Chapter 3307:1-7 Disability Benefits

Chapter 3307:1-7 of the Administrative Code is adopted to establish the definitions, procedures and guidelines needed to fulfill the requirements of sections 3307.62, 3307.63, 3307.631 and sections 3307.64 of the Revised Code and to assure fair and impartial evaluation of all applications for disability benefits.

As used in Chapter 3307:1-7 of the Administrative Code:

(A) “Applicant” shall mean the member for whom an application form and statement of an attending physician on forms provided by the retirement system have been completed and filed with the retirement system.

(B) “Attending physician” shall mean an applicant’s physician of choice.

(C) “Board,” shall mean the state teachers retirement board.

(D) “Independent medical examiner” shall mean a competent physician neither involved in a treatment relationship with an applicant or recipient nor otherwise employed by the retirement system, who shall be designated by the chair of the medical review board to conduct an impartial examination.

(E) “Medical review board” shall mean the group of independent physicians designated by the retirement board under the direction of a chair appointed by the retirement board to assist in the evaluation of medical examinations and information. The members of the medical review board may be asked in panels of three or more to review any application and provide their conclusions as to whether an applicant will be mentally or physically incapacitated from the performance of duty for at least twelve months.

(F) “Party of interest” shall mean the signer of an application for disability benefits, other than the state teachers retirement system member, as authorized by section 3307.62 of the Revised Code.

(G) A disabling condition shall be “presumed to be permanent,” if it physically or mentally incapacitates an applicant from the performance of regularduty for a period of at least twelve months.

(H) “Recipient” shall mean a person granted benefits pursuant to section 3307.62 to section 3307.64 of the Revised Code.

Effective: 07/01/2006

R.C. 119.032 review dates: 04/06/2006 and 04/01/2011

Promulgated Under: 111.15

Statutory Authority: 3307.04

Rule Amplifies: 3307.62, 3307.63, 3307.631, 3307.64

Prior Effective Dates: 12/23/76, 12/26/77, 2/26/81, 7/3/91, 10/29/98 (emer.), 1/17/99, 7/1/01 (emer.) 9/17/01, 9/17/02

(A) The retirement board shall appoint an independent physician to serve as chair of the medical review board and as medical advisor to the retirement board. The chair so appointed shall:

(1) Request and review medical evidence from the applicant’s attending physicians and other relevant sources regarding the nature, findings, extent, treatment, duration and functional limitations imposed by the conditions the applicant claims as disabling.

(2) Assign and oversee competent and impartial independent medical examiners to conduct the medical examinations and tests the chair deems necessary and appropriate to the evaluation of an application. The independent medical examiners shall provide written reports of their findings and conclusions as to whether applicants are mentally or physically incapacitated from the performance of regular duties for a period of at least twelve months.

(3) Review the reports of the independent medical examiners. Once the chair is satisfied that no further examinations or tests are needed, a recommendation shall be submitted to the retirement board if the chair concurs in the conclusions of the independent medical examiner or examiners that an applicant is or will be mentally or physically incapacitated from regular duties for a period of at least twelve months.

(4) If the chair concurs in the conclusions of the independent medical examiners that an applicant is not incapacitated from the performance of regular duties or will not remain incapacitated for at least twelve months, convene a panel of three other members of the medical review board who shall review the reports of the independent medical examiners. The panel may obtain such further examinations and tests as it may judge necessary and appropriate and may direct delay of consideration of an application for treatment.

(5) Submit to the retirement board a report summarizing the conclusions and recommendations of the panels of the medical review board members.

(6) Attend and participate in hearings pursuant to rule 3307:1-7-05 of the Administrative Code as the medical advisor to the retirement board.

(7) Recommend to the retirement board independent physicians from a wide range of medical expertise and specialties to serve as members of the medical review board.

(B) The retirement board shall designate independent physicians to serve as members of the medical review board and shall endeavor to appoint members with a range of medical expertise, disciplines and specialties.

Effective: 08/01/2006

R.C. 119.032 review dates: 04/06/2006 and 04/01/2011

Promulgated Under: 111.15

Statutory Authority: 3307.04

Rule Amplifies: 3307.62, 3307.63, 3307.631, 3307.64

Prior Effective Dates: 12/23/76, 12/26/77, 2/26/81, 7/3/97, 10/29/98 (Emer.), 1/17/99, 7/1/01 (Emer.), 9/27/01

Each applicant or recipient shall be responsible for providing medical information needed by the retirement system and reporting for medical examination, as follows:

(A) Information or reports from an attending physician shall be filed with the retirement system within fifteen calendar days of the date the retirement systems requests such information.

(B) The retirement system shall provide written notice of the independent medical examiners who will conduct medical examinations and testing. The applicant or recipient shall, within fifteen days of notice from the retirement system, schedule appointments so that examination or testing is completed within the following ninety days, as instructed in the notice. In the event the appointment times available with an independent medical examiner preclude completion of the examination or testing within ninety days, a request for extension to the earliest practicable appointment date may be granted by staff members of the retirement system.

(C) The applicant or recipient shall travel to the offices of the independent medical examiners appointed, unless the retirement system determines that medical information submitted by the applicant or recipient demonstrates that the or she is not able to travel to the examination site. A request that the retirement system make such a determination shall be made by the applicant or receipient within fifteen days of notice of the assignment of the independent medical examiners.

(D) The retirement system will accept responsibility for a missed appointment fee if an applicant or recipient fails for good cause demonstrated to the retirement system to keep the first appointment scheduled with an independent medical examiner, but in no case will payment of more than one such fee per applicant or recipient be made.

(E) An applicant or recipient shall request any extension or exceptions to the foregoing requirements in writing directed to the disability staff of the retirement system, which will be granted only if the request demonstrates good cause. In the event an applicant or recipient fails to carry out the foregoing duties in a timely manner, the application for benefits will be cancelled. In the event a recipient fails to carry out the foregoing duties in a timely manner, notice will be given by the retirement system that the failure will be deemed a refusal if the required examinations and testing are not completed by a specified date. If the recipient has not by that date submitted to the required examination and testing, benefits will be suspended as of the first of the month following the specified date. If the refusal continues for one year, all of the recipient’s rights to the benefit shall be terminated as of the effective date of the original suspension without further action of the board.

Effective: 07/01/2006

R.C. 119.032 review dates: 04/06/2006 and 04/01/2011

Promulgated Under: 111.15

Statutory Authority: 3307.04

Rule Amplifies: 3307.62, 3307.63, 3307.631, 3307.64

Prior Effective Dates: 12/23/76, 12/26/77, 2/26/81, 7/3/97, 10/29/98 (Emer.), 1/17/99, 7/1/01 (Emer.), 9/17/01

(A) If the medical review board determines that through medical treatment or mechanical devices an applicant’s condition might be improved, within the twelve month period following the filing of an application, consideration of the application may be delayed while the applicant obtains the treatment or mechanical devices specified by the medical review board provided that:

(1) The medical review board has determined that medical treatment or mechanical devices offer a reasonable expectation of correction or rehabilitation of the disabling condition to the extent that the applicant could be expected to be capable of performing teaching duties within a reasonable time, but not to exceed six months.

(2) The medical review board has determined that the medical treatment or mechanical devices specified are of wide acceptance and readily available.

(3) The medical treatment or mechanical devices specified under this paragraph-shall not include invasive procedures or shock treatment.

(B) The retirement board may specify medical treatment or mechanical devices as described in paragraph (A) of this rule, as a condition of eligibility for the grant of disability benefits pursuant to division (G) of section 3307.62 of the Revised Code. Where such treatment is required:

(1) The applicant or recipient shall agree in writing before disability benefits are granted or continued to acquire the treatment or devices specified by the retirement board or its designee(s) upon the recommendation of the medical review board or its chair. An applicant or recipient shall further agree to timely submit periodic reports of the effect of such continuing treatment or devices.

(2) The retirement board will assume the cost of medical treatment or mechanical devices for a recipient only to the extent such treatment or devices are covered under the state teachers retirement health care program and such a recipient has enrolled in a plan in the program that covers the treatment.

(3) A disability benefit shall be suspended if the recipient fails to agree or obtain the medical treatment or devices required or to submit timely reports of such treatment. Notice shall be given to the recipient at least thirty days in advance of suspension. If the required written agreement, treatment and/or reports are thereafter not received for a period of one year, the benefit shall terminate as of the date of the original suspension without further action of the board.

(C) Following receipt of notice that consideration of the application is being delayed due to paragraph (A) of this rule, the applicant may submit additional medical evidence supporting why treatment or mechanical devices should not be pursued. The evidence will be reviewed by the medical review board and its determination that the application be delayed while the applicant obtains medical treatment or medical devices shall be final.

Effective: 07/01/2006

R.C. 119.032 review dates: 04/06/2006 and 04/01/2011

Promulgated Under: 111.15

Statutory Authority: 3307.04

Rule Amplifies: 3307.62, 3307.63, 3307.631, 3307.64

Prior Effective Dates: 12/23/76, 12/26/77, 2/26/81, 7/3/97, 10/29/98 (Emer.), 1/17/99, 7/1/01 (Emer.), 9/27/01

The following procedures are hereby established for the appeal of any denial or termination of benefits.

(A) At least seven days before a recommendation is presented to the retirement board, written notification shall be issued to the applicant or recipient. This notice shall include the recommendation to be presented to the board.

(1) No additional medical evidence shall be considered once written notification has been issued to an applicant or recipient pursuant to paragraph (A) of this rule.

(2) Should the retirement system receive additional medical evidence after written notification has been issued to an applicant or recipient pursuant to paragraph (A) of this rule, the evidence shall be held and included as part of the appeal documentation if a right to appeal is exercised as set forth in paragraph (B)(2) of this rule. Should a right to an appeal not be exercised as set forth in paragraph (B)(2) of this rule, the evidence will be returned to the applicant or recipient.

(B) Following board action terminating or denying disability benefits:

(1) The applicant or recipient will be informed in writing of the action taken by the board. Notification shall include:

(a) A statement that medical evaluation and board action was conducted in accordance with section 3307.62 or 3307.64 of the Revised Code.

(b) Confirmation that the applicant or recipient has the right to appeal the board action.

(c) A statement explaining that written notice of appeal must be filed with the retirement system no later than fifteen calendar days from receipt of notification of denial or termination.

(d) An explanation of future rights and limitations upon the rights to again apply for disability benefits if an appeal is not pursued.

(2) Procedure for exercising right to appeal:

(a) Written notice of appeal, accompanied by a statement from the applicant or recipient, his or her counsel and/or attending physician that an appeal will be based on evidence contrary to the findings of the independent medical examiners, must be filed with the retirement system within fifteen calendar days of receipt of notification of board action.

(b) If an applicant or recipient does not appeal the action of the retirement board, a person acting on the member’s behalf or the member’s employer may exercise the right to appeal in the same manner and subject to the same procedures and requirements as specified for an applicant or recipient.

(3) Following the retirement system’s timely receipt of written notice of appeal from an applicant or recipient, the retirement system shall provide the applicant or recipient with the following information confirming the appeal:

(a) Confirmation that the applicant or recipient, counsel for the applicant or the recipient, and/or person acting on the member’s behalf, member’s employer, or attending physician may present additional medical evidence orally at an appeal hearing that will be scheduled by the retirement system or that additional medical evidence may be presented in writing. Such additional medical evidence shall not have been previously considered by the independent medical examiner or the medical review board. Additional medical evidence presented in writing must be received by the retirement system on or before the deadline date provided by the retirement system and may not be submitted at the appeal hearing. The deadline date for submitting additional medical evidence in writing shall be at least twelve business days before the date of the scheduled appeal hearing.

(b) Notice that the applicant or recipient may appear at the appeal hearing in person, be represented by counsel and/or an attending physician, or may choose to not appear in person but have the case reviewed by the retirement board or its designee(s).

(c) Notice that if a personal appearance at the appeal hearing is requested by the deadline date provided by the retirement system, the applicant or recipient shall inform the board of the name, title, and position of each person appearing on his/her behalf.

(d) Notice that the applicant or recipient may request up to two delays of the deadline date provided by the retirement system, as set forth in paragraph (B)(4) of this rule.

(e) An explanation of the procedures and limitations applicable to the appeal hearing, as set forth in paragraph (B) of this rule.

(f) A statement explaining that any costs incurred by the applicant or recipient in the appeal will not be reimbursed by the retirement system.

(4) An applicant or recipient may request in writing up to two delays of the deadline date provided by the retirement system as outlined below, provided that the request for a delay is received on or before the deadline date provided by the retirement system.

(a) One forty-five calendar day delay may be requested for any reason. A new deadline date will be provided by the retirement system to the applicant or recipient that is forty-five calendar days from the original deadline date provided by the retirement system.

(b) One additional forty-five calendar day delay may be requested if the request is provided to the retirement system in writing by the deadline date set in paragraph (B)(4)(a) of this rule, good cause for the request for an additional delay is provided, and the retirement system approves the request for an additional delay. Approval of the request for an additional delay for good cause shall be determined solely by the retirement system. If the retirement system approves the request for an additional delay, a new deadline date will be provided to the applicant or recipient that is forty-five calendar days from the deadline date set in paragraph (B)(4)(a) of this rule.

(5) Scope and procedure upon appeal:

(a) An appeal hearing will be scheduled and conducted by the retirement board or its designee(s).

(b) The chairman of the retirement board or the designee(s) shall be responsible for conducting the appeal hearing and the executive director, deputy executive director — member benefits, or the designee(s) and chair or designated member of the medical review board shall be in attendance to act as advisor, if required.

(c) The purpose of the appeal hearing shall be for the applicant or recipient to present information to the retirement board or its designees(s) based on additional objective and pertinent medical evidence not previously considered by the independent medical examiner or the medical review board. Additional written information or evidence to be presented at the hearing must be provided to the system by the deadline in paragraph (B)(3)(a) of this rule and should substantiate the applicant’s or recipient’s claim that the eligibility requirements of section 3307.62 or 3307.64 of the Revised Code have been met and that the applicant or recipient is medically incapacitated from the performance of duty by a previously reported mental or physical condition that is permanent or presumed to be permanent.

(d) Additional written medical evidence or written information may not be submitted at the hearing.

(e) Upon consideration of the record on appeal and the information, positions, contentions and arguments of the applicant or recipient, the retirement board may direct further examination or testing by independent medical examiners and may return a record for review and recommendation by the medical review board.

(f) When the retirement board is satisfied that the record before it is complete and has completed its deliberations, it may affirm, disaffirm or modify its prior action by a majority vote. Written notice of such action shall be given to the applicant or recipient.

(g) A stenographic record of the appeal hearing will be made only upon request of the applicant or recipient and any and all costs shall be at the applicant’s or recipient’s expense. Such request must be made at least twelve business days in advance of the scheduled appeal hearing. An audio recording will be made if a stenographic record is not requested and all costs of the audio recording will be at the system’s expense.

(h) The state teachers retirement system’s administrative staff shall have authority to act for the board in matters relevant to, but not in lieu of, the actual appeal proceeding.

(i) All communications or notifications during the appeal process shall be sent to the applicant or recipient by certified or priority mail, with copies by regular mail to counsel if the applicant or recipient has notified the retirement system of representation by counsel and signed an appropriate authorization for release of information.

(C) Any subsequent applications for disability benefits filed after a denial of appeal shall be submitted with medical evidence supporting progression of the former disabling condition or evidence of a new disabling condition. If such evidence is evaluated by the medical review board and found to be inadequate to establish the progression of the disabling condition or the existence of a new disabling condition, the application shall be voided and a notice will be sent to the applicant. If two years have elapsed since the date the member’s contributing service terminated, no subsequent application shall be accepted.

Replaces: 3307:1-7-05

Effective: 07/24/2008

R.C. 119.032 review dates: 07/10/2013

Promulgated Under: 111.15

Statutory Authority: 3307.04

Rule Amplifies: 3307.62, 3307.63, 3307.631, 3307.64

Prior Effective Dates: 12/23/76, 12/26/77, 2/26/81, 7/3/97, 10/29/98 (Emer.), 1/17/99, 7/1/01 (Emer.), 9/17/01, 7/1/2006

The following rule is established pursuant to section 3307.64 of the Revised Code which specifies that each recipient be examined annually to determine whether he or she remains medically incapacitated from teaching duty, but provides for the board to waive the medical examination if the board’s physician certifies that the disabling condition is ongoing.

(A) The retirement board may require a recipient to submit to medical examinations and tests by independent medical examiners as provided in rule 3307:1-7-03 of the Administrative Code and shall require such examinations and tests if:

(1) The chair of the medical review board recommends such examinations and tests as necessary and appropriate to evaluate the recipient’s continued eligibility for disability benefits, or

(2) A recipient requests re-examination to evaluate capacity to return to teaching duty, and the chair of the medical review board concurs in such request. The board need not grant a request from a recipient for such an evaluation more often than once during any twelve-month period.

(B) If the independent medical examiner appointed pursuant to paragraph (A) of this rule reports the conclusion that the recipient is medically capable of returning to teaching duty, the procedures for review, notification and appeal set forth in rule 3307:1-7-05 of the Administrative Code shall be applied.

Effective: 07/01/2006

R.C. 119.032 review dates: 04/06/2006 and 04/01/2011

Promulgated Under: 111.15

Statutory Authority: 3307.04

Rule Amplifies: 3307.64

Prior Effective Dates: 12/23/76, 12/26/77, 2/26/81, 7/3/97, 10/29/98 (Emer.), 1/17/99 (Emer.), 7/1/01 (Emer.), 9/17/01

(A) Pursuant to section 3307.64 of the Revised Code each recipient shall by April thirtieth of each year, or such other date designated by the retirement board, file a notarized statement of annual earnings with the retirement system.

(B) The statement filed by each benefit recipient shall be on a form provided by the retirement system and shall include a description of work performed during the preceding calendar year, a statement of compensation for work performed, current medical information and such additional information as may be required.

Unless the requirement of annual reporting is waived by the medical review board, a disability benefit shall be suspended if the annual statement is not received within thirty days after notice that it is delinquent. If the statement is found to be delinquent, participation in the retirement system’s health care program, if elected, shall be terminated as of the date the benefit is suspended. If the required statement or reports are thereafter not received for a period of one year, the benefit shall terminate as of the date of the original suspension.

Effective: 07/01/2006

R.C. 119.032 review dates: 04/06/2006 and 04/01/2011

Promulgated Under: 111.15

Statutory Authority: 3307.04

Rule Amplifies: 3307.64

Prior Effective Dates: 12/23/76, 12/26/77, 2/26/81, 7/3/97, 10/29/98 (Emer.), 1/17/99, 7/1/01 (Emer.), 9/17/01