call, staff shall send notice by letter (Insured
Due Process) via fax, email, or mail to the applicable party:
i. Document
action taken in claim notes for each party.
ii. Set a work
item as follows:
a) Three full
business days to respond if the letter is sent by fax or email; or
b) Seven full
business days to respond if the letter is sent by mail.
4. Continue
reviewing the scheduled loss compensation request after sufficient notice has
been provided or when work item(s) has expired with no response.
5. Claim services
staff shall process the scheduled loss compensation request as long as it is
feasible that an allowed condition in the claim could result in a scheduled
loss.
6. If medical documentation
is insufficient to support the request or additional evidence is necessary, Claims
Services staff must request the applicable evidence from the IW, claimant,
authorized representative, MCO, or provider.
a. Make a telephone
call to all applicable parties.
i. Document
the attempt/contact made in claim notes for each party.
ii. Set a work
item for three business days, not including the date the telephone call was
placed. (e.g., call placed on Thursday, left a message. Set a work item for three
business days – Friday, Monday, Tuesday – claims staff can continue processing
application on Wednesday.)
b. If there is no
response or a returned call, staff shall send notice by letter via fax, email,
or mail to the applicable party.
i. Document
action taken in claim notes for each party.
ii. Set a work
item as follows:
a) Three full
business days to respond if the letter is sent by fax or email; or
b) Seven full
business days to respond if the letter is sent by mail.
c. Continue
reviewing request after requesting the insufficient or additional medical
documentation or when work item(s) has expired with no response.
7. Claims Services
staff shall review the IWs or claimants’ medical evidence and staff the next
course of action with the supervisor and BWC attorney, which may be one of the
following:
a. Evidence
supports the request; the CSS shall staff the request with a supervisor and BWC
attorney prior to issuing a determination consistent with Section E of this
procedure; or
b. Evidence does
not clearly support the request, or the date of loss is not clearly indicated,
in which case the CSS may discuss the evidence with a nurse prior to staffing
with a supervisor and BWC attorney to determine if a physician file review
(PFR) or independent medical examination (IME) may be necessary.
c. Issue a
BWC Miscellaneous Order to dismiss if there is a lack of evidence on file to
support the request.
1. Claims Services
staff does not need to do a PFR or IME if eligibility requirements and
sufficient proof of a scheduled loss compensation award is submitted.
2. Claims Services
staff may schedule a PFR or IME when there is an outstanding issue(s) and shall
consult with their supervisor to determine which, a PFR or IME, is appropriate.
Examples:
a. An outstanding
issue(s) regarding the request; or
b. A question on the
onset of the date of loss.
3. If an IW has
previously been granted a %PP award for the same body part, claims staff shall
send for a PFR or IME and use the specific question requesting the DEP physician
to explain what portion of the %PP award is encompassed by the scheduled loss and
what portion of the %PP might be due to residual effects.
4. Claims Services
staff shall discuss with the nurse situations where it is alleged that the loss
of vision or loss of hearing is based on psychiatric factors to determine what
medical specialty to consult to appropriately address the issue.
5. For a unique or
unusual fact pattern, Claims Services staff must work with the nurse and BWC
attorney to add specific questions to the standard scheduled loss compensation
questions.
6. Claims Services
staff shall refer to the Independent
Medical Exams (IME) and Physician File Reviews (PFR) policy for the
specific questions to use.
E. Issuing a
Decision for Scheduled Loss Compensation
1. Claims Services
staff must staff all scheduled loss compensation requests with a
supervisor and BWC attorney prior to publication of the order addressing the
award. Claims Services staff must enter a required claim note with the specific
note title: SL CSS Staffed with IMS, Legal.
2. Claims Services
staff shall use the DOI, not the date of amputation or actual loss of use, when
determining the rate at which the award will be paid.
3. Claims Services
staff shall use the following dates to begin the scheduled loss compensation
award:
a. The date of
amputation or actual loss of use date; or
b. For loss of use
by reason of ankylosis, the date the physician makes the diagnosis of the loss
of use; or
c. The date
of the loss as determined by the medical documentation from the physician or
the IME report.
4. Prior to issuing
the determination on the scheduled loss compensation request, Claims Services
staff shall build the scheduled loss compensation indemnity benefits plan and
use the Scheduled Impairment Awards window, as follows:
a. For an award in
a claim with a DOI prior to November 3, 1989, Claims Services staff must:
i. Manually
calculate the award using the statutory formula in place at the time of the DOI;
and
ii. Build it
as a miscellaneous payment.
iii. Use the
compensation rate chart located on COR, or the schedule in R.C. 4123.57(B) when
determining the number of weeks payable for the loss of the applicable body
part. Claims Services staff shall refer to Section IV.G.2.a for the
calculation.
b. For an award in
a claim with a DOI on or after November 3, 1989, Claims Services staff must enter
in the claims management system as follows:
i. For
amputations, loss of use, and loss of hearing:
a) Select scheduled
loss;
b) Amputations,
loss of use, and loss of hearing are entered as a 100%;
c) Enter the
percentage in the Scheduled Impairment Awards window.
ii. For loss
of vision:
a) Select scheduled
loss –vision;
b) Enter the percentage
of loss cited in the medical documentation in the Scheduled Impairment Awards
window.
c. Claims
Services staff shall not schedule the award; just build it in the claims
management system so the correct dates and amounts appear in the BWC order.
5. Claims Services
staff shall issue a decision on a scheduled loss compensation request as
follows:
a. A BWC Subsequent
Order if allowing the request for scheduled loss compensation in its entirety
as requested and employer is in agreement or did not respond to notice; or
b. A BWC Death
Subsequent Order on a death claim if allowing the request for scheduled loss
compensation in its entirety as requested and employer is in agreement or did
not respond to notice; or
c. A notice
of referral (NOR) to the Industrial Commission (IC) when there is a conflict, such
as:
i. An
employer disagrees with the request for scheduled loss compensation;
ii. BWC’s
recommendation is to deny the request for scheduled loss compensation in its
entirety;
iii. BWC’s
recommendation is to allow in part and deny in part the request for scheduled
loss compensation.
6. Claims Services
staff shall refer to the Notice
of Referral to the Industrial Commission policy for additional
information.
7. Claims Services
staff shall use specific language when issuing a notice of referral to the IC
and staff with a BWC attorney for the language to use:
a. When a loss of
use of the interphalangeal joint (the joint between the distal and proximal
phalanges) is requested as total loss of the first finger (i.e., the thumb) as
discussed in Section IV.D.2.b.
b. When a request
for an amputation award is for a severed body part that was successfully
reattached, as discussed in Section IV.C.1.a.
c. For any
unique or unusual fact patterns.
8. Claims Services
staff may, as needed, work with a BWC attorney for specific language for a BWC order
or a notice of referral.
9. Claims Services
staff shall pay an amputation or loss of use award less the previous paid award
when there is an increase in the scheduled loss compensation due to an
additional amputation or loss of use to the same area of the body.
a. Example: When
granting an increase from the loss of fingers to a loss of the hand, the loss
of the hand is granted less the weeks previously paid for the individual
fingers.
b. Example: When
granting an increase from the loss of the toes to a loss of the foot, the loss
of the foot is granted less the weeks previously paid for the individual toes.
10. Claims Services staff shall
use the ‘previous impairment offset worksheet’ located on COR to calculate the
amount to enter as an offset, under Indemnity Payments > Adjustment tab >
Adjustments drop-down > Add Adjustment.
11. Claims Services staff must
address when a deduction will occur to the scheduled loss compensation award in
the BWC order or in the notice of referral due to:
a. A previous %PP
award granted for the same part of body for which a scheduled loss compensation
award will be granted.
b. An overpayment.
c. Family
support.
12. When Claims Services staff
arrive at the dollar amount of the previously paid scheduled loss compensation
or %PP compensation that is attributed to the same body part as the scheduled
loss compensation award, the amount is entered as an offset, under Indemnity
Payments > Adjustment tab > Adjustments drop-down > Add Adjustment.
13. Claims Services staff shall
choose the appropriate order insert to describe the situation where there will
be a reduction in the amount of scheduled loss compensation paid out due to
previous awards granted, such as previous scheduled loss compensation or %PP
awarded. The reduction of award shall be noted in the BWC order.
14. The claims services
supervisor is required to review and electronically approve (i.e., respond by
email) all correspondence orders granting scheduled loss compensation. Claims
services supervisor must enter a required claim note with the specific note
title:
a. SL IMS Reviewed
Order – Approved (if order is correct); or
b. SL IMS Reviewed
Order – Returned (if order needs to be corrected).
1. Claims Services
staff shall pay a scheduled loss compensation award at the expiration of the
appeal period.
2. Claims Services
staff shall pay all awards of scheduled loss compensation in weekly
installments in accordance with the schedule associated with the loss of the
applicable body part, unless ordered by the IC to pay differently.
3. Claims Services
staff shall pay the scheduled loss compensation award based on the DOI and is
payable at the rate defined in Section IV.G.3. For a DOI prior to December 2,
1975, staff shall send an email to BWC Claims Policy Field Tech mailbox to work
with BWC Legal Division to determine the rate in effect for the DOI.
4. Claims Services
staff shall honor an Authorization to Receive Workers Compensation Payment (C-230)
filed by the IW’s representative for payment of a scheduled loss compensation
award for the initial accrued lump sum payment (i.e., the first check). Future
payments shall be set up on scheduled weekly payments.
5. Deductions from
a scheduled loss compensation award
a. Family Support
i. Claims
Services staff shall apply family support weekly deduction orders to scheduled
loss compensation awards that are being paid biweekly.
ii. Accrued
scheduled loss compensation awards are subject to hold for lump sum family
support processing. Claims Services staff shall refer to the Family
Support and Attorney Fees policy for additional information regarding
family support obligations.
b. Overpayments
i. Claims
Services staff may recoup overpayments from a scheduled loss compensation award
at 40%. However, if fraudulent activity is determined, recoupment is 100%.
ii. Claims
Services staff shall refer to the Overpayments
of Compensation and Adjustment
of Overpaid Compensation policies for additional information.
6. Claims Services
staff shall pay multiple scheduled loss compensation awards for multiple body
parts consecutively, not concurrently, unless otherwise ordered.
7. Claims Services
staff may pay a scheduled loss compensation award concurrently with:
a. Temporary total
disability compensation;
b. Wage loss
compensation;
c. Permanent
total disability
d. Statutory
permanent total disability;
e. Living
maintenance;
f. Living
maintenance wage loss;
g. Facial
disfigurement;
h. %PP;
i. Disabled
Workers Relief Fund;
j. Death
benefits.
8. Claims Services
staff may pay a scheduled loss compensation award for periods after the IW’s
date of death in biweekly payments to the widow(er) or other dependent unless
otherwise ordered.
9. Claims Services
staff may consider a lump sum advancement on a scheduled loss compensation
award for an IW but not for any other claimant or dependent in a death claim. Claims
Services staff shall refer to the Lump
Sum Advancement policy for additional information.
G. IC Orders on Scheduled
Loss Compensation
1. Claims Services
staff shall timely review an IC order and if there is an issue with the
decision shall staff the order with the supervisor and BWC attorney.
2. Claims Services
staff shall staff all issues of concurrent payments or lump sum payments with BWC
Legal.
3. Claims Services
staff shall perfect the order consistent with Orders,
Waivers, Appeals and Hearings policy unless the BWC attorney has
provided other direction.
1. Claims Services
staff may receive the Agreement as to Compensation for Permanent Partial
Disability (IC-GC1) form which is used in a self-insured claim when a
self-insuring employer and IW have entered into an agreement for compensation
of permanent partial disability or scheduled loss compensation.
2. Claims Services
staff shall review the IC-GC1 to determine if:
a. The number of
weeks being paid corresponds with the medical documentation on file;
b. The number of
weeks payable is in accordance with the rate chart; and
c. The Waiver
of Notice of Hearing and Waiver of Right of Appeal section of the IC-GC1 is
signed by the self-insuring employer and IW with a copy sent to all parties.