OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Permanent Total Disability (PTD) and Disabled Workers’ Relief Fund (DWRF)

Policy #:

CP-16-03.2

Code/Rule Reference:

R.C. 4123.411 through 4123.417; 4123.58; 4123.62

O.A.C. 4123-3-31; 4123-3-34

Effective Date:

11/17/21

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

Policy # CP-16-03, effective 04/20/2015 and Procedure # CP-16-03-PR.1, effective 05/06/2019

History:

Previous versions of this policy are available upon request


 

Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Disabled Workers’ Relief Fund (DWRF)

DWRF Eligibility Amount

Excess Carrier

Permanent Total Disability (PTD)

PTD Declared Rate

PTD With SSD Maximum Rate

PTD Without SSD Maximum Rate

PTD Minimum Rate

PTD Paid Rate

Social Security Crossmatch

Social Security Disability (SSD)

Social Security Retirement (SSR)

Split PTD

Statutory PTD

Total PTD Declared Rate

Wage Replacement Compensation

Weekly Social Security Disability Rate – DWRF (SSD-DWRF)

Weekly Social Security Disability Rate – PTD (SSD-PTD)

Weekly Worker’s Compensation Amount (WWCA)

IV. POLICY

A.          PTD Awards

B.          DWRF Awards

V. PROCEDURE

A.          General Claim Note and Documentation Requirements

B.          SSA Crossmatch

C.         PTD Declared Rate

D.         Determining DWRF Eligibility and Rates

E.          Paying PTD and DWRF

F.          Re-calculating the PTD Declared Rate

G.         Re-Evaluating DWRF Eligibility and Rates

H.         Terminating/Suspending PTD

I.           PTD Annual Review

J.          DWRF Annual Processing

K.          PTD/DWRF and LSS

L.          PTD/DWRF and LSA

M.         SI Bankrupt and Excess Carriers

N.         PTD and Concurrency with Other Compensation Types

O.         Statutory PTD and Concurrency with Other Compensation Types and Employer-Paid Benefits in the Same Claim

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that BWC calculates and pays PTD compensation and Disabled Workers’ Relief Fund (DWRF) benefits in compliance with the Ohio Revised Code and the Ohio Administrative Code when PTD is granted.

 

II. APPLICABILITY

  

This policy applies to all claims services staff.

 

III. DEFINITIONS

 

Disabled Workers’ Relief Fund (DWRF): A fund, separate from the state fund, established to provide supplemental benefits to injured workers who are receiving PTD compensation when the total of the PTD compensation plus the social security disability (SSD) benefit is less than the DWRF eligibility amount.

 

DWRF Eligibility Amount: The threshold amount, adjusted annually based on the consumer price index, used to determine an IW’s eligibility for DWRF benefits and established by the BWC DWRF Unit and BWC’s Actuarial Department. 

 

Excess Carrier: An insurance entity that assumes the liability of a self-insured claim that has reached a pre-determined limit.

 

Permanent Total Disability (PTD)Compensation granted to an injured worker for the duration of his/her life when the Industrial Commission of Ohio (IC) determines that the injured worker is unable to perform any sustained remunerative employment or is statutory PTD as defined in R.C. 4123.58.

 

PTD Declared Rate: The amount of the weekly PTD compensation payable to an injured worker prior to reduction for repayment of any lump sum advancement (LSA).

 

PTD With SSD Maximum Rate: For injured workers receiving SSD benefits, a rate equal to 2/3 of the statewide average weekly wage (SAWW) for the date of injury, also known as the PTD offset rate.

 

PTD Without SSD Maximum Rate: For injured workers not receiving SSD benefits, a rate equal to the SAWW for the date of injury.

 

PTD Minimum Rate: A rate equal to ½ of the SAWW for the date of injury, unless the average weekly wage (AWW) for the claim is less than that amount; in that case, the PTD rate is equal to the AWW.

 

PTD Paid Rate: The weekly PTD benefit BWC pays to an injured worker; calculated by subtracting the amount being collected to recoup any LSA(s) from the PTD declared rate.

 

Social Security Crossmatch: The electronic receipt of information from the Social Security Administration (SSA) which provides the name, date of birth, date of death (if applicable) and social security benefits received (if any) associated with a Social Security Number (SSN), used by BWC to validate information in the claim file and/or to calculate temporary total compensation (TT), PTD and/or DWRF payment rates.

 

Social Security Disability (SSD): Benefits paid by the SSA to persons who cannot work because they have a medical condition that is expected to last at least one year or result in death. BWC uses the SSD amount prior to any reduction for Medicare benefits in calculation of PTD and/or DWRF. SSD is not used in the calculation of TT.

 

Social Security Retirement (SSR): Benefits paid by the SSA to persons who have met the eligibility requirements. SSR benefits may begin as early as a person’s sixty-second birthday. SSD benefits automatically convert to SSR at the person’s full retirement age. BWC does not use SSR benefits in the calculation of PTD and/or DWRF but may use it in the calculation of TT.

 

Split PTD: PTD compensation allocated by the IC to more than one claim for an injured worker. 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.

 

Total PTD Declared Rate: When PTD is split among two or more claims, the total amount when the declared rate for all claims in the split are added together.      

 

Wage Replacement Compensation: Compensation intended to replace an injured worker’s earnings. This includes TT, living maintenance (LM), living maintenance wage loss (LMWL), wage loss (working and non-working) (WL), PTD and salary continuation (SC).

 

Weekly Social Security Disability Rate – DWRF (SSD-DWRF): The SSD amount used for calculation of DWRF benefits. The rate is determined by the monthly SSD amount for the time period being paid multiplied by 12 and divided by either 365 days, or 366 days in a leap year, and then multiplying the result by seven. This rate is recalculated whenever there is a change in the SSD rate.

 

Weekly Social Security Disability Rate – PTD (SSD-PTD): The SSD amount used for the calculation of PTD compensation. For the initial payment of PTD the rate is determined by the monthly SSD amount as of the PTD begin date being multiplied by 12 and divided by 52. This rate is recalculated if the SSD decreases below the rate on the PTD begin date, begins after the PTD begin date, changes from SSD to SSR, or ends for another reason.

 

Weekly Worker’s Compensation Amount (WWCA): A component of the PTD declared rate calculation that is calculated as follows:  

1.     If 2/3 of the AWW is greater than or equal to the PTD with SSD maximum rate, the PTD with SSD maximum rate is the WWCA; or

2.     If the AWW is less than the PTD minimum rate, the AWW is the WWCA; or,

3.     If the AWW is greater than or equal to the PTD minimum rate, but 2/3 of the AWW is less than the PTD minimum rate, the PTD minimum rate is the WWCA; or

4.     If 2/3 of the AWW is more than the PTD minimum rate, but less than the PTD with SSD maximum rate, 2/3 of the AWW is the WWCA, not to exceed the PTD without SSD maximum rate.

 

IV. POLICY

 

A.     PTD Awards

1.     PTD Payments

a.     It is the policy of BWC to pay PTD as ordered by the Industrial Commission of Ohio (IC) as follows:

i.       Hold the payment of PTD until a copy of the IC order is received by BWC from the IC;

ii.      Continue to pay PTD until the death of the injured worker (IW), the PTD claim is settled or until BWC receives an IC order terminating PTD; and

iii.     Continue to pay PTD to IWs who have been found PTD as the result of a traumatic brain injury and who return to work in a sheltered workshop earning $2000 or less in any calendar quarter.

b.     It is the policy of BWC to pay PTD less other wage replacement compensation and/or percentage of permanent partial (%PP) impairment paid over the same period.

c.      The initial accrued payment of PTD may be issued in care of the IW’s representative if a properly completed Authorization to Receive Workers’ Compensation Check (C-230) has been submitted prior to the initial payment. For additional information, refer to the Authorization to Receive a Workers’ Compensation Payment policy.

d.     PTD payments, both accrued in the past and scheduled biweekly into the future, are subject to weekly family support withholding.

i.       Accrued PTD payments are not subject to lump sum processing for child support.

ii.      Refer to the Family Support and Attorney Fees Paid Pursuant to Deductions of Child Support from Lump Sum Payments policy for additional information

e.     PTD payments are subject to collection of overpayments. Refer to the Adjustment of Overpaid Compensation policy for additional information.

f.       IWs may receive a Lump Sum Advancement (LSA) from future PTD compensation. For additional information, refer to the Lump Sum Advancement policy.

2.     Declared Rate Calculation

a.     No type of retirement benefit will be considered when calculating the PTD declared rate.

b.     BWC shall not recalculate the PTD declared rate when the SSD increases. It is the policy of BWC to recalculate the PTD declared rate only when:

i.       The AWW in the claim changes;

ii.      The SSD weekly rate decreases to a rate lower than the original PTD declared rate;

iii.     The IW begins receiving SSD; or

iv.    The IW stops receiving SSD.

c.      External customers may access the PTD Rate Calculation Worksheet on BWC’s website in the “Tools for Authorized Representatives” offering.

3.     Statutory PTD

a.     IWs who are statutorily PTD may return to work and continue to receive PTD compensation.  

b.     In claims other than the IW’s statutory PTD claim, it is the policy of BWC to pay:

i.       TT or LM, as appropriate; and

ii.      WL or LMWL, as appropriate so long as the wage loss is caused by conditions other than those which are the basis for statutory PTD.  

4.     Multiple Claims

a.     When the IC orders PTD paid in more than one claim, it is the policy of BWC to calculate the PTD rate for each claim individually.

b.     BWC shall then apply the split percentage ordered by the IC to determine the declared rate for each claim.

5.     Incarceration

a.     It is the policy of BWC to refer the issue of PTD suspension to the IC when the IW is incarcerated. 

b.     For additional information, refer to the Incarceration policy.

 

B.     DWRF Awards

1.     It is the policy of BWC to use the IW’s PTD declared rate to proactively determine if the IW is eligible to receive DWRF benefits when PTD is granted in both SF and SI claims. No application is necessary.

2.     It is the policy of BWC to consider Social Security Administration (SSA) benefits in the calculation of DWRF benefits as follows:

a.     SSD benefits are included in the calculation of DWRF benefits.

b.     SSR benefits are not included in the calculation of DWRF benefits.

c.      Widow’s benefits or other benefits received by the IW under another person’s SSN are not considered in the calculation of DWRF benefits.

3.     It is BWC’s policy to issue an order to provide notice of the decision regarding DWRF when:

a.     The initial evaluation is complete; and

b.     Anytime DWRF benefits change.

4.     DWRF Re-Evaluation

a.     BWC must re-evaluate DWRF eligibility and payment rate for IWs receiving PTD when:

i.       The PTD rate is changed;

ii.      The IW begins receiving SSD benefits;

iii.     The IW’s SSD-DWRF weekly rate changes; 

iv.    The IW stops receiving SSD benefits; or

v.      The DWRF eligibility amount changes, usually January 1 each year.

b.     BWC shall not honor a C-230 for any DWRF payment or for any other request for fees associated with assisting the IW in receiving DWRF benefits.

5.     LSAs

a.     An IW may not receive an LSA from future DWRF benefits. 

b.     For additional information, refer to the Lump Sum Advancement policy.

6.     Lump Sum Settlements (LSS)

a.     When calculating a settlement of a claim, if DWRF is being paid in the claim, the DWRF settlement amount will be calculated separately.

b.     For additional detail, please reference the BWC’s Lump Sum Settlement policy.

7.     Family Support

a.     DWRF benefits are not compensation, but rather a supplemental award, and therefore are not subject to family support order withholding.

b.     BWC shall not withhold any amount from DWRF benefits for family support orders.

8.     DWRF Overpayments

a.     If an overpayment of DWRF is identified, it is the policy of BWC to refer the claim to the IC to determine if the:

i.       IW is overpaid; and

ii.      Overpayment will be collected from the IW.  

b.     If the DWRF overpayment is to be collected, it is the policy of BWC to only collect from future DWRF increases, according to Adjudications Before the Ohio Industrial Commission, Memo S2 – Overpayment Policy.  

9.     DWRF Payments in SI Claims

a.     BWC will bill SI employers for DWRF paid in all SI claims.

a.     BWC will also bill employers in claims that were previously SF, when the employer was SF and is now SI.

 

V. PROCEDURE

 

A.     General Claim Note and Documentation Requirements

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 and documentation included in this procedure.

 

B.     SSA Crossmatch

1.     Claims services support staff shall manually request a current social security crossmatch in the claims management system when:

a.     There is not a crossmatch record which has been verified within the last month; and

b.     A claim for the IW is listed on the PTD hearing docket provided by the IC.

2.     After PTD is granted, the PTD/DWRF CSS must:

a.     Update any non-verified responses from the crossmatch which indicates that the BWC and SSA data does not match; or

b.     Resolve any conflicting information, such as date of birth, on a verified record.

3.     The PTD/DWRF CSS must enter a note to document the outcome of the review of the verified information from the crossmatch.

4.     If the IW does not have an SSN or the SSN cannot be verified with the crossmatch, the PTD/DWRF CSS must attempt to verify social security status with the IW prior to making payment. The PTD/DWRF IMS must perform an override to make payments if the SSN cannot be verified.

5.     PTD/DWRF staff will receive a work item and enter a retirement date for the IW in the claims management system when:

a.     The crossmatch indicates that the IW is receiving SSR; or

b.     The IW reaches full retirement age as determined by SSA.

 

C.    PTD Declared Rate

1.     The following information must be available to calculate the PTD declared rate:

a.     The IW’s average weekly wage (AWW). For some IWs, their AWW is zero (see the Wages policy for further information);

b.     The PTD without SSD maximum rate for the year of the injury or occupational disease (commonly referred to as PTD max, this amount is equal to the statewide average weekly wage [SAWW] for the year of injury or occupational disease);

c.      The PTD with SSD maximum rate for the year of the injury or occupational disease (commonly referred to as PTD offset, this amount is equal to two-thirds of the SAWW for the year of injury or occupational disease);

d.     The PTD minimum rate for the year of the injury or occupational disease (commonly referred to as the PTD min, this amount is equal to one-half of the SAWW for the year of injury or occupational disease); and,

e.     A current verified social security crossmatch record (i.e., verified within the last 30 days), which includes the amount of SSD received by the IW.

2.     For claims with dates of injury prior to 1/1/1976, the PTD/DWRF CSS shall verify social security crossmatch information for SSD only for the calculation of DWRF benefits. There are no impacts to the PTD calculation for these claims.

3.     For claims with dates of injury on or after 1/1/1976, the PTD/DWRF CSS shall review claims notes for a note regarding information received in the SSA crossmatch.

4.     The PTD/DWRF CSS must use the SSD amount received by the IW on the PTD begin date for the calculation of the initial PTD declared rate.

5.     Calculating the PTD Declared Rate

a.     The PTD/DWRF CSS shall calculate the PTD declared rate by combining the SSD-PTD weekly rate with the WWCA.

b.     If the AWW is below the PTD minimum rate, the AWW is the PTD declared rate; or

c.      If the AWW is above the PTD minimum rate, but 2/3 of the AWW is under the PTD minimum rate, the PTD minimum rate is the PTD declared rate; or

d.     If 2/3 of the AWW is above the PTD minimum rate, but below PTD with SSD maximum, 2/3 of the AWW is the PTD declared rate; or

e.     If 2/3 of the AWW is above the PTD with SSD maximum rate, SSD benefits must be considered to determine the PTD rate.

i.       If the total of the SSD weekly rate and the WWCA is above the SAWW for the DOI, the PTD declared rate is the PTD with SSD maximum rate for the DOI; or

ii.      If the total of the SSD weekly rate and the WWCA is below the SAWW but greater than or equal to 2/3 of the SAWW, the PTD declared rate is 2/3 of the AWW, not to exceed the WWCA.

6.     The PTD/DWRF CSS shall complete PTD Rate Calculation Worksheets, found on the PTD/DWRF CSS job site in COR, and image them into the claim.

a.     A worksheet shall be completed using SSD rate in effect on the PTD start date (if IW is not receiving SSD the PTD/DWRF CSS would then enter $0 as the rate.) 

b.     Subsequently, if any of the following changes occur to the SSD rate, a new worksheet shall be completed:

i.       IW is granted SSD;

ii.      The IW’s SSD rate decreases; or

iii.     The IW SSD payments end.

 

D.    Determining DWRF Eligibility and Rates

1.     DWRF Eligibility Determination

a.     The PTD/DWRF CSS must determine DWRF eligibility for every IW who is granted PTD compensation.

b.     The PTD/DWRF CSS must issue an order regarding the IW’s eligibility for DWRF in every claim where PTD is granted. The order shall include:

i.       BWC’s decision to find the IW eligible or ineligible for DWRF;

ii.      The DWRF weekly rate if the IW is found to be eligible; and

iii.     BWC’s decision regarding any back period of eligibility and any rate changes.

2.     DWRF Calculation

a.     The PTD/DWRF CSS must calculate DWRF benefits as follows:

i.       Add the total PTD declared rate to the weekly SSD-DWRF rate.

ii.      Compare the total of 2(a)(i). above to the DWRF eligibility amount. If the total is less than the DWRF eligibility amount, the IW is entitled to DWRF benefits.

iii.     If the IW is entitled to DWRF benefits, the DWRF rate is the lesser of the following calculations:

a)     The DWRF eligibility amount minus the total PTD declared rate; or

b)     The DWRF eligibility amount minus the weekly SSD-DWRF rate.

b.     For example:

i.       The DWRF eligibility amount for the current year is $350.

ii.      The IW’s PTD declared rate is $100 per week and SSD-DWRF rate is $150 per week.

iii.     The two rates combined equal $250, which is below the DWRF eligibility amount for the current year, so the IW is eligible for DWRF benefits.

iv.    To calculate the DWRF weekly rate the following comparison is made:

a)     $350 (DWRF eligibility amount) - $100 (PTD declare rate) = $250; and

b)     $350 (DWRF eligibility amount) - $150 (SSD DWRF rate) = $200.

v.      The DWRF rate is the lesser of the two, or $200.

c.      If PTD is split across multiple claims, the DWRF amount is allocated across claims based on the split PTD percentages. For example:

i.       The IC has split PTD across three claims, allocating 20% in claim one, 30% in claim two and 50% in claim three; and

ii.      The DWRF amount for the IW is $200 per week; then

iii.     BWC shall pay $40 in claim one ($200 times 20%); $60 in claim two ($200 times 30%) and $100 in claim three ($200 times 50%).

d.     If the IW is incarcerated but is eligible to receive DWRF benefits, the SSD amount the IW would be receiving, but for the incarceration, is used in the calculation of DWRF benefits.

 

E.     Paying PTD and DWRF

1.     Payment and Apportionment of PTD

a.     The PTD/DWRF CSS will pay PTD upon receipt of the SHO hearing order granting PTD as follows:

i.       Payment cannot be made until BWC receives the order from the IC.

ii.      If an IW representative contacts BWC requesting payment of PTD and the IC order has not been received by BWC, the PTD/DWRF CSS shall contact the IC to request a copy of the order.

iii.     Upon receipt of a tentative order from the IC, the PTD/DWRF CSS shall release the PTD payment:

a)     Immediately upon receipt of a waiver of the objection period from the employer of record; or

b)     At the end of the 14-day (plus four for mailing) objection period for non-statutory PTD; or

c)     At the end of the 30-day (plus four for mailing) objection period for statutory PTD; or

d)     If an objection is filed, payment is held until receipt of an SHO hearing order granting PTD.

iv.    Upon receipt of the IC order addressing an Agreement as to Award for Permanent Total Disability (IC-22), the PTD DWRF CSS shall release the PTD payment.

b.     The PTD/DWRF CSS must apportion PTD benefits across claims if ordered to do so by the IC (split PTD).

2.     PTD Payment Begin and End Dates

a.     PTD payments shall begin on the date ordered by the IC.

b.     The initial PTD payment end date is built to end on the IW’s 90th birthday.

i.       The PTD/DWRF CSS shall use the “Age 90 Calc” tab of the PTD calculation worksheet on COR to determine the end date that should be entered in the claims management system.

ii.      Except for black lung and marine fund claims, the PTD/DWRF CSS shall not end the PTD payment plan in November, December, or January of any year.

3.     Wage Replacement and Other Compensation

a.     The PTD/DWRF CSS must deduct any wage replacement or %PP compensation paid on or after the PTD begin date from the PTD payment if the IC order indicates that PTD is to be paid less previously paid compensation.

i.       The PTD/DWRF CSS must void any wage replacement paid on or after the PTD begin date and absorb the resulting overpayment from the PTD payments.

ii.      If the weekly rate of the wage replacement is higher than the PTD rate, the PTD/DWRF CSS must process the remaining overpayment as directed in the Overpayment of Compensation policy and procedure.

b.     The PTD/DWRF CSS must not void a %PP award paid on or after the PTD begin date. The PTD/DWRF CSS shall:

i.       Calculate the offset; and

ii.      Refer to the PTD/DWRF training material on COR for additional information.

c.      The PTD/DWRF CSS must staff with a BWC attorney if TT or %PP compensation was previously paid over the same period for which PTD is now ordered and the IC order does not indicate that previously paid compensation must be deducted.

4.     Black Lung and Marine Fund Claims

a.     Black lung and marine fund claims shall be paid as ordered by the Department of Labor.

b.     The Black Lung/Marine Fund CSS must pay PTD at the rate ordered by the Department of Labor.

c.      The Black Lung/Marine Fund CSS must build payments for black lung and marine fund claims to end on December 31, pending notice from the Department of Labor of the rate for the next year.

5.     Honoring a C-230

a.     The PTD/DWRF CSS must honor a properly completed C-230 for the initial payment of PTD.

b.     See the Authorization to Receive a Workers’ Compensation Payment policy for additional information.

6.     Family Support Withholding

a.     The PTD/DWRF CSS must implement weekly withholding orders for family support for all PTD payments.

b.     The initial payment of accrued PTD is not subject to lump sum processing for family support but is subject to weekly withholding orders.

c.      See the Family Support and Attorney Fees Paid Pursuant to Deductions of Child Support from Lump Sum Payments policy and procedure for additional information.

7.     Overpayments: The PTD/DWRF CSS must ensure that overpayments are collected from PTD as directed in the Adjustment of Overpaid Compensation and Overpayment of Compensation policies and procedures.

8.     Settlements

a.     The PTD/DWRF CSS must continue to pay PTD and/or DWRF during processing of a Settlement Agreement and Application for Approval of Settlement Agreement (C-240) up to the date the BWC Approval of Settlement letter is mailed.

b.     See the Lump Sum Settlement policy and procedure for additional information regarding processing of C-240s.

9.     SSN Discrepancies

a.     If the IW does not have a valid SSN, the PTD/DWRF CSS must perform a thorough investigation of the SSN/SSN discrepancy.

b.     If the IW does not have a valid SSN, but the discrepancy is resolved prior to an EBT card being sent, the PTD/DWRF CSS must notify:

i.       The PTD/DWRF IMS to override the SSN; and

ii.      Benefits Payable to Block the issuance of an EBT card and issue a paper warrant.

c.      If the IW does not have a valid SSN, but the discrepancy is resolved after an EBT card was sent, the PTD/DWRF CSS must notify:

i.       The PTD/DWRF IMS to override the SSN; and

ii.      Benefits Payable to Block the EBT card and issue a paper warrant.

d.     The PTD/DWRF CSS continues process as normal if the SSN is valid and the discrepancies are resolved.

10.  Paying DWRF

a.     Once the IW is determined to be eligible to receive DWRF benefits, the PTD/DWRF CSS shall:

i.       First build the PTD benefit plan in the claims management system; and

ii.      Then build the DWRF benefit plan in the claims management system.

b.     The PTD/DWRF CSS shall then release the PTD and DWRF payment.

11.  PTD/DWRF Payment Adjustments: For specific direction on processing PTD/DWRF payment adjustments, please reference the PTD/DWRF training manual on the COR PTD and DWRF policy page.

 

F.     Re-calculating the PTD Declared Rate

1.     The PTD/DWRF CSS must complete a review of the PTD rate calculation for potential changes when:

a.     The AWW in the claim is modified;

b.     The IW begins receiving SSD after the PTD begin date;

c.      The SSD rate decreases to an amount less than the IW was receiving on the PTD begin date;

d.     The IW is no longer receiving SSD; or

e.     When the PTD start date changes.

2.     The PTD rate is not recalculated if the SSD rate increases.

3.     If the review indicates a change in the PTD declared rate:

a.     The PTD/DWRF CSS must issue an order for the new PTD declared rate.

b.     The order must include:

i.       The begin date for the new rate;

ii.      A statement that previously paid compensation will be adjusted, if appropriate; and

a)     That the adjustment will result in additional payment to the IW; or

b)     That the adjustment will result in an overpayment which will be established by a separate order.

4.     Before recalculating the PTD declared rate, the PTD/DWRF CSS must make certain that the wages were not set based on the earnings for the 52 weeks prior to the date of disability.  In some claims PTD payments are done in this manner based on the State ex rel. Price v. Cent. Serv., Inc. court decision.

a.     Wages in Price claims are set based on the earnings for the 52 weeks prior to the date of disability.

b.     The maximum and minimum PTD rates are based on the date of disability.

c.      If the PTD/DWRF CSS believes the claim is a Price claim, the PTD/DWRF CSS shall:

i.       Staff the claim with a BWC attorney; and

ii.      If the claim is found to be a Price claim, update the adjustment.

 

G.    Re-Evaluating DWRF Eligibility and Rates

1.     The PTD/DWRF CSS must re-evaluate the IW’s eligibility for DWRF and/or the rate of DWRF payment when:

a.     The PTD declared rate changes; or

b.     The amount of SSD received by the IW changes outside of a yearly increase in SSD received by all SSD recipients.  

2.     The claims management system re-evaluates all IWs receiving PTD when there is a change in SSD rate for all persons receiving SSD benefits, usually beginning January 1 of each year (annual processing). See Section V.J of this procedure for more information.

3.     The PTD/DWRF CSS shall use $0 as the SSD to recalculate DWRF if:

a.     The IW requests that the DWRF be recalculated because SSD is being paid at $0 due to the collection of an overpayment by SSA; 

b.     The IW provides proof that the overpayment of SSD occurred during a time in which SSD & PTD were paid simultaneously, thereby artificially depressing the DWRF amounts; and

c.      SSD is $0.00 (including if the IW is receiving SS benefits, but it is a retirement benefit).

4.     The PTD/DWRF CSS shall staff claims where DWRF must be recalculated with the PTD/DWRF IMS.

5.     A DWRF order shall be issued:

a.     By the PTD/DWRF CSS if the evaluation results in a DWRF rate change, other than for annual processing; or

b.     By the claims management system during annual processing.

6.     The PTD/DWRF CSS must create a case and complete a NOR to the IC if an overpayment of DWRF benefits has been identified.

a.     Upon receipt of the IC order, the PTD/DWRF CSS must modify the compensation as directed by the IC.

b.     If the IC order indicates that an overpayment is not to be collected from the IW, the PTD/DWRF CSS must request that the overpayment be removed from the claim.

 

H.    Terminating/Suspending PTD

1.     The PTD/DWRF CSS must terminate PTD benefits only upon:

a.     The death of the IW; or

b.     The receipt of an order from the IC terminating PTD benefits.

2.     Upon the death of the IW the PTD/DWRF CSS shall:

a.     First reduce the DWRF payment plan, if applicable;

b.     Then reduce the PTD payment plan to equal the date of death;

c.      Then enter the date of death in the claim;

d.     Determine if accrued compensation is payable (see the Accrued Compensation policy and procedure). If, after the investigation process is complete, the PTD/DWRF CSS determines that accrued compensation:

i.       Is payable:

a)     Issue an order which includes both the accrued PTD and DWRF; and

b)     Pay the accrued PTD and DWRF when the award becomes payable.

ii.      Is not payable, it is not necessary to issue an order to stop PTD due to the IW’s death.

3.     The PTD/DWRF CSS must make a referral to the Special Investigations Unit (SIU) if the IW reports working while receiving PTD.

a.     PTD compensation will continue until direction is received from the SIU.

b.     An IC order must be received prior to suspending or terminating PTD payments.

4.     The PTD/DWRF CSS must follow the Incarceration policy and procedure if BWC receives notice that an IW receiving PTD benefits is incarcerated.

5.     The PTD/DWRF CSS shall not terminate or withhold PTD and/or DWRF benefits due to the IW’s failure to respond to an annual contact letter.

6.     The PTD/DWRF CSS may withhold PTD and/or DWRF benefits if the IW is paid via paper warrant and more than two consecutive warrants are returned to BWC as undeliverable due to a bad address.

a.     The PTD/DWRF CSS must complete a thorough investigation to attempt to identify a new address for the IW.

b.     The PTD/DWRF CSS must staff with the PTD/DWRF IMS prior to withholding benefits.

 

I.       PTD Annual Review

1.     The claims management system will create a work item once a year for each IW receiving PTD and/or DWRF benefits.

2.     Upon receipt of the annual contact work item, the PTD/DWRF CSS shall send the PTD annual contact letter to the IW.

a.     If it is documented in notes that contact has been made with the IW in the last year, no annual contact letter is necessary if the IW answered the following questions:

i.       Is the address we have on file correct?

ii.      What is the best phone number to use to contact you?

iii.     Have you worked anywhere since you were found to be PTD?

a)     If yes, was the work part time, full time or volunteer?

b)     If yes, what is the name, address and/or phone number of the company or organization you worked for? 

b.     If there is no response is received from the first letter, the PTD/DWRF CSS must attempt a second letter.

c.      If there no response to the second letter, the PTD/DWRF CSS must  attempt to contact the IW by phone.

d.     The PTD/DWRF CSS must complete the SIU referral form found on the PTD policy page in COR if unable to contact the IW after two letters and a phone contact.

i.       The CSS shall:

a)     Document the dates of any notes regarding attempted contact with the IW;

b)     Document the date of imaged copies of any returned mail;

c)     Document the dates of the annual contact letters; and

d)     Document attempts to find a new address for the IW, if appropriate.

ii.      The PTD/DWRF CSS shall not withhold PTD benefits based on the lack of response by the IW to the annual contact letter.

iii.     Requests from SIU to place the PTD/DWRF benefits on hold shall be staffed with the PTD/DWRF IMS.

e.     Upon receipt of a returned annual contact letter, contact with the IW, or staffing with SIU/Legal, if necessary, the PTD/DWRF CSS must:

i.       Rename the returned letter if necessary;

ii.      Update the IWs name and/or phone number if necessary;

iii.     Update the document turnaround timeframe;

iv.    Make a referral to SIU if the IW indicates that they have worked since the PTD begin date;

v.      Extend any payment plans that end in November, December, or January of any year to end in a different month that occurs sometime after the IW’s ninetieth birthday;

vi.    Extend any plans that will end in the next 12 months to at least the IW’s ninetieth birthday, but still not ending in November, December, or January of any year;

vii.   Extend any plans for IWs who are over 90 to at least the IW’s one hundredth birthday, but still not ending in November, December, or January of any year; and

viii. Review the SSA information making certain the IW has not changed to SSR due to early retirement or reached full retirement and make the appropriate updates, if necessary.

 

J.      DWRF Annual Processing

1.     The claims management system will re-evaluate the eligibility and rate of DWRF compensation for every IW in the claims processing system with an ongoing PTD payment plan when the DWRF eligibility amount changes.

2.     The PTD/DWRF CSS must comply with processing restrictions for annual processing as identified by the claims services division (usually in November and December of each year).

3.     The PTD/DWRF CSSs must complete the necessary review and clean-up of claims prior to annual processing, based on the pre-annual processing reports.

4.     The claims management system generates annual processing orders when:

a.     The DWRF rate for the IW will change;

b.     The IW becomes newly entitled to DWRF;

c.      The IW is no longer entitled to DWRF.

5.     Neither the PTD/DWRF CSS nor the system shall issue an annual processing order when the IW’s DWRF benefit is increased but no additional payment is made to the IW because the increase will be withheld to reduce an overpayment in DWRF benefits.

 

K.     PTD/DWRF and LSS

1.     Upon receipt of a C-240, the PTD claim shall be reassigned.

a.     The work items associated with the claim will automatically reassign to the assigned LSS CSS.

b.     The LSS CSS shall coordinate with the PTD/DWRF CSS regarding events in the claim that may impact the PTD rate.

2.     The DWRF portion of any settlement is calculated and paid independent of other compensation included in the settlement.

3.     LSS CSS may approve settlement of DWRF benefits with the proper authority without settling the associated PTD.

4.     See the Lump Sum Settlement policy and procedure for additional information.

 

L.     PTD/DWRF and LSA

1.     The PTD/DWRF CSS must build an LSA offset for the reduction of any LSA paid from future PTD.

2.     The PTD/DWRF CSS shall not modify the PTD declared rate when an LSA is granted.

3.     No LSA shall be granted from future DWRF payments.

4.     Additional information regarding LSAs can be found in the Lump Sum Advancement policy and procedure.

 

M.    SI Bankrupt and Excess Carriers

1.     Excess Carriers may periodically request information regarding a SI banrupt claim by emailing Excessinsurance@bwc.state.oh.us. The request may include:

a.     The amount of medical benefits and compensation payments;

b.     Authorizations; and

c.      Invoices.

2.     If the request is claims related, the SI department will contact the PTD/DWRF CSS to respond. The PTD/DWRF CSS must respond to these requests as soon as possible, as a delay in response may result in BWC becoming permanently responsible for the payment of the claim.

3.     The PTD/DWRF CSS or PTD/DWRF IMS must forward all email inquiries they receive directly to Excessinsurance@bwc.state.oh.us for review and assignment.

 

N.    PTD and Concurrency with Other Compensation Types

1.     TT

a.     Claims services staff shall not pay TT in the same claim as PTD.

b.     Claims services staff may pay TT in a claim other than the PTD claim when an IW is found to be statutorily PTD and continues to work. See Section V.O of this procedure for more information.

2.     LM

a.     Claims services staff shall not pay LM in the same claim as non-statutory PTD has been ordered.

b.     Claims services staff may pay LM in lieu of PTD in a claim for an IW who was found to be statutorily PTD. See Section V.O of this procedure for more information.

3.     %PP

a.     The PTD/DWRF CSS shall deduct %PP from PTD paid in the same claim and over the same period.

b.     Claims services staff shall not pay %PP in a claim once PTD is granted.

4.     WL and LMWL

a.     Claims services staff shall not pay WL or LMWL in any claim for an IW receiving non-statutory PTD.

b.     For IWs who are statutorily PTD, claims services staff may pay WL or LMWL in a claim other than the statutory PTD claim, when the wage loss in the different claim is a result of conditions other than those that were the basis for the finding of statutory PTD. See Section V.O of this procedure for more information.

5.     Claims services staff shall pay scheduled loss compensation, including facial disfigurement, concurrently with PTD in the same or another claim, if appropriate.

6.     The PTD/DWRF CSS shall pay violation of specific safety rule (VSSR) awards concurrently with PTD if appropriate.

7.     See the specific policy and procedure for each of these compensation types for more information.

 

O.    Statutory PTD and Concurrency with Other Compensation Types and Employer-Paid Benefits in the Same Claim

1.     The PTD/DWRF CSS shall not offset statutory PTD benefits for payments the IW receives for disability benefits from an employer.

2.     The PTD/DWRF CSS shall not pay TT, WL, or LMWL in the same claim in which statutory PTD benefits are being paid.

3.     The PTD/DWRF CSS shall suspend PTD and pay LM compensation if the IW enters a vocational rehabilitation plan in a PTD claim and chooses to receive LM.