Table of Contents
I. POLICY
PURPOSE
II.
APPLICABILITY
III.
DEFINITIONS
Apprentice
Apprenticeship
Agreement
Bona fide
equipment/vehicle lease agreement
Calendar
Quarter:
Casual Worker
Church
Construction
Contract
Coverage
Elective
Coverage
Emergency
Management Worker
Employee
Employer
Entry-level
Trainee
General
Contractor
Household
Worker
Independent
Contractor
“Leasing
Onto” Agreement
Minister
Ohio
Organized Militia
Owner-Operator
Peace Officer
Placeholder
Policy
Pre-apprentice
Professional Employer
Organization (PEO)
Subcontractor
Sub-subcontractor
State Active
Duty
Statutory
Employer
Temporary
Service Agency
Transportation
Network Company
Transportation
Network Company Driver
IV. POLICY
A.
Injured Worker Coverage
B.
Special Coverage Circumstances
V. PROCEDURE
A.
Standard Claim File Documentation
B.
Initial Review and Investigation
C.
Decision
D.
Independent Contractors
E.
Elective Coverage
F.
Transportation Network Company
G.
Temporary Service Agencies
H.
PEO
I.
Apprenticeship
J.
Casual or Household Worker
K.
Emergency Management Worker
L.
Responders to an Inherently Dangerous Situation
M.
Ohio Organized Militia (Ohio National Guard, Ohio Naval Militia, Ohio
Military Reserve)
N.
Performing Special Services for the State or a Political Subdivision
O.
Individuals Injured or Killed While Performing a Request or Order of a
Duly Authorized Public Official
P.
Injuries Incurred While Participating in a Rehabilitation Plan
Q.
Coverage Exemption for Religious Sects
R.
No Coverage/Non-Complying Employer Claims
The purpose of this policy is to ensure BWC staff
appropriately recognizes when an IW is considered an employee for workers’
compensation coverage purposes and other circumstances that determine the
nature of the applicable workers’ compensation coverage.
This policy applies to claims services staff and employer
services.
Apprentice:
An individual at least sixteen (16) years of age, who is in a registered
apprenticeship program to learn a skilled occupation pursuant to a registered
apprenticeship agreement. For purposes of this policy “apprentice” shall
include a:
·
Pre-apprentice;
·
Entry-level trainee;
·
Journeyperson.
Apprenticeship
Agreement: A written agreement, registered with the apprenticeship council,
providing for not less than two thousand hours of reasonably continuous
employment, and for participation in an approved schedule of work experience
through employment, which must be supplemented by a minimum of one hundred
forty-four hours per year of related and supplemental instructions.
Bona fide
equipment/vehicle lease agreement: An arrangement between the owner
of a truck and a driver, where the driver is given legal control of the vehicle
to use as if he/she is the owner in exchange for a payment to the owner for
such use. In the transportation industry, a bona fide lease agreement contains
commercially reasonable terms made with earnest intent, without fraud or
deceit.
Calendar
Quarter: One fourth of a calendar year as follows:
1st quarter – January 1
through March 31;
2nd quarter - April 1
through June 30;
3rd quarter - July 1
through September 30;
4th Quarter - October 1
through December 31.
Casual
Worker: An individual whose work is occasional and not on a
regular basis. A casual worker can include a member of a labor crew brought to
a jobsite to labor on completing the task a contractor is responsible to
perform.
Church:
An established and legally recognized, congregation, denomination, society,
corporation, fellowship, convention or association formed primarily or
exclusively for religious purposes.
Construction
Contract: An oral or written agreement involving any activity
in connection with the erection, alteration, repair, replacement, renovation,
installation, or demolition of any building, structure, highway, or bridge.
Coverage:
For purposes of this policy, reference to an injured worker’s inclusion in a workers’
compensation policy, whether mandated by law or elective.
Elective
Coverage: Workers’ compensation coverage an employer or individual
may obtain pursuant to R.C. 4123.01,
for workers that are not defined as employees for purposes of workers’
compensation. The following are entities or persons not defined as employees
who must elect to purchase workers’ compensation coverage to be covered:
·
Entity: a sole proprietorship, a partnership, a limited
partnership, an individual incorporated as a corporation with no employees, a
family farm corporation or an LLC filing a federal tax form as a sole
proprietor or partnership.
·
Person: a sole proprietor, a member of a partnership, a member of
a limited partnership, an individual incorporated as a corporation with no
employees, an officer of a family farm corporation, or an individual member of
a limited liability company (LLC) filing a federal tax form as a sole
proprietor or partnership., a duly ordained, commissioned, or licensed minister
or assistant or associate minister of a church (or equivalent position and
organization) in the exercise of a ministry.
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.
4123.031-4123.037, or who
has been registered as an emergency management worker pursuant to R.C. 5502.34 during a disaster or
emergency.
Employee:
As defined in R.C. 4123.01(A),
the term “employee” includes the following persons that do not meet the
definition of independent contractor and are:
·
In the service of the state or political subdivision (e.g., a county,
township, school district), including:
o Regular members of
lawfully constituted police and fire departments, whether paid or volunteer;
o Executive officers of
boards of education; and
o Elected officials.
·
In the service of any person, firm, or private corporation, including
any public service corporation, that employs one or more persons regularly in
the same business or establishment;
·
Household or casual workers who earn one-hundred sixty-dollars or more
in cash in any calendar quarter from a single household or employer; or
·
Performing labor or other services pursuant to a construction contract.
·
Operating a vehicle in the performance of services for or on behalf of a
motor carrier transporting property, unless the person is an owner-operator
(see owner-operator definition below).
Employer:
As defined in R.C. 4123.01(B)
the term “employer” includes:
·
The state, including state hospitals; each county, municipal
corporation, township, school district; and hospital owned by a political
subdivision or subdivisions other than the state; (also known as a “Public
Employer”).
·
A person, firm, professional employer organization, and private
corporation, including any public service corporation, that (a) has in service
one or more employees or shared employees regularly in the same business or in
or about the same establishment under any contract of hire, express or implied,
oral or written, or (b) is bound by any such contract of hire or by any other
written contract, to pay into the insurance fund the premiums as provided by
law (Also known as a “Private Employer”).
Entry-level
Trainee: An individual who possesses experience that qualifies the
individual as a journeyperson but for the existence of certain other disqualifying
conditions, and who receives on-the-job training accompanied by classroom
instruction outside of normal working hours.
General
Contractor: An entity with whom a principal/property owner directly
contracts to perform certain jobs. Some or all of the enumerated tasks are
subsequently contracted to other entities (subcontractors) for performance.
·
For general contractor relationships to exist there must be three
parties: 1) a principal/property owner, 2) an independent contractor, and 3) a
subcontractor hired by the independent contractor (making the independent
contractor a general contractor).
Household
Worker: A worker hired to perform services in the home (e.g.,
housekeeper, nanny, and gardener).
Independent
Contractor: An entity with whom the principal/owner directly
contracts to perform a certain task or tasks. Independent contractors are
generally engaged to perform operations not within the usual trade or business
of the principal/owner and such tasks are contract-specific.
“Leasing Onto” Agreement: An arrangement between
an owner-operator of a vehicle and a motor carrier whereby the owner-operator
drives their own vehicle under the motor carrier’s USDOT operating authority.
Minister:
A duly ordained, commissioned, accredited, or licensed minister, member of the
clergy, rabbi, priest, or Christian Science practitioner. This definition
includes assistant ministers and associate ministers.
Ohio
Organized Militia: Members of one of the following:
·
The Ohio National Guard, which includes both the Ohio Air National Guard
and the Ohio Army National Guard;
·
The Ohio Naval Militia;
·
The Ohio Military Reserve.
Owner-Operator:
A person who owns and may operate a vehicle that is used to transport property.
In the event the owner-operator is operating a vehicle in the performance of
services for or on behalf of a motor carrier transporting property, they are
considered an independent contractor if all of the following factors apply:
·
The person owns the vehicle, or leases the vehicle under a bona fide
equipment/vehicle lease agreement;
·
The person is responsible for supplying the necessary personal services
to operate the vehicle or vessel used to provide the service;
·
The compensation paid to the person is based on factors related to work
performed, including on a mileage-based rate or a percentage of any schedule of
rates, and not solely on the basis of the hours or time expended;
·
The person substantially controls the means and manner of performing the
services, in conformity with regulatory requirements and specifications of the
shipper.
·
The person enters into a written contract with the carrier for whom the
person is performing the services that describes the relationship between the
person and the carrier to be that of an independent contractor and not that of
an employee.
·
The person is responsible for substantially all of the principal
operating costs of the vehicle and equipment used to provide the services,
including maintenance, fuel, repairs, supplies, vehicle insurance, and personal
expenses, except that the person may be paid by the carrier the carrier’s fuel
surcharge and incidental costs, including tolls, permits, and lumper fees.
·
The person is responsible for any economic loss or economic gain from
the arrangement with the carrier.
Peace
Officer: For purposes of this policy, an individual legally
vested with law enforcement rights who generally works for a city, county or
state public employer and can be either “traditional” (e.g., police officer) or
“non-traditional” (e.g., certain park rangers, tax agents or liquor agents).
Placeholder
Policy: An employer policy number
that is created when an alleged employer has never established a policy with
BWC, BWC no longer has a record of the policy number, or the policy is in a
“cancelled” status and the date of injury occurred after the policy was
cancelled. Previously
known as a dummy risk number.
Pre-apprentice:
An individual receiving formal classroom training designed to provide basic
education, attitudes, skills, trade knowledge, and motivation necessary to
enter a formal apprenticeship program.
Professional
Employer Organization (PEO): A sole proprietor, partnership,
association, limited liability company or corporation that enters into an
agreement with one or more employers, known as client-employers, for the
purpose of co-employing all or part of the client-employer’s work force at the
client-employer’s work site.
Subcontractor: An entity
who is hired by a general contractor (or prime contractor, or main contractor)
to perform a specific task as part of the overall project and is normally paid
for services provided to the project by the originating general contractor.
Sub-subcontractor:
An individual or firm having a contract with a subcontractor to perform a
portion of the work.
State Active
Duty: Status of a member of the Ohio organized militia
who is performing duty by order of a state authority, and while in this state
active duty status injury and occupational disease benefits are not provided by
the federal government.
Statutory
Employer: An entity in any industry who is responsible for a
claim by operation of law due to using an uninsured independent contractor or
subcontractor, or where ten or more of R.C. 4123.01(A)(1)(c) employee
criteria are applicable when a person is performing labor or providing services
pursuant to a construction contract.
Temporary
Service Agency: An entity that as part of its trade or business
provides workers to unrelated third-party clients to perform services on a
temporary basis and derives revenue or other benefits from providing the
workers.
Transportation
Network Company: A corporation, partnership, association, limited
liability company, proprietorship, or any other entity operating in this state
that uses a digital network to connect transportation network company riders to
transportation network company drivers who provide transportation network
company services.
Transportation
Network Company Driver: An individual to whom both of the
following apply:
·
The individual receives connections to passengers and potential
passengers and related services from a transportation network company in
exchange for the payment of a fee to the company.
·
The individual uses a personal vehicle to offer or provide
transportation network company services to riders upon connection through a
digital network controlled by a transportation network company in return for
compensation or payment of a fee.
A.
Injured Worker Coverage
1.
It is the policy of BWC to consider an injured worker (IW) to be covered
for possible Ohio Workers’ Compensation benefits when:
a.
The IW meets the definition of employee; or
b.
Does not meet the definition of employee but has elective coverage.
2.
It is the policy of BWC to:
a.
Recognize that the existence of workers’ compensation coverage for an
employer does not automatically mean a particular IW is covered; and
b.
Investigate fully all coverage issues in a claim prior to making a
determination.
B.
Special Coverage Circumstances
1.
When special circumstances exist, BWC will properly apply relevant
sections of the Ohio Revised Code when making coverage determinations.
2.
Special circumstances are defined by Ohio Revised Code and outlined
throughout the procedure below.
A.
Standard Claim File Documentation
1.
BWC staff shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note requirements; and
2.
Shall follow any other specific instructions for claim notes included in
this procedure.
B.
Initial Review and Investigation
1.
When a new claim is filed, claims services staff must:
a.
Review the information in the claim file and, if necessary, investigate
and gather evidence to determine:
i.
If the alleged employer has an existing policy and whether the policy
was active at the time of injury; and
ii.
If the IW is an employee, or if the IW does not meet the definition of
employee, whether the IW has elective coverage.
b.
Investigate whether any special provisions of the Ohio Revised Code
exist that may impact the IW’s coverage or right to participate in the Ohio
workers’ compensation system.
i.
Types of coverage that may have special provisions are detailed in
sections V.D-V.R of this procedure, and include:
a)
Independent contractors;
b)
Elective coverage;
c)
Transportation network companies;
d)
Temporary service agencies;
e)
Professional Employer Organizations (PEO);
f)
Apprenticeships;
g)
Casual or household workers;
h)
Emergency management workers;
i)
Responders to inherently dangerous situations;
j)
Ohio organized militia;
k)
Individuals performing special services for the state or a political
subdivision;
l)
Individuals killed while performing requests or orders of a duly
organized public official;
m) Injuries
incurred while participating in a vocational rehabilitation plan;
n)
Coverage exemption for religious sects; and
o)
No-coverage/Non-complying employers.
ii.
All claims involving the special provisions of Ohio Revised Code listed
above and further discussed in this policy and procedure must be staffed with a
BWC attorney.
2.
If claims service staff has difficulty finding an employer policy:
a.
Claims services staff shall complete and enter a referral on the EM
referral tracker requesting assistance in locating the employer policy. The
referral must include:
i.
The IW’s claim demographic information;
ii.
All available demographic information of the alleged employer; and
iii.
The following verbiage in the reason for referral:
a)
“Based on the initial investigation, it appears that the employer has
never had a policy and the IW alleges they were injured at this place of
employment.”; or
b)
“Based on the initial investigation, it appears that the employer had a
cancelled policy at the time the IW alleges they were injured at this place of
employment.”
b.
If, upon completion of the EM investigation, the IW’s employee or
employer coverage status is unclear, claims services staff must seek assistance
from a BWC attorney.
C.
Decision
1.
After completion of the investigation, claims services staff must either
allow the claim if it meets all of the criteria outlined above and those
outlined in the Jurisdiction
(Statute of Limitations, Statutory Life of a Claim) and Compensable
Injuries policies and procedures; or
2.
Disallow the claim based on coverage issues if:
a.
The IW is not an employee,
b.
The IW is not otherwise covered by an elective coverage policy, and
c.
The IW is not entitled to coverage under any of the specific Ohio
Revised Code sections discussed in this policy and procedure.
D. Independent
Contractors
1.
If information received in a claim asserts the IW is a subcontractor or
independent contractor, claims services staff must send the IW and the alleged
employer the Independent Contractor/Employee Questionnaire, or obtain
answers to the questionnaire during an interview of the IW and the employer,
documenting all the answers in the claims management system. Claims services
staff must also:
a.
Review documentation of the IW’s wages;
b.
Request from the employer and/or IW any written agreement between the IW
and the alleged employer;
c.
Review other claims against the same employer; and
d.
Seek any other information available that may help clarify the IW’s
employment status.
2.
If the claim involves the construction industry and the alleged employer
claims the IW is a subcontractor or independent contractor, claims services
staff must attempt to identify the contractor tier for the project using the
job aid, Project Contractor Investigation Sheet, on COR.
3.
If the claim involves the trucking industry and the alleged employer
claims the driver is an independent contractor, claims services staff must
request:
a.
Motor vehicle crash report, if applicable; and
b.
Any agreements between the driver and alleged employer. These agreements
may have titles like “Independent Contractor Agreement”, “Driver Agreement”,
“Lease Agreement”, or “Leasing Onto” Agreement;
c.
Settlement sheets or statements for one month prior to the date of
injury.
4.
Once all the available documentation is received, claims services staff
must staff the issue with a BWC attorney to determine employee status and if a
different employer than listed on the FROI is responsible for the claim by
operation of law.
5.
Upon completion of the staffing with a BWC attorney, claims services
staff will publish an order with one of the following findings:
a.
The IW is an employee of the original alleged employer;
b.
The statutory employer is responsible for the claim.
i.
In this case, claims services staff must use the applicable statutory
employer order language found on COR on the Coverage policy page;
ii.
Update the statutory employer’s policy number as the insured employer in
the claims management system; and
iii.
Add the original alleged employer as an additional recipient on the
order;
c.
The IW is an independent contractor.
i.
Claims services staff must retain the name of the alleged employer in
the claim for due process purposes but shall deny the claim.
ii.
The order must indicate that:
a)
There is no proof of an employee/employer relationship; and
b)
The IW is an independent contractor.
E.
Elective Coverage
1.
Some categories of workers are not required to have workers’
compensation coverage. Thus, an employer may have coverage for the business,
but has elected not to have coverage for an individual.
2.
Indicators that an elective coverage situation may exist include:
a.
The IW’s last name is also the name of the business;
b.
The IW’s address is the same as the business address;
c.
The IW's phone number and the business phone number are the same or very
similar;
d.
The IW is listed as an owner, sole proprietor, partner, principal, or
officer on the First
Report of an Injury Occupational Disease or Death (FROI);
e.
The IW appears to be a family farmer;
f.
The IW’s social security number and the employer’s Federal Tax ID number
are the same;
3.
If it appears the claim may involve an elective coverage situation,
claims services staff must research the employer customer record in the claims
management system to see if the IW is listed as having elective coverage when
the IW is:
a.
The owner of a sole proprietorship;
b.
A member of a partnership;
c.
An individual in a limited liability company (LLC) acting as a sole
proprietorship or partnership;
d.
An officer of a family farm corporation;
e.
An individual incorporated as a corporation (with no employees);
f.
A duly ordained, commissioned, or licensed minister or assistant or
associate minister of a church (or equivalent position and organization) in the
exercise of a ministry which can be covered electively under the church or
under their own sole proprietor policy.
4.
When an employer has elected coverage for any individual listed above,
claims services staff must not provide workers’ compensation benefits or
compensation until elective coverage is verified for the date of injury. To
verify elective coverage, claims services staff must:
a.
From with the open claim, select the Participants section of the left
side header;
b.
Highlight the Insured’s name;
c.
Click the Details tab;
d.
Under Policy Individuals, see if they are checked as covered; and
e.
Coverage Status dropdown verifies whether the employer of record had
coverage on the date of injury.
5.
The employer of record must have coverage on the date of injury for the
elective coverage to be valid.
6.
Pursuant to R.C.
4123.01(A)(2), a volunteer officer of a nonprofit corporation is
specifically excluded from the definition of employee and the employer does not
have the option to elect coverage.
7.
Claims services staff may obtain further guidance and/or evidence
regarding elective coverage issues by:
a.
Referring to “Viewing EM Information for IM”
on COR and other job aids, as needed;
b.
Contacting the IW and employer to clarify coverage status; or
c.
Staffing with the Employer Services Specialist (ESS) or supervisor.
8.
Before making a final determination of the status of elective coverage,
claims services staff must staff the claim with a BWC attorney.
F.
Transportation Network Company
1.
If the IW appears to be a transportation network company driver (for
example, the employer is listed as UBER or LYFT), claims services staff must
determine if:
a.
The transportation network company has an agreement with the
transportation network driver to provide workers’ compensation coverage; or
b.
The transportation network driver has purchased workers’ compensation
coverage for him or herself.
2.
Claims services staff must review these claims with a:
a.
Supervisor;
b.
Employer Management (EM) staff; and/or
c.
BWC attorney.
G.
Temporary Service Agencies
1.
When a claim involves an IW who is employed by a temporary agency but is
performing services for a third-party client, claims services staff must
identify the temporary agency as responsible for coverage in the claim.
2.
Refer to the Violation
of Specific Safety Requirement (VSSR) policy and procedures for
exceptions concerning Violations of a Specific Safety Requirement awards
following the initial coverage determination.
1.
Claims services staff must identify the PEO as the employer responsible
for coverage in a claim involving an employee of the PEO, regardless if the
IW/employee is co-employed by a client of the PEO.
2.
When a PEO has been identified as the employer, claims services staff
must verify the PEO information by contacting BWC’s PEO Unit supervisor and
providing:
a.
The claim number;
b.
The date of injury;
c.
The policy number of the employer the claim has been filed under; and
d.
Any information pertaining to the PEO contained in the claim file.
3.
Claims services staff must note any corrections to the PEO information
made by the PEO Unit.
4.
See the BWC Employer Services Professional
Employer Organizations (PEOs) policy for further information.
I.
Apprenticeship
1.
If it appears the IW may be an apprentice pursuant to R.C. 4123.038 and 4123.039 (including
pre-apprentice, entry-level trainee or journeyperson), claims services staff
must contact the IW and/or the identified employer and:
a.
Verify the IW’s status as an apprentice;
b.
Determine if the IW is covered by an Apprenticeship
Elective Coverage Contract (U-80) with BWC; and
c.
Determine if, in addition to being an apprentice, the IW is an employee
of the identified employer.
2.
Claims services staff must email BWC Policy Processing
if there are any questions regarding apprenticeship coverage under a U-80.
J.
Casual or Household Worker
1.
Before determining if the IW is a casual or household worker that
qualifies for coverage pursuant to R.C.
4123.01(A)(1)(a)(iii)(b), claims services staff must first determine if the
IW is an independent contractor, as described above.
2.
If the IW is not an independent contractor, claims services staff must
determine if the IW meets the following criteria to be covered as a casual or
household worker:
a.
The IW earns one hundred sixty dollars ($160) or more in any calendar
quarter during the year of injury from a single household or employer.
b.
This includes situations where:
i.
At the time of injury, the IW already earned $160 or more during the
calendar quarter; or
ii.
But for the injury, the IW would have earned $160 or more during the
calendar quarter.
3.
To establish this, claims services staff must request documentation such
as:
a.
Copies of paychecks or documentation from electronic money transfer
systems showing payment for services transactions (e.g., PayPal, Venmo,
Bitcoin)
b.
Tax documents showing how the IW reports the income;
c.
Any written agreement between the IW and the alleged employer.
K.
Emergency Management Worker
1.
Pursuant to R.C. 4123.031-4123.037, an emergency management
worker, whether paid or volunteer, is eligible for benefits payable on account
of total disability, loss of member, or death. Volunteer emergency management
workers qualify for the maximum benefits applicable to accidental injury or
death.
2.
If the IW is filing a claim as an emergency management worker, claims
services staff must verify that the IW:
a.
Is registered for service as an emergency worker and has taken the
appropriate state or federal oath;
b.
Was acting in good faith in performing his or her emergency management
duty, function, or act,
c.
Was performing such duty in conjunction with the development, training,
maintenance, or operation of the emergency management agency; and
d.
Was under express or constructive instruction or orders of a duly
appointed director or an authorized staff member of the emergency management
agency charged with the authority and responsibility for issuing such
instructions or orders.
3.
Prior to receiving any compensation or benefits, claims services staff
shall require the IW or other claimant to provide:
a.
A copy of the “loyalty oath” filed with the political subdivision; and
b.
A certified copy of the permanent record attesting to the participation
of the IW as an emergency management worker in the emergency management
activity during, or as a result of which the claim is being made.
L.
Responders to an Inherently Dangerous Situation
1.
An IW is covered by workers’ compensation pursuant to R.C.4123.01(A)(1)(a) when:
a.
The IW is one of the following:
i.
A peace officer;
ii.
A firefighter, of a lawfully constituted fire department;
iii.
A first-responder, emergency medical technician-basic, emergency medical
technician-intermediate, or emergency medical technician-paramedic of an
ambulance service organization or emergency medical service organization
pursuant to R.C. 4765.01;
b.
The situation being responded to is inherently dangerous;
c.
The situation requires immediate response on the part of the worker; and
d.
The worker is responding in the same manner as he or she would when
on-duty.
2.
Claims services staff must apply this provision even if the injury
occurred outside of the IW’s regular jurisdiction and regardless of whether the
IW works in a paid or volunteer position.
M.
Ohio Organized Militia (Ohio National Guard, Ohio Naval Militia, Ohio
Military Reserve)
1.
If it appears the IW is filing a claim as a member of the Ohio Organized
Militia (the State of Ohio would most likely be listed as the employer), claims
services staff must verify that the IW meets the following criteria to be
covered by workers’ compensation pursuant to R.C. 4123.021-4123.024:
a.
The IW must have been in a state active duty status at the time of
injury; and
b.
Injury and occupational disease benefits are not otherwise provided by
the federal government.
2.
Claims services staff must request from the IW a copy of his or her
order to report to duty or other documentation to establish the duty status.
3.
Claims services staff must contact the Ohio Adjutant General’s
Department for assistance in determining whether that IW is eligible to apply
for Ohio workers’ compensation benefits or federal workers’ compensation
benefits.
N.
Performing Special Services for the State or a Political Subdivision
1.
Claims services staff must consult with EM staff to determine if a
public employer has an applicable Contract for
Coverage of State Agency or Political Subdivision (U-69) when a claim
is received alleging an injury while the IW was acting in the following
capacity, pursuant to R.C. 4123.03:
a.
The IW was performing community service (typically an individual on
probation or performing community service in lieu of a criminal conviction);
b.
The IW was incarcerated in a state or local correctional facility
participating in an inmate work program;
c.
The IW was working as a non-emergency volunteer; or
d.
The IW was serving as a juror.
2.
Claims services staff may refer to BWC Employer Services Contract
for Coverage of State Agency or Political Subdivision policy for
further information.
O.
Individuals Injured or Killed While Performing a Request or Order of a
Duly Authorized Public Official
1.
If an IW is not otherwise covered by elective coverage of a public
employer, claims services staff shall find the IW covered pursuant to R.C. 4123.025 when:
a.
The injury or death is a direct result of performing any act at the
request or order of a duly authorized public official of
i.
The state, or any institution or agency of the state, or
ii.
Any political subdivision, including a county, township, or municipal
corporation; and
b.
The request or order was made in a time of emergency.
2.
If the criteria above are met, claims services staff must consider the
IW or the IW’s dependents eligible for all workers’ compensation benefits as
provided by law.
3.
Claims services staff must ensure any payments made under this provision
are charged to the Surplus Fund.
P.
Injuries Incurred While Participating in a Rehabilitation Plan
1.
Claims services staff will verify that the alleged injury occurred while
participating in an active BWC vocational rehabilitation plan.
2.
Claims services staff shall ensure the correct policy number has been
assigned to any claim involving an IW injured while participating in a
vocational rehabilitation program.
3.
Claim services staff may contact the Rehab Policy unit as needed.
4.
BWC shall charge all compensation and benefits paid in this type of
claim to the Surplus Fund, provided the employer in the source claim pays into
the Surplus Fund.
Q.
Coverage Exemption for Religious Sects
1.
If an IW and employer indicate to claims services staff that they hold a
religious exemption (e.g. Amish) from workers’ compensation coverage, claims
services staff must verify with EM staff that the employer and the IW both have
an approved religious exemption before finding that the IW is not covered by
workers’ compensation.
2.
In general:
a.
BWC may approve an employer and employee exemption from workers’
compensation coverage upon the filing of an Application for
Exemption from Ohio Workers’ Coverage and Waiver of Benefits (U-3E);
b.
The employer and the employee must both file the U-3E and obtain
approval for the waiver;
c.
An employer may have some employees that are exempt from coverage and
some that are not; and
d.
The employer and employee do not have to be members of the same
religious sect.
R. No
Coverage/Non-Complying Employer Claims
1.
Following a claim investigation pursuant to the Initial
Claim Determination policy and procedures, claims services staff must
investigate to determine whether:
a.
The correct employer has been identified; and
b.
The correct employer has:
i.
Never had an established policy with BWC; or
ii.
A policy that is so old that BWC no longer has record of the policy
number (for occupational disease claims);
iii.
A policy is in “cancelled” status, and the date of injury occurred after
the policy was cancelled (see occupational disease exception below).
2.
If claims services staff determines the employer lacks workers’
compensation coverage, claims services staff must obtain a new policy number
(known as a “placeholder policy”) by:
a.
Inserting the following information on Request for Placeholder Policy
form:
i.
Legal business name or homeowner name;
ii.
Primary physical location of business or homeowner;
iii.
Business/homeowner phone, if available;
iv. A
notation of “Placeholder Policy - claim number #xx-xxxxxx” and the date of
injury; and
v.
A brief description of the accident.
b.
Sending the Request for Placeholder Policy to the “BWC PPD Rush”
email box using the subject line: “Placeholder Policy Due to Claims”.
3.
The responsibilities regarding obtaining placeholder policy number may
be assigned to various claims services staff members within the service office
at management discretion.
a.
The Claims Service Specialist (CSS) in the lost time service offices
must:
i.
Refer the policy issue to Employer Management (EM) staff for
investigation, via an IM to EM referral, to ensure that an employer policy
number does not already exist; and
ii.
Request creation of a placeholder policy number if EM staff verifies no
policy currently exists for the alleged employer.
b.
Medical Claims Supervisors in Central Claims will complete an employer
investigation in the claims management system then, if appropriate, refer the
request from their staff directly to Policy Processing to obtain a placeholder
policy.
4.
The Policy Processing Department must manually place an installment
block on all placeholder policies to prevent installments from billing. This
block does not prevent invoices and documents from being sent to the employer.
5.
If claims services staff discover or identify an existing policy number
for the employer that appears to be applicable to the claim after obtaining a
placeholder policy number, claims services staff must email Policy Underwriting
via the “BWC Combine Unit Inquiries” mailbox and request the policy numbers be
reviewed and possibly combined. For example:
a.
Claims services staff’s investigation of the correct employer determines
the correct employer to be ABC Garage, but ABC Garage has no policy number or
coverage. Therefore, a placeholder policy number is requested for the employer.
b.
After the placeholder policy number is obtained, it is discovered that
ABC Garage did have a policy number and coverage when the placeholder policy
number was requested.
c.
Claims services staff will contact Policy Underwriting via the “BWC
Combine Unit Inquiries” mailbox and request the review the two policy numbers
assigned to ABC Garage to determine if the two policies should be combined.
6.
If the claim is for an occupational disease and the correct employer
policy is in a “cancelled” status, the creation of a placeholder policy is not
necessary. Claims Services Staff must update the coverage override drop down to
“Cov-active on DOO” in the Insured Participant details tab so the employer
policy will reflect a covered status for that claim.