This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and
universities.
| Rule |
Rule 4123-3-01 | Office locations; scope of rules.
Effective:
December 1, 2024
(A) Offices of the bureau of
workers' compensation will be located in cities as the administrator
establishes and each office will be open during posted hours of operation,
holidays excepted, for the receipt and filing of claim applications or any
other documents and for the transaction of any business pertinent to the
administration of the workers' compensation law. (B) Any application, form, or document
required to be filed with the bureau but received by the industrial commission
or managed care organization (MCO) is considered filed on the date stamped
received by the commission or MCO and will be forwarded to the bureau for
processing. Any application, form, or document required to be filed with the
commission but received by the bureau or MCO is considered filed on the date
stamped received by the bureau or MCO and will be forwarded to the appropriate
commission office or section for processing. (C) The rules in this chapter govern
claims procedures before the bureau, and include related matters applicable to
claims procedures before the industrial commission. (D) Failure to adhere to the rules of the
bureau is a valid ground for refusal by the bureau to grant the relief sought
and may result in further action as may be applicable under each
case. (E) All claims will be processed in a
consistent and timely manner.
Last updated December 2, 2024 at 8:55 AM
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Rule 4123-3-02 | Forms.
Effective:
December 1, 2024
(A) Printed forms for all applications,
reports, notices, proofs, etc., necessary for perfecting any claim before the
bureau or commission will be furnished without charge by the bureau. Such forms
may be obtained online or from any office of the bureau or
commission. (B) Each employer shall make such forms
available to employees who sustain industrial injuries or contract occupational
diseases. (C) Any required form or equivalent must
include sufficient detail to facilitate the prompt and accurate adjudication of
the questions presented. (D) The bureau will furnish to the public without charge printed
forms for use in filing applications for benefits or compensation, or for
submitting other necessary proof in any claim before the bureau and the
industrial commission.
Last updated December 2, 2024 at 8:55 AM
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Rule 4123-3-03 | Employers' reports of injuries and occupational diseases.
Effective:
December 1, 2024
(A) Every employer shall keep a record of
all injuries and occupational diseases resulting in seven days or more of total
disability or death and report them to the bureau of workers' compensation
within one week of acquiring knowledge of such injury or death and within one
week after acquiring knowledge of or the diagnosis or death from the
occupational disease as set forth in section 4123.28 of the Revised
Code. (B) Public employers and employers
contributing to the private fund of the state insurance fund shall make such
reports on the application for benefits or equivalent. (C) Self-insuring employers shall use the
application for benefits or equivalent provided by the bureau of workers'
compensation to make the report of injury or occupational disease as set forth
in section 4123.28 of the Revised Code, within the prescribed time limits set
forth. Reports of death due to injury and occupational disease shall be on the
application for benefits or equivalent. (D) Self-insuring employers shall make a
similar report on the application for benefits or equivalent in claims for
injury, involving seven days or less of lost time, wherein it is apparent that
there will be permanent partial disability under division (B) of section
4123.57 of the Revised Code. In such cases involving occupational disease, the
report shall be on the application for benefits or equivalent. (E) In order to assist in determining
whether the claimant is entitled to an extension of the statute of limitations
as set forth in section 4123.28 of the Revised Code, the bureau shall maintain
a record of all injuries and occupational diseases reported by each
employer. (F) Each employer shall give a copy of
each report to the employee it concerns or their surviving dependents as set
forth in section 4123.28 of the Revised Code.
Last updated December 2, 2024 at 8:55 AM
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Rule 4123-3-07 | Applications for death benefits.
Effective:
April 15, 2022
When the death of an employee is the result of a
work related injury or occupational disease, the employee's dependents may
file an application for death benefits. To be considered a
"dependent", a person must be a member of the family of the deceased
employee, or bear to the employee the relation of surviving spouse, lineal
descendant, ancestor, or brother or sister. An application signed by a person
claiming to be a dependent, as described herein, shall be accepted for filing
and shall be sufficient to initiate proceedings for workers' compensation
benefits and to obtain a ruling on the validity of the claim. If there are no
dependents, the application may be filed by the estate of the deceased
employee, the attending physician, the funeral director, by a volunteer paying
the funeral bill, by a person who authorized the burial and funeral expenses or
by the employer, for services rendered because of the injury or occupational
disease causing the employee's death.
Last updated October 7, 2024 at 12:02 PM
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Rule 4123-3-08 | Preparation and filing of applications for compensation and/or benefits.
Effective:
December 1, 2024
(A) Preparation and execution of
forms. (1) The "First
Report of Injury" form (FROI) or equivalent for applying for payment from
the state insurance fund due to an injury, occupational disease, or death may
be completed by the employee, employer, medical provider, or other interested
party. If someone other than the employee submits a FROI or equivalent, the
bureau may contact the employee to attempt to verify that the employee wishes
to pursue the application. To accept or deny the validity of the claim, the
employer may complete and sign the form at the designated point or may use a
separate writing, telephone, or other means of telecommunication. (2) The FROI for applying
for payment from a self-insuring employer shall be completed, signed by the
employee, and returned to the self-insuring employer. In situations where there
is no prescribed form, a notice in writing shall be given in a manner
sufficient to inform that a claim for benefits is being presented. (3) An injured or
disabled employee who is a minor (under eighteen years of age) shall file a
claim in his or her own name and right. A report of injury signed by such minor
employee is sufficient to initiate proceedings for compensation and/or
benefits. (4) In the event the
injured or disabled employee is unable to complete the first report of injury
by reason of physical or mental disability, the report may be completed and
filed by the employee's spouse, next friend, the guardian of the employee,
or the employee's employer. In claims for death benefits where the
dependents are a spouse and one or more minor children, it shall be sufficient
for the spouse to make application for benefits on behalf of the spouse and the
minor children. In the event a dependent minor child has a guardian of the
person other than the spouse of the deceased, such guardian shall execute the
report on behalf of such minor child. If there is no spouse surviving, the
report on behalf of the dependent minor children, or children who are mentally
or physically incapacitated, may be filed by a guardian or next friend of such
children. (5) It is the duty of every employer to
assist injured or disabled employees in the preparation and submission of
reports for compensation and/or benefits. In the event the employer refuses,
neglects, or unduly delays the completion of a report, the report may be filed
without the part pertaining to the employer having been completed. The fact of
refusal or neglect should be noted upon the report or with it by way of
separate letter. (6) In cases where the death of the
employee is not the result of injury or occupational disease, an application
for accrued compensation may be made as provided in sections 4123.57 and
4123.60 of the Revised Code. (7) Application for payment of the
balance of a percentage permanent partial disability compensation awarded under
division (A) of section 4123.57 of the Revised Code prior to the
employee's death may be made by the injured employee's dependents.
The application may be filed whether the death was related or unrelated to an
industrial injury or occupational disease. (B) Certification by the
employer. (1) An employer shall
accept or reject the validity of a claim filed against its risk within the time
provided by sections 4123.511 and 4123.84 of the Revised Code and the rules of
the industrial commission and bureau of workers' compensation. If the
employer fails to comply with the established time limits, the bureau will take
such further action in the claim as provided by section 4123.511 of the Revised
Code and the rules of the industrial commission and the bureau. (2) If the employer
accepts or denies the validity of the claim, the employer may sign the report
at the designated point and return the requested information to the bureau, or
the bureau may obtain the employer's certification or denial of the claim
by a separate writing, by telephone, or by other forms of
telecommunication. If the employer denies the validity of the
claim, the employer shall state the reasons for rejecting the validity of the
claim. (3) Certification by the
employer in state fund cases is not determinative of compensability. Every such
claim is subject to administrative review as to compensability. (4) An employer's
certification of a claim may be made by the employer, by an officer of the
business entity which is the employer, or by a duly designated representative
of the employer. The person certifying a claim for the employer shall indicate
in what capacity the person is employed (title). No other person or entity may
make such certification. No person may certify his or her own claim, except in
cases of a sole proprietor who has obtained coverage as an employee within
Chapter 4123. of the Revised Code. (C) Place and manner of filing
applications for benefits. Any first report of injury will be accepted for
filing in any office of the bureau, MCO, or industrial commission during
working hours, and reports may be filed by mail or reported by
telecommunication. (D) Time limitations within which claims
must be filed. (1) Injury claims
applying for compensation and/or benefits shall be in writing or by
telecommunication as provided in division (E) of section 4123.84 of the Revised
Code, and shall include the specific part or parts of the body alleged to have
been injured, the claimant's name and address, and the date of injury.
Such claims are forever barred unless notice is filed with the bureau of
workers' compensation, MCO or the industrial commission within one year
from the date when injured, unless the applicable statute of limitations is
extended due to the employer's failure to file a report as set forth in by
section 4123.28 of the Revised Code. Except as provided in paragraph (D)(3) of
this rule, any claim or application for compensation and/or benefits for an
injury to any part or parts of the body not specified in the original claim is
barred unless notice of the additional part or parts of the body claimed to
have been injured is filed by the claimant with the bureau of workers'
compensation, MCO, or the industrial commission within one year of the date
when injured. (2) In self-insuring
employers' claims, the time limitation is tolled if the employer has
provided treatment by a licensed physician in the employ of the employer or has
paid compensation or benefits within the period. "Benefits" means
payment by the self-insuring employer to, or on behalf of, an employee
for: (a) A hospital bill; (b) A medical bill for treatment by a licensed physician, other
than a salaried physician in the employ of the self-insuring
employer; (c) An orthopedic or prosthetic device. (3) The bureau of
workers' compensation and the industrial commission have continuing
jurisdiction over a claim which meets the provisions of section 4123.84 of the
Revised Code, including jurisdiction to award compensation and/or benefits for
a condition (or conditions) or disability developing in part or parts of the
body not specified pursuant to division (A)(1) of section 4123.84 of the
Revised Code, if it is found that the condition (or conditions) or disability
was due to and a result of or a residual of the injury to one of the parts of
the body set forth in the written notice filed pursuant to division (A)(1) of
section 4123.84 of the Revised Code. (4) Claims for
occupational disease arising prior to September 28, 2021 must be filed within
two years after the disability begins, or within such longer period as does not
exceed six months after diagnosis by a licensed physician, as provided in
section 4123.85 of the Revised Code, excepting claims enumerated in paragraph
(D)(6) of this rule, or where the applicable statute of limitations is extended
due to the employer's failure to file a report as required by section
4123.28 of the Revised Code. The filing limitation of six months after
diagnosis, where it applies, can only lengthen, not shorten, the two-year
statute of limitations. (5) Claims for
occupational disease arising on or after September 28, 2021 must be filed
within one year after the disability begins, or within such longer period as
does not exceed six months after diagnosis by a licensed physician, as provided
in section 4123.85 of the Revised Code, excepting claims enumerated in
paragraph (D)(6) of this rule, or where the applicable statute of limitations
is extended due to the employer's failure to file a report as required by
section 4123.28 of the Revised Code. (6) Special statutory provisions (section
4123.68 of the Revised Code) exist as to claims for silicosis, cardiovascular,
pulmonary, or respiratory diseases of fire fighters and police officers, coal
miners' pneumoconiosis, asbestosis, berylliosis, radiation illness, and
all other occupational diseases of the respiratory tract resulting from
injurious exposures to dust. (7) Death claims, alleging that the death
is the result of an injury occurring prior to September 29, 2017, must be filed
within two years of the death or be forever barred, except as provided in
paragraphs (D)(8) and (D)(9) of this rule. Death claims, alleging that the
death is the result of an injury occurring on or after September 29, 2017, must
be filed within one year of the death or be forever barred. (8) Where the death is the result of an
occupational disease with a date of disease prior to September 28, 2021, the
claim must be filed within two years of the death, as provided in section
4123.85 of the Revised Code. Where the death is the result of an occupational
disease with a date of disease on or after September 28, 2021, the claim must
be filed within one year of the death. (9) Emergency management claims for
injury or death must be filed within one year from the date when injured or
from the date of death, or be forever barred. If an injury claim has been filed
within the one-year period and the claimant subsequently dies, a death claim
must be filed within six months after the death or be forever
barred. (10) Public works relief employees'
claims occurring prior to September 29, 2017, must be filed within two years
after the date when injured or the date of death, or be forever barred. Public
works relief employees' claims occurring on or after September 29, 2017,
must be filed within one year after the date when injured or the date of death,
or be forever barred. (11) Militia claims, special contract
claims, and apprentice claims are governed by the general time limits
applicable to injury and occupational disease claims, as provided by sections
4123.84 and 4123.85 of the Revised Code.
Last updated December 2, 2024 at 8:56 AM
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Rule 4123-3-09 | Procedures in the processing of applications for benefits.
Effective:
December 1, 2024
(A) Numbering and recording. (1) Upon receipt, the
bureau will assign a claim number to each initial application for benefits and
provide the claim number to the claimant and employer. In cases where a
deceased employee has filed, during his or her lifetime, an industrial claim
for the injury or disability which is the subject matter of the death claim,
the application for death benefits will be assigned the original claim
number. (2) The claim number
should be placed on all documents subsequently filed in each claim and the
claim number should be given when inquiry is made concerning each
claim. (B) Initial review and processing of new
claims. Immediately after numbering and recording, all
new claim applications, except applications of employees of self-insuring
employers, will be reviewed and processed by the bureau. "Processing on
the question of compensability" means making a determination on the
validity of the industrial claim. (1) Uncontested or
undisputed claims. A "contested or disputed claim," as
used herein, is where the employer or the bureau of workers' compensation
questions the validity of a claim for compensation or benefits. No claim will
be regarded as a contested or a disputed claim requiring a formal (public)
hearing, solely by reason of incomplete information, unless every effort has
been made to complete the record. (a) If a state fund claim meets the statutory requirements of
compensability, the claims specialist may approve such claim for payment of
medical bills and temporary total disability compensation or other appropriate
compensation. The approval of the claim will contain the description of the
condition or conditions for which the claim is being allowed and part or parts
of the body affected. (b) In the processing of initial applications in state fund
claims requesting payment of compensation in addition to medical benefits, the
claims specialist may approve temporary total disability compensation over a
period not to exceed four weeks, without medical proof in the record, provided
that the application has been properly completed and signed, certified by the
employer, and was otherwise noncontroversial. If medical proof was submitted
with the initial application, the above limitation does not apply. Upon
approval of the claim the claimant will be notified in writing that his or her
attending physician's report will be necessary for consideration of any
additional payment of compensation and an appropriate form will be enclosed,
with the necessary instructions, for the claimant's
convenience. (2) Contested or disputed
claims. (a) Contested or disputed claims as well as claims requiring
investigation will be referred, immediately after the initial review, to the
appropriate office of the bureau from which investigation and determination of
issues may be made most expeditiously. (b) If the bureau or the employer contests the claim application
and the claimant is not available for an adjudication due to the
claimant's service in the armed services of the United States, the bureau
will continue the matter in accordance with the Servicemembers Civil Relief Act
until the claimant is available for adjudication of the claim. (3) Applications for
death benefits. Immediately after numbering and recording, all
applications for death benefits will be referred to the appropriate office of
the bureau from which investigation and determination of issues may be made
most expeditiously. Every effort should be made to complete the investigation
within the shortest time possible, depending on the facts and circumstances of
each particular case, to enable prompt adjudication of such claims by the
bureau. (4) Contested (disputed)
applications for workers' compensation benefits filed by employees of
self-insuring employers will be referred to the industrial commission for a
hearing. (C) Proof. (1) In every instance the
proof shall be of sufficient quantum and probative value to establish the
jurisdiction of the bureau to consider the claim and determine the rights of
the applicant to an award. "Quantum" means measurable quantity.
"Probative" means having a tendency to prove or
establish. (2) Proof may be
presented by affidavit, deposition, oral testimony, written statement,
document, or other forms. (3) The burden of proof
is upon the claimant (applicant for workers' compensation benefits) to
establish each essential element of the claim by preponderance of the evidence.
Essential elements include, but will not be limited to: (a) Establishing that the applicant is one of the persons who
under the act have the right to file a claim for workers' compensation
benefits; (b) That the application was filed within the time period as
required by law; (c) That the alleged injury or occupational disease was sustained
or contracted in the course of and arising out of employment; (d) In death claims, that death was the direct and proximate
result of an injury sustained or occupational disease contracted in the course
of and arising out of employment; the necessary causal relationship between an
injury or occupational disease and death may be established by submission of
sufficient evidence to show that the injury or occupational disease aggravated
or accelerated a pre-existing condition to such an extent that it substantially
hastened death; (e) Any other material issue in the claim, which means a question
that must be established in order to determine claimant's right to
compensation and/or benefits. "Preponderance of the evidence"
means greater weight of evidence, taking into consideration all the evidence
presented. Burden of proof does not necessarily relate to the number of
witnesses or quantity of evidence submitted, but to its quality, such as merit,
credibility, and weight. The obligation of the claimant is to make proof to the
reasonable degree of probability. A mere possibility is conjectural,
speculative, and does not meet the required standard. (4) The bureau or
commission may, at any point in the processing of an application for benefits,
require the employee to submit to a physical examination or may refer a claim
for investigation. (5) Procedure on
employer's request for medical examination of the claimant by a doctor of
employer's choice. The employer may require a medical examination
of the employee as provided in section 4123.651 of the Revised Code under the
following circumstances: (a) Such an examination, if requested, shall be in lieu of any
rights under paragraph (C)(5)(b) of this rule and in no event will the claimant
be examined on the same issue by a physician of the employer's choice more
than one time. The exercise of this examination right shall not be allowed to
delay the timely payment of benefits or scheduled hearings. Requests for
further examinations will be made to the bureau or commission following the
provisions of paragraph (C)(5)(b) of this rule. The cost of any examination
initiated by the employer shall be paid by the employer including any fee
required by the doctor, and the payment of all of the claimant's traveling
and meal expenses, in a manner and at the rates as established by the bureau
from time to time. If employed, the claimant will also be compensated for any
loss of wages arising from the scheduling of an examination. All reasonable expenses shall be paid by the
employer immediately upon receipt of the billing, and the employer shall
provide the claimant with a proper form to be completed by the claimant for
reimbursement of such expenses. The employer shall promptly inform the bureau
or the commission, as well as the claimant's representative, as to the
time and place of the examination, and the questions and information provided
to the doctor. A copy of the examination report shall be submitted to the
bureau or commission and to the claimant's representative upon the
employer's receipt of the report from the doctor. Emergency treatment does not constitute an
examination by the employer for the purposes of this rule. Treatment by a
company doctor as the treating physician constitutes an examination for the
purposes of this rule. The procedure set forth in paragraph (C)(5)(a) of this
rule applies to claims where the date of injury or the date of disability in
occupational disease claims occur on or after August 22, 1986. (b) If, after one medical examination of the claimant under
paragraph (C)(5)(a) of this rule, an employer asserts that a medical
examination of the claimant by a doctor of the employer's choice is
essential in the defense of the claim by the employer, a written request may be
filed with the bureau for that purpose. In such request the employer shall
state the date of the last examination of the claimant by a doctor of
employer's choice on the question pending. If there was no such prior
examination, the request must so indicate. (c) If the claim is pending before the industrial commission or
its hearing officers and the question sought to be clarified by such
examination is not within the jurisdiction of the bureau (for example:
permanent total disability), the request will be referred to the industrial
commission or to the appropriate hearing officer, as the case may be, for
further consideration. (d) If the question sought to be clarified by the requested
examination is within the bureau's jurisdiction (for example: temporary
total disability in otherwise undisputed claim, allowance of additional
condition), the bureau will immediately act upon the request. If, upon a review of the claim file the
bureau is of the opinion that the request should be denied for the reason that
the claimant has been recently examined by a doctor of the employer's
choice, or for any other reason indicating that further examination would not
be pertinent to the defense of the claim, based on the facts and circumstances
of each particular case, the matter will be referred to the appropriate
district hearing officer for further consideration. In cases of temporary total
disability, a medical examination performed within the past thirty days is
considered "recent." If the question involves additional allowance of
claim for an additional condition allegedly causally related to the allowed
injury or occupational disease, a medical examination performed within the past
sixty to ninety days may be regarded as "recent," depending on the
nature and type of the condition and/or disability. (e) All reasonable expenses incurred by the claimant in
submitting to such examination, including any travel expense that the claimant
may properly incur, shall be paid by the employer immediately upon receipt of
the billing. Payment for traveling expenses shall not require an order of the
bureau or commission, unless there is a dispute. The employer shall provide the
claimant with a proper form to be completed by the claimant for reimbursement
for traveling expenses. In addition, if the claimant sustains lost wages as a
result of such examination, the employer shall reimburse the claimant for such
lost wages within three weeks from the date of examination. Expenses incurred
by the claimant and wages lost by reason of attending such examination are not
to be paid in the claim. (f) The employer shall make arrangements for such examination
within fifteen days from the date of receipt of the order of approval. The
examination shall be performed not later than within thirty days from the date
of the receipt of approval. The doctor's report shall be filed with
the bureau immediately upon its receipt. Failure of the employer to comply with
this rule will not delay further action in the claim, unless it is established
that the omission was due to causes beyond the employer's control. (6) Procedure for
obtaining the deposition of an examining physician. Authority to allow
depositions is within the exclusive jurisdiction of the industrial commission.
Any such request, if filed with the bureau, will be referred to the industrial
commission for further consideration. (D) Hearings and orders. (1) Unless required by
law or by the circumstances of the claim, the claim will be adjudicated without
a formal hearing. (2) Disputed or
contested claims will be set for a formal (public) hearing on the question of
allowance before the district hearing officers. A "disputed or contested
claim," as used herein, is where the employer or the claimant questions
the decision of the bureau regarding a request for compensation or benefits. No
claim shall be regarded as a contested or disputed claim requiring a formal
(public) hearing, solely by reason of incomplete information unless every
effort has been made to complete the record. In the event the employer or
claimant object to the decision of the bureau, such objection shall be made in
writing with rationale and supporting evidence, as appropriate. (3) The administrator or his or her
designee may appear at such hearings to represent the interest of the state
insurance fund and/or the surplus fund. (4) The bureau will make payment on
orders of the commission, and district or staff hearing officers in accordance
with law and rules of the bureau and the industrial commission. (5) If the administrator or their
designee is of the opinion that an emergency exists which requires an immediate
hearing of a claim, they may request an emergency hearing, in accordance with
rule 4121-3-30 of the Administrative Code. "Emergency," as used
herein, means a sudden, generally unexpected occurrence or set of circumstances
demanding immediate action. (E) Representation of claimants and
employers before the bureau. Representation of claimants and employers before
the bureau is a matter of individual free choice. The bureau does not require
representation, nor does it prohibit it. No one other than an attorney at law,
authorized to practice in the state of Ohio, shall be permitted to represent
claimants for a fee before the bureau. (F) If the bureau or the parties believe
that clarification of issues will facilitate the processing of the claim, the
claimant, employer, and their duly authorized representatives, as defined in
rule 4123-3-22 of the Administrative Code, will be given an opportunity to
provide additional evidence on questions pertaining to the claim pending before
the bureau. The evidence will be made a part of the claim
file to be considered by the bureau when the determination is made on the issue
pending before the bureau.
Last updated December 2, 2024 at 8:56 AM
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Rule 4123-3-10 | Awards.
Effective:
December 1, 2024
(A) Compensation check issuance, delivery
and endorsement. (1) Definition of
claimant. As used in this rule the word
"claimant" applies to an employee who sustained an injury or
contracted an occupational disease in the course of and arising out of
employment, to the dependent of a deceased employee, as well as to any person
who was awarded compensation under the Ohio Workers' Compensation
Act. (2) Time limit for
issuance. (a) Any order, finding, or decision of the bureau, the industrial
commission, or its hearing officers wherein payment of compensation is to be
made will be promptly forwarded to the appropriate department of the bureau
charged with the duty of making the payment, or in the case of a self-insuring
employer to the personnel of such employer charged with the disbursement of
funds in industrial claims. (b) The initial payment of the bureau in payment of compensation
under an order shall be issued within the time limits set forth in division (H)
of section 4123.511 of the Revised Code. The payment will include compensation
accrued and due the claimant at that time. Further payment of compensation due
under that order shall be made by the bureau in biweekly installments. In
self-insuring employers' claims payment will be made in accordance with
applicable laws and rules. (3) To whom
paid. (a) Awards of compensation shall be made payable only to the
claimant as defined in paragraph (A)(1) of this rule, except in cases of lump
sum advancements, or where the claimant is an incompetent person or is a minor
awarded a lump sum of compensation, or in the case of attorneys fees as
provided in paragraph (A)(7) of this rule. (b) If the claimant is an incompetent person, payment shall be
issued payable and shall be mailed to the claimant's legally appointed
guardian upon the receipt of documentary proof establishing the existence of
such guardianship. (c) If the claimant is a minor and was awarded a lump sum of
compensation, such sum shall be paid to the claimant's legally appointed
guardian or in accordance with section 2111.05 of the Revised
Code. (d) If the bureau or the industrial commission determines it is
in the best interest of the claimant that a guardian of the property be
appointed to receive the benefits payable, payment shall be withheld until such
guardian is appointed. (4) Delivery of the bureau's
payment to claimant and exceptions. The standard method of delivering payment to a
claimant or benefit recipient is by electronic transfer, as provided in
paragraph (D) of this rule. Where the bureau issues a check, the bureau's
checks payable to a claimant shall be mailed to the claimant's address, as
officially recorded in the claim file, except as follows: (a) The mailing of the bureau's compensation check to a
place requested by the claimant in an authorization to receive workers'
compensation payment or equivalent, executed in accordance with paragraph
(A)(5) of this rule, must be approved by the administrator or the
administrator's designee, or by the industrial commission or
designee. (b) Checks for lump sum settlements or lump sum advancements
shall be disbursed in accordance with instructions of the bureau or industrial
commission, as indicated in the order approving such advancements. (c) In cases of advancements made by the employer during a period
of disability, the bureau's checks shall be delivered in accordance with
rule 4123-5-20 of the Administrative Code. (5) Personal pick-up of the bureau's
checks by a claimant or by parties other than a claimant. (a) Provided approval has been given by a member of the
industrial commission or designee, the administrator of the bureau of
workers' compensation or the administrator's designee, or a hearing
officer, a claimant, an attorney for a claimant, or any other person authorized
by a claimant may pick up a compensation check issued by the
bureau. (b) When a claimant authorizes another person to pick up the
claimant's compensation check, the authorization constitutes an
authorization to receive workers' compensation payment or equivalent. On
all types of compensation other than percentage of permanent partial
compensation, the authorization must be filed prior to or at the hearing, or
prior to the date of payment of the award of compensation, whether the award of
compensation was made at a hearing or without a hearing. For authorization to
receive compensation checks in connection with permanent partial disability
applications and applications for increases thereof, the authorization must be
filed with the application, with the agreement of permanent partial disability,
with the election, or with the industrial commission at formal hearing or not
later than prior to the date of mailing of the findings resulting from the
formal hearing. (c) The warrant will be made payable to the claimant and sent in
care of the attorney/representative identified on the authorization to receive
workers' compensation payment or equivalent. The warrant shall be mailed
to the address that the claimant indicated on the request, or at a place
designated by the administrator. (d) A person authorized to pick up the check at the bureau shall
furnish adequate identification and sign a dated receipt verifying acceptance
of the check. (e) In self-insuring employers' claims, the claimant and the
employer may agree on check delivery or pick up, such agreement to be based on
the same principles as outlined in this rule. (6) Endorsement of checks and procedure
in the event of claimant's death. (a) Checks payable to a claimant's guardian must be
endorsed by said guardian in the guardian's official
capacity. (b) When a claimant dies prior to endorsing a compensation check
or accessing an electronic benefit payment, no one has the right to endorse and
cash such check or access the electronic benefit funds. Each check payable to a
claimant shall bear on the reverse side, immediately above the point specified
for endorsement, the standard printed certification explaining the limitations
and penalties for false endorsements, as required by the department of
administrative services for state warrants and checks. Checks that cannot be endorsed because the
claimant is deceased must be returned to the bureau's benefits payable
section, at the address designated by the administrator, by the party handling
the claimant's affairs, notifying the bureau of the date of death, if
known. Upon receipt of information of claimant's death, payment of
compensation shall be terminated and proper entry made in the records of the
bureau. (7) Procedure for a lump sum payment and
attorney fees where the claimant is an obligor for child support
payments. (a) If a claimant is entitled to a lump sum payment of one
hundred and fifty dollars or greater and the claimant is an obligor for child
support payments, prior to issuing the lump sum payment, the bureau shall
notify the claimant and the claimant's attorney in writing that the
claimant is subject to a support order. The bureau shall hold the lump sum
payment for thirty days, pending application by the attorney for attorney fees
as provided in paragraph (A)(7)(b) of this rule. (b) The bureau shall instruct the claimant's attorney in
writing to file a copy of the fee agreement signed by the claimant, along with
an affidavit signed by the attorney setting forth the amount of the
attorney's fee with respect to that lump sum payment award to the claimant
and the amount of all necessary expenses, along with documentation of those
expenses, incurred by the attorney with respect to obtaining that lump sum
award. The attorney shall file the fee agreement and affidavit with the bureau
within thirty days after the date the bureau sends the notice under paragraph
(A)(7)(a) of this rule. (i) The attorney shall
file a copy of the fee agreement that clearly establishes the fee for the lump
sum payment in the claim. The attorney's failure to file a copy of the fee
agreement is a reason for the bureau to reject the application. (ii) The attorney shall
file a notarized affidavit in the form provided by the bureau. The attorney may
complete the affidavit on the form provided by the bureau or in an affidavit
that contains at least all of the elements of the form established by the
bureau. The attorney's failure to file an affidavit in the form proscribed
by the bureau or failure to obtain a notary signature are reasons for the
bureau to reject the application. (iii) The attorney fee is
limited to the fee for obtaining the specific lump sum payment that is the
subject of the bureau notice provided in paragraph (A)(7)(a) of this rule. The
attorney fee is limited to the written fee agreement of the initial lump sum
payment of the award. The bureau will reject a fee application that includes
fees from awards other than the subject lump sum payment or that requests a fee
from future payments of the award after the lump sum payment. (iv) If the attorney
claims reimbursement for expenses in the affidavit, the expenses shall be
limited to the expenses for obtaining the specific lump sum payment that is the
subject of the bureau notice provided in paragraph (A)(7)(a) of this rule. The
attorney shall provide itemized expenses and documentation to support the
expenses. If the attorney fails to provide the required information on
expenses, the bureau may reject that portion of the fee application, but
process the attorney fee portion of the application. (v) Where the bureau has
paid the attorney fee under paragraph (A)(7)(c) of this rule, the bureau will
not honor an authorization to receive workers' compensation payment or
equivalent for that award under paragraph (A)(5) of this rule, except in cases
of court settlement of the workers' compensation claim. (vi) Before rejecting an
attorney fee affidavit or fee agreement due to noncompliance with any part of
this rule, the bureau shall notify the attorney of the noncompliance and
provide the attorney an opportunity to submit additional information during the
thirty day hold period provided in paragraph (A)(7)(a) of this
rule. (c) Upon receipt of the fee agreement and attorney affidavit, the
bureau will review the affidavit as provided in this rule. If the affidavit
complies with this rule, the bureau shall deduct from the lump sum payment the
amount of the attorney's fee and necessary expenses and pay that amount
directly to and solely in the name of the attorney within fourteen days after
the fee agreement and attorney affidavit have been filed with the
bureau. (d) After deducting any attorney's fee and necessary
expenses, if the lump sum payment is one hundred fifty dollars or more, the
bureau shall hold the balance of the lump sum award in accordance with division
(A)(11) of section 3121.037 of the Revised Code. (B) Medical awards. Medical awards shall be paid by the bureau within
the time limits set forth in rule 4123-6-42 of the Administrative Code. (C) Rules for self-insuring
employers. Self-insuring employers shall make payment of
compensation and benefits within the time as required by law and rules of the
bureau. (1) It is the duty of the
employer to pay, in accordance with the act, the amount of compensation due a
claimant whose injury or occupational disease has resulted in more than seven
days lost time. Payment shall be made in the manner provided by law and the
rules of the bureau. (2) It is the duty of the
employer to pay for necessary medical services rendered by health care
providers as a result of an injury or occupational disease for which a claim
was recognized by the employer or allowed by the industrial
commission. (3) It is the duty of the
employer to pay the amount of compensation and benefits due in a compensable
death case, and to make payment to the proper dependents or to such other
persons who may be entitled thereto in accordance with the governing statutes
and the orders and rules of the bureau. In the event death is the result of a
compensable injury or occupational disease, the employer shall also pay the
funeral allowance provided by statute at the time of death. (4) All awards made by
self-insuring employers must be at least equal to the amounts specified in the
applicable statutes, the rules of the bureau and the industrial
commission. (5) Self-insuring
employers shall follow the procedures in paragraph (A)(7) of this rule relating
to a lump sum payment and attorney fees where the claimant is an obligor for
child support payments. (D) Electronic payment of compensation
and benefits. (1) For any compensation paid directly to
a claimant, the bureau shall either direct deposit funds by electronic transfer
into a savings or checking account designated by the payee, or issue to the
payee an electronic benefits card. (a) The bureau will provide to the claimant notice of the types
of compensation or payments paid directly to a benefit recipient that are
included in the electronic benefits program. (b) The bureau will provide to the claimant notice of the types
of compensation or payments not paid directly to a benefit recipient that are
not included in the electronic benefits program. Payments made under an
authorization to receive workers' compensation checks are excluded from
the electronic benefits program. (2) The bureau shall notify a benefit
recipient of the requirement for electronic payment of benefits and
compensation and ask the benefit recipient to designate a financial institution
and account to which the bureau shall deposit the benefit recipient's
compensation or benefits. If the benefit recipient does not have an account or
does not respond, the bureau shall issue the payment by a bureau debit card.
(3) The bureau shall contract with a
vendor for the debit cards to allow benefit recipients to receive payment
without a monthly maintenance fee and issue the debit card only to the benefit
recipient. (4) The bureau shall provide to a benefit
recipient who lives in a foreign country an electronic benefit
card. (5) The bureau shall provide notice of
electronic payment delivery on the payment remittance of each paper warrant
issued to eligible benefit recipients. The notice shall include the two
different payment options and provide the benefit recipient the opportunity to
select between the two electronic payment options. (6) A benefit recipient may request a
waiver of the electronic payment delivery of compensation or benefits under
this rule for special circumstances due to hardship in establishing a personal
checking or savings account or in accepting the bureau debit card. The request
for a waiver will be referred to the bureau benefits payable department and may
be reviewed by the administrator's designee.
Last updated December 2, 2024 at 8:56 AM
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Rule 4123-3-11 | Reports of payments by self-insuring employers.
Effective:
December 1, 2024
(A) During the continuance of temporary
total disability, temporary partial disability, or wage loss compensation
caused by an injury or occupational disease, the employer shall, at the request
of the bureau of workers' compensation or the industrial commission at any
time or at the request of the claimant or claimant's representative where
the issue of compensation is pending in a workers' compensation hearing or
adjudication matter, file a report of compensation payments with the bureau
showing the amount and type of compensation paid to such employee during the
preceding period. The report shall indicate the date when the first installment
of the type of compensation reported was paid. (B) In the event an injury or
occupational disease results in a disability compensable under division (A) or
(B) of section 4123.57 of the Revised Code, and an agreement has been entered
into between the employee and the employer as to the compensation to be paid
for such permanent partial disability, the agreement shall state when the first
installment of such compensation is to be paid. Such agreement shall be signed
by the employee and employer and filed with the bureau as soon as it has been
completed. Such agreement shall be accompanied by a report from the attending
physician which indicates the extent of the permanent partial disability
sustained. (C) In cases of compensable death claims,
where the employer and the dependents or legal representatives of a deceased
employee agree that the death is compensable, and there being no question of
apportionment of death benefits, they enter into an agreement in writing as to
the benefits which are to be paid; such agreement shall be reported by the
employer. It shall indicate the date of the first installment of payment, the
weekly rate of death benefits, the period of time over which such benefits will
be paid (lifetime or specific dates) and the total amount of benefits in cases
where it is known. Such agreement shall be signed by the employer and the
dependent, dependents, or legal representatives and be filed with the bureau
within one month of the date of execution of the agreement. Such agreement
shall include provision for the payment of appropriate funeral, medical,
hospital, and other expenses. Subsequent reports of the payment of death
benefits shall be filed with the bureau at the request of the bureau or the
commission at any time or at the request of the claimant or claimant's
representative where the issue of compensation is pending in a workers'
compensation hearing or adjudication matter. Should there be a change in death
benefits as a result of changes in the dependency status of the recipients,
employer's reports shall reflect same. In cases of compensable death claims, where the
employer and the dependents or legal representatives of a deceased employee
agree that the death is compensable but where there is a question of
apportionment, the self-insuring employer may choose to pay death benefits
before a hearing at the industrial commission. The first such payment should
indicate to the beneficiaries that because there is a question of apportionment
among the surviving spouse, dependent children, or other dependents, the
commission must issue an order apportioning the payment; therefore, payments
until such order issues are subject to an adjustment in accordance with the
apportionment ordered by the commission among the beneficiaries at such time as
the apportionment order issues. In other death claims approved for payment by the
industrial commission or its hearing officers, the employer shall report
payments in the same general manner as indicated above. (D) In all claims, the self-insuring
employer shall, upon completion of the payment of compensation and benefits,
report that fact to the bureau at the request of the bureau or the commission
at any time or at the request of the claimant or claimant's representative
where the issue of compensation is pending in a workers' compensation
hearing or adjudication matter indicating the dates of the payment of the first
and last installments of compensation, and the total amount of each type paid,
together with the total amounts expended for benefits other than compensation
according to type of benefit. (1) Such report shall be
signed by the employer and the employee or his or her dependents or their legal
representatives as the circumstances may require. (2) Upon receipt of such
report by the bureau, it shall be examined to determine whether or not the
payments made have been in conformity with the provisions of the workers'
compensation law. If it is found that the reported payments do conform to the
provisions of the workers' compensation law, the same shall be approved by
the bureau and the employer advised thereof. If it is found that the reported
payments do not conform, the bureau shall notify the employer of that fact
indicating the further payments that are to be made. The employer shall make
such payments and file a revised report with the bureau. (3) If, for any reason,
it is impossible for the employer to promptly file a report of payments or an
agreement as to compensation paid or to be paid, the employer shall immediately
report that fact and the reason to the bureau. Failure to do so constitutes
sufficient reason for the administrator to take such action as may be
indicated. (E) Where compensation has been ordered
paid or where the employee and employer have agreed upon the compensation to be
paid, request to the bureau may be made by either the employer, the employee,
or the employee's dependents for authorization to pay all or part of the
unpaid balance of the award in one or more lump sum payments. (F) Whenever a self-insured employer that
is a professional sports franchise domiciled in Ohio makes payment pursuant to
the terms of a contract of hire or a collective bargaining agreement during a
period of disability resulting from the injury or occupational disease, the
self-insurer shall report such payments on the same basis as required in
paragraph (A) of this rule. The total amount of such payments, the period of
disability for which those payments were made, and the amount such payments
exceed the compensation that was due for that period shall be reported. The
amount such payments exceed the compensation payable or, in the event no
compensation was payable, the total amounts of such payments, is deemed an
advanced payment of compensation and shall be applied to offset future payments
of compensation for disability under sections 4123.56 to 4123.58 of the Revised
Code. The self-insurer shall report these offsets on the same basis as required
in paragraph (A) of this rule. Such offsets apply only in cases where the
employee's application for compensation is pending on or after August 22,
1986.
Last updated December 2, 2024 at 8:57 AM
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Rule 4123-3-14 | Procedure in the original adjudication of non-complying employers' claims.
Effective:
December 1, 2024
Where the bureau originally adjudicates a claim and
determines that the employer is a non-complying employer, the bureau shall note
the employer's non-complying employer status in the claim and the bureau
order. The bureau shall notify the employer of the filing of the application
and the employer's noncompliance, and proceed to secure the
employer's obligation to reimburse the bureau for any cost of the claim as
provided in rule 4123-14-04 of the Administrative Code.
Last updated December 2, 2024 at 8:57 AM
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Rule 4123-3-15 | Claim procedures subsequent to allowance.
Effective:
December 1, 2024
(A) Requests for subsequent actions when a state fund claim has
not had activity or a request for further action within a period of time in
excess of twenty-four months. (1) The bureau shall
consider a request for subsequent action in a claim in the following
situations: (a) Where the employee requests that the bureau or commission
modify or alter an award of compensation or benefits that has been previously
granted; or (b) Where the employee requests that the bureau or commission
grant a new award of compensation or to settle the claim; or (c) Where the claimant requests the allowance of a disability or
condition not previously considered; or (d) Where the claimant dies and there is potential entitlement
for accrued benefits or payment of medical bills, or the decedent's
dependent is requesting death benefits due to relatedness between the
recognized injury and death. (e) Except for a medical issue relating to a prosthetic device
or durable medical equipment as designated by the administrator, the bureau, in
consultation with the MCO assigned to the claim, shall issue an order on a
medical treatment reimbursement request in a claim which has not had activity
or a request for further action within a period of time in excess of
twenty-four months as follows: (i) The MCO shall refer a
medical treatment reimbursement request in a claim which has not had activity
or a request for further action within a period of time in excess of
twenty-four months to the bureau for an order when the request is accompanied
by supporting medical evidence dated not more than sixty days prior to the date
of the request, or when such evidence is subsequently provided to the MCO upon
request (via "Form C-9A" or equivalent). The bureau's order
shall address both the causal relationship between the original injury and the
current incident precipitating the medical treatment reimbursement request in a
claim and the necessity and appropriateness of the requested treatment. The
employer or the employee or the representative may appeal the bureau's
order to the industrial commission pursuant to section 4123.511 of the Revised
Code. (ii) The MCO may dismiss
without prejudice, and without referral to the bureau for an order, a medical
treatment reimbursement request in a claim which has not had activity or a
request for further action within a period of time in excess of twenty-four
months when the request is not accompanied by supporting medical evidence dated
not more than sixty days prior to the date of the request and such evidence is
not provided to the MCO upon request (via "Form C-9A" or
equivalent). (2) Proof shall conform
to the standards set forth in paragraph (C) of rule 4123-3-09 of the
Administrative Code and rules 4123-5-18 and 4123-6-20 of the Administrative
Code. Medical evidence is required to substantiate: (a) A request for temporary total disability. (b) The allowance of a disability or condition not previously
considered. (3) In state fund cases,
upon a request for subsequent action under paragraph (A)(1) of this rule, the
bureau , upon notification, will inform the parties to the claim of the pending
action prior to issuing a decision. Upon request, the bureau will provide a
copy of the request and proof to the employer and the claimant, and their
representatives, where applicable. Requests in self-insuring employers'
cases shall be submitted to the self-insuring employer, which shall accept or
refuse the matters sought. (4) The bureau or commission may require
the filing of additional proof or legal citations by either party or may make
such investigation or inquiry as appropriate under the
circumstances. (5) A state fund employer shall, upon
receipt of notification of the request, notify the bureau of any objection to
the granting of the relief requested. Such notification must be filed within
the time set forth in the rules of the bureau and industrial
commission. (6) If the request is within the
jurisdiction of the bureau and the matter is not contested or disputed, the
bureau will adjudicate the request in the usual manner. In all other cases, the
request shall be acted upon by the industrial commission's hearing officer
or as otherwise in accordance with the rules of the commission, depending on
the subject matter. (7) Failure by the employee to furnish
information as specifically requested by the bureau or commission is sufficient
reason for the dismissal of the request. If the employer fails to furnish any
information requested by the bureau or commission, the request may be
adjudicated upon the proof filed. (B) "Application for Determination of Percentage of
Permanent Partial Disability or Increase of Permanent Partial Disability"
pursuant to division (A) of section 4123.57 of the Revised Code in state fund
and self-insured claims. (1) An "Application
for Determination of Percentage of Permanent Partial Disability or Increase of
Permanent Partial Disability" shall be completed and signed by the
applicant or applicant's representative and be filed with the bureau of
workers' compensation. An application for an increase in permanent partial
disability must be accompanied by substantial evidence of new and changed
circumstances which have developed since the time of the hearing on the
original or last determination. The bureau shall dismiss an unsigned
application. Except where an additional condition has been allowed in the claim
and the request is for an increase in permanent partial disability based solely
on that additional condition, the bureau shall dismiss a request for an
increase in permanent partial disability filed without medical documentation.
Whenever the applicant or applicant's representative leaves a question or
questions in the application form unanswered, the bureau shall contact the
applicant and applicant's representative to obtain the information
necessary to process the application. Should the applicant or applicant's
representative inform the bureau that the failure to provide the information
necessary to process the application is beyond the applicant's control,
the bureau shall take appropriate action to obtain such
information. (2) Upon the filing of
the application for either of these requests, the application shall be referred
to the bureau for review and processing. The bureau shall send notice of the
application to the employer and the employer's representative, unless the
employer is out of business. The employer shall submit any proof within its
possession bearing upon the issue to the bureau within thirty days of the
receipt of the claimant's application. (3) The bureau shall
contact each applicant for a determination of the percentage of permanent
partial disability to schedule an examination by a physician designated by the
bureau. If the applicant fails to respond to the bureau's attempt to
schedule the examination or fails to appear for the examination, the bureau may
dismiss the application as provided in rule 4123-3-15.1 of the Administrative
Code. The examining physician shall file a report of such examination, together
with an evaluation of the degree of impairment as a part of the claim file. The
bureau shall send a copy of the report of the medical examination to the
employee, the employer, and their representatives. (4) Upon receipt of the
examining physician's report, the bureau shall review the medical evidence
in the employee's claim file and make a tentative order as the evidence at
the time of the making of the order warrants. If the bureau determines there is
a conflict of evidence, the bureau shall forward the application, along with
the claimant's file, to the industrial commission to set the application
for hearing before a district hearing officer. (5) Where there is no
conflict of evidence, the bureau shall enter a tentative order on the request
for percentage of permanent partial disability and notify the employee, the
employer, and their representatives, in writing, of the tentative order and of
the parties' right to request a hearing. Unless the employee, the
employer, or their representative notifies the bureau, in writing, of an
objection to the tentative order within twenty days after receipt of the notice
thereof, the tentative order shall go into effect and the employee shall
receive the compensation provided in the order. In no event shall there be a
reconsideration of a tentative order issued under this division. (6) If the employee, the
employer, or their representatives timely notify the bureau of an objection to
the tentative order, the bureau shall refer the matter to a district hearing
officer who shall set the application for hearing. Upon referral to a district
hearing officer, the employer may obtain a medical examination of the employee,
pursuant to the rules of the industrial commission. (7) Where the application
is for an increase in the percentage of permanent partial disability, no sooner
than sixty days from the date of mailing of the application to the employer and
the employer's representative, the applicant shall either be examined, or
the claim referred for review by a physician designated by the bureau. Such
period may be extended or the processing of the application suspended by the
bureau for good cause shown. If the bureau has determined the employer is out
of business the bureau will not mail the application and may process the
application without waiting the sixty day period. The bureau physician shall
file a report of such examination or review of the record, together with an
evaluation of the degree of impairment, as part of the claim file. Either the
employee or the employer may submit additional medical evidence following the
examination by the bureau medical section as long as copies of the evidence are
submitted to all parties. (8) After completion of
the review or examination by a physician designated by the bureau, the bureau
may issue a tentative order based upon the evidence in file. If the bureau
determines that there is a conflict in the medical evidence, the bureau shall
adopt the recommendation of the medical report of the bureau medical
examination or medical review. (9) The bureau shall
enter a tentative order on the request for an increase of permanent partial
disability and notify the employee, the employer, and their representatives, in
writing, of the nature and amount of any tentative order issued on the
application requesting an increase in the percentage of the employee's
permanent disability. The employee, the employer, or their representatives may
object to the tentative order within twenty days after the receipt of the
notice thereof. If no timely objection is made, the tentative order shall go
into effect. In no event shall there be a reconsideration of a tentative order
issued under this division. If an objection is timely made, the bureau shall
refer the matter to a district hearing officer who shall set the application
for a hearing in accordance with the rules of the industrial commission. The
employer may obtain a medical examination of the employee and submit a defense
medical report at any stage of the proceedings up to a hearing before a
district officer. (10) Where an award under
division (A) of section 4123.57 of the Revised Code has been made prior to the
death of an employee, the bureau shall pay all unpaid installments accrued or
to accrue to the surviving spouse, or if there is no surviving spouse, to the
dependent children of the employee, and if there are no such children
surviving, then to such other dependents as the bureau may
determine. (C) Payment of permanent partial
disability pursuant to division (B) of section 4123.57 of the Revised Code
(scheduled loss) in state fund and self-insured employer claims. (1) The bureau or
self-insuring employer will determine the payment of scheduled loss for a loss
by amputation or for a loss of use upon the motion of a party for such award.
To determine the payment of the award, the bureau or self-insuring employer may
review the medical evidence in the file, may request additional medical
information from the parties, or may refer the claimant for an examination by a
physician designated by the bureau or self-insuring employer. (2) The bureau shall
enter an order on or the self-insuring employer shall make a decision on the
payment of scheduled loss and shall notify the employee, the employer, and
their representatives, in writing, of the order or decision. The parties have a
right to appeal the order or contest the decision pursuant to section 4123.511
of the Revised Code. (3) Upon an order for the
payment of scheduled loss for a loss, the bureau or self-insuring employer
shall calculate such award pursuant to the statutory schedule of division (B)
of section 4123.57 of the Revised Code. The bureau or self-insuring employer
shall pay the award to the claimant in weekly payments as provided in division
(B) of section 4123.57 of the Revised Code. (4) Where a scheduled
loss has been ordered but not paid prior to the death of an employee, upon
application, the award is payable to the surviving spouse, or if there is no
surviving spouse, to the dependent children of the employee, and if there are
no such children surviving, then to such other dependents as the bureau may
determine.
Last updated December 2, 2024 at 8:57 AM
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Rule 4123-3-15.1 | Dismissal of an application for the determination of percentage of permanent partial disability.
Effective:
December 1, 2024
(A) This paragraph of this rule applies
to any employee's application for a determination of the percentage of
permanent partial disability or for an increase of permanent partial disability
filed on or after September 29, 2017. (1) If an employee who
files an application for a determination of percentage of permanent partial
disability or for an increase of permanent partial disability fails to respond
to the bureau's attempt to schedule a medical examination, or fails to
attend a medical examination scheduled under section 4123.57 of the Revised
Code without notice or explanation, the bureau shall dismiss the application
without prejudice. The employee, the employer, or their representative may
object to the bureau's tentative order dismissing the application within
twenty days after receipt of the notice as provided in section 4123.57 of the
Revised Code, and if the employee, the employer, or their representative timely
notify the bureau of an objection, the bureau shall refer the matter to a
district hearing officer for a hearing. (a) The bureau shall contact the employee to schedule the
employee for an examination on an application for a determination of percentage
of permanent partial disability or for an increase of permanent partial
disability. The bureau may use a variety of communication methods to contact
the employee, such as by telephone, mail, or other methods, but the bureau
shall not limit the contact to one method or one attempt if the bureau is not
able to contact the employee on the first attempt. If the bureau is unable to
contact the employee and the employee is represented, the bureau shall contact
the employee's representative for assistance in scheduling the
examination. The bureau shall document its contacts in the claim file. If the
bureau attempts to contact the employee by mail and the mail is returned
undeliverable, the bureau shall attempt to find a correct address for the
employee and shall document the attempt in the claim file. If the employee
fails to respond to the bureau's attempts to contact the employee to
schedule the examination, the bureau shall dismiss the
application. (b) If the bureau schedules the employee for an examination on
the employee's application for a determination of the percentage of
permanent partial disability or for an increase of permanent partial disability
and the employee fails to attend the examination, the bureau shall contact the
employee for an explanation why the employee did not attend the examination. If
the employee is represented, the bureau shall contact the employee's
representative. If the employee provides an explanation for missing the
examination, the bureau shall reschedule the employee for an examination. If
the employee fails to respond or fails to provide an explanation, the bureau
shall dismiss the application. (2) If the bureau
dismisses an employee's application for a determination of percentage of
permanent partial disability or for an increase of permanent partial disability
under this rule, the employee may refile an application as provided in
paragraph (B) of rule 4123-3-15 of the Administrative Code subject to the
continuing jurisdiction limitations of section 4123.52 of the Revised Code. A
dismissed application does not toll the continuing jurisdiction of the bureau
or the industrial commission under section 4123.52 of the Revised
Code. (B) This paragraph of this rule applies
to an employee's application for a determination of the percentage of the
employee's permanent partial disability or for an increase of permanent
partial disability filed under section 4123.57 of the Revised Code that has
been suspended pursuant to division (C) of section 4123.53 of the Revised Code
as of September 29, 2017. (1) For an
employee's application for a determination of the percentage of the
employee's permanent partial disability or for an increase of permanent
partial disability filed under section 4123.57 of the Revised Code that has
been suspended pursuant to division (C) of section 4123.53 of the Revised Code
as of September 29, 2017, the bureau shall send a notice to the employee's
last known address informing the employee that the bureau may dismiss the
application unless the employee schedules a medical examination with the bureau
within thirty days after receiving the notice. (a) If the employee does not schedule a medical examination with
the bureau within thirty days after receiving the notice provided in paragraph
(B)(1) of this rule, the bureau may dismiss the application. The employee, the
employer, or their representative may object to the bureau's tentative
order dismissing the application within twenty days after receipt of the notice
as provided in section 4123.57 of the Revised Code, and if the employee, the
employer, or their representative timely notify the bureau of an objection, the
bureau shall refer the matter to a district hearing officer for a
hearing. (b) For an employee whose application has been suspended who
schedules an examination but fails to appear for the examination, the bureau
shall follow the same procedure as provided in paragraph (A)(1)(b) of this
rule. (2) If the bureau
dismisses an employee's application for a determination of percentage of
permanent partial disability or for an increase of permanent partial disability
under this rule, the employee may refile the application as provided in
paragraph (B) of rule 4123-3-15 of the Administrative Code, subject to the
continuing jurisdiction limitations of section 4123.52 of the Revised Code. A
dismissed application does not toll the continuing jurisdiction of the bureau
or the industrial commission under section 4123.52 of the Revised
Code.
Last updated December 2, 2024 at 8:57 AM
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Rule 4123-3-16 | Motions.
Effective:
December 1, 2024
(A) Form C-86 motion or its equivalent
shall be used to request action from the bureau or commission. (B) A motion may be submitted by the
employee or the employer to seek a determination by the bureau or the
commission on any matter not otherwise provided for in this chapter. It is
appropriate to file a motion in order to secure allowance of a disability or
condition not previously considered in a claim. A motion shall not be used as a
substitute for an untimely appeal. (C) A motion shall fully set forth the
question presented together with a succinct statement of the action or relief
sought. (D) A motion shall be accompanied by
competent proof conforming to the standards established in paragraph (C) of
rule 4123-3-09 of the Administrative Code. (E) Except in matters not affecting the
rights of the opposite party, the applicant filing a motion shall provide a
copy of the motion to the opposite party and the copy of the motion filed with
the bureau or the commission shall indicate that a copy has been so provided.
When in doubt, the applicant shall provide a copy of the motion to the opposite
party. (F) A motion shall bear the signature of the applicant or the
applicant's authorized representative. (G) Failure to comply with the provisions of this rule is
sufficient reason for the dismissal of the motion. (H) Motions will be adjudicated in the same manner as provided in
paragraph (A)(7) of rule 4123-3-15 of the Administrative Code, except motions
for allowance of a psychiatric disability (paragraph (I) of this
rule). (I) Procedure governing motions for allowance of a psychiatric
disability: (1) A motion requesting
that a claim be additionally recognized for a psychiatric or psychological
condition shall include a statement, personally signed and dated by the
claimant, acknowledging the claimant is aware the motion is being filed to
request that the bureau or commission recognize a psychiatric or psychological
condition as being a result of the injury for which the claim is
allowed. (2) A motion requesting
the recognition of an additional condition of a psychiatric or psychological
nature shall be accompanied by supporting evidence consisting of a report by a
doctor of medicine (MD), doctor of osteopathic medicine (DO), a clinical
psychologist, a licensed professional clinical counselor (LPCC), or a licensed
independent social worker (LISW). (3) The bureau may have
the claimant scheduled for an examination by an independent
specialist. (4) If the claimant fails
to comply with the bureau's request relating to the motion as provided in
paragraphs (I)(1) to (I)(3) of this rule, the bureau will refer the motion to
the commission with a recommendation to dismiss the motion. (5) If there is no
conflict in the evidence or the motion is not contested or disputed, the bureau
will adjudicate the motion. If there is a conflict in the evidence or the
motion is contested or disputed, the bureau will refer the motion to the
commission for further consideration.
Last updated December 2, 2024 at 8:58 AM
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Rule 4123-3-17 | Briefs.
Effective:
February 10, 2009
(A) Parties may, of their own volition, file briefs with the bureau or commission on legal questions presented in claims. (B) The bureau or commission may require parties to file briefs on legal questions presented in claims. A time certain shall be fixed for the filing of such briefs allowing a reasonable time for preparation. (C) In either instance, the submitted briefs shall be legibly typewritten on paper not exceeding eight and one-half inches by eleven inches in size and filed without a protective cover. The party filing a brief shall furnish a copy to the opposite party at the time that the brief is filed with the bureau or the commission. If the brief is directed to a matter before the bureau, the brief shall be filed with the bureau. If the brief is directed to the attention of the commission, the brief shall be filed with the commission unless otherwise directed by the commission.
Last updated October 7, 2024 at 12:02 PM
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Rule 4123-3-18 | Appellate procedure.
Effective:
December 1, 2024
(A) Administrative appeals. (1) The right of an
administrative appeal is limited to the claimant, the dependents of a deceased
worker, the employer, and the administrator, where the administrator or the
administrator's representative appeals on behalf of the state insurance
fund or the surplus fund. (2) The named eligible
appellants may appeal decisions of district hearing officers or staff hearing
officers, in accordance with rule 4121-3-18 of the Administrative
Code. (3) Decisions of district
hearing officers are appealable to staff hearing officers. Decisions of the
staff hearing officers are appealable to the industrial
commission. (4) Appeal applications shall be signed
by the party appealing or by an authorized representative on behalf of such
party. The same applies to the administrator when filing an
appeal. (5) Such applications may be filed with
any office of the bureau or of the industrial commission. (6) The same time limits apply to appeals
filed from the decision of the staff hearing officers to the industrial
commission. (7) Appellate review and determination of
claims being within the exclusive jurisdiction of the industrial commission,
the conduct of hearings and other incidental matters are governed by the rules
of the industrial commission. (8) The bureau's legal division
shall act as attorney in appeals filed by the bureau on behalf of the state
insurance fund; it may also act as a representative of the administrator in
appeals filed by the bureau on behalf of the surplus fund. As a party to the
proceedings, the bureau's legal divisionis entitled to proper notice of
any action taken by the appellate body on appeals filed by the
bureau. (9) The bureau will make payment of an
award of compensation in a claim at the earliest time provided in division (H)
of section 4123.511 of the Revised Code, except that, in all cases of a
determination made under division (A) of section 4123.57 of the Revised Code
for percentage permanent partial disability compensation, payment will not be
made to the claimant until a final decision on reconsideration allows such
compensation. (10) In all other cases, if the decision
of the district hearing officer is appealed by the employer or the
administrator, the bureau will withhold medical benefits during the course of
appeal to the staff hearing officer, but where the staff hearing officer rules
in favor of the claimant, the bureau will pay medical benefits immediately upon
the receipt of the order, regardless of whether or not further appeal is taken.
In self-insuring employers' claims, payment shall be made in accordance
with applicable laws and rules. (11) Payments of an award of compensation
and/or benefits made by the bureau pursuant to a decision of a staff hearing
officer will commence immediately upon the bureau's receipt of the
order. (B) Appeals to court. (1) The claimant or the
employer may appeal an order of the industrial commission made under division
(E) of section 4123.511 of the Revised Code in any injury or occupational
disease case, other than a decision as to the extent of disability, to the
court of common pleas of the county in which the injury was inflicted or in
which the contract of employment was made if the injury occurred outside the
state, or in which the contract of employment was made if the exposure occurred
outside the state. If no common pleas court has jurisdiction for the purposes
of an appeal by the use of the jurisdictional requirements described in this
division, the appellant may use the venue provisions in the Rules of Civil
Procedure to vest jurisdiction in a court. If the claim is for an occupational
disease, the appeal shall be to the court of common pleas of the county in
which the exposure which caused the disease occurred. Like appeal may be taken
from an order of a staff hearing officer made under division (D) of section
4123.511 of the Revised Code from which the commission has refused to hear an
appeal. Except as otherwise provided in paragraph (B)(2) of this rule, the
appellant shall file the notice of appeal with a court of common pleas within
sixty days after the date of the receipt of the order appealed from or the date
of receipt of the order of the commission refusing to hear an appeal of a staff
hearing officer's decision under division (D) of section 4123.511 of the
Revised Code. The filing of the notice of the appeal with the court is the only
act required to perfect the appeal. (2) Either the claimant
or the employer may file a notice of intent to settle the claim within thirty
days after the date of the receipt of the order appealed from or of the order
of the commission refusing to hear an appeal of a staff hearing officer's
decision. The claimant or employer shall file notice of intent to settle on the
appropriate form with the administrator of workers' compensation, and the
notice shall be served on the opposing party and the party's
representative. The filing of the notice of intent to settle extends the time
to file an appeal to one hundred fifty days, unless the opposing party files an
objection on the appropriate form within fourteen days after the date of the
receipt of the notice of intent to settle. The party shall file the objection
with the administrator, and the objection shall be served on the party that
filed the notice of intent to settle and the party's
representative. (3) "Notice of
Appeal" stating the names of the administrator of workers'
compensation, the claimant, and the employer, the number of the claim, the date
of the order appealed from, and the fact that the appellant appeals from such
order must be filed with the industrial commission and with the court of common
pleas within the timeframes provided in paragraphs (B)(1) and (B)(2) of this
rule. (4) Such appeal or any
other action filed from a decision of the industrial commission in a claim in
which an award of compensation has been made shall not stay the payment of
compensation under such award or payment of compensation for subsequent periods
of total disability during the pendency of the appeal.
Last updated December 2, 2024 at 8:58 AM
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Rule 4123-3-20 | Additional awards by reason of violations of specific safety requirements.
Effective:
December 1, 2024
The determination of awards by reason of violation
of specific safety requirements being within the exclusive jurisdiction of the
industrial commission, the bureau will refer any such applications filed with
the bureau to the industrial commission for further consideration.
Last updated December 2, 2024 at 8:58 AM
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Rule 4123-3-22 | Inspection of claim files.
(A) Authorizations for representation
shall be in writing and signed by the authorizing party. When the authorization
is on behalf of the employee, it shall be filed on an "Claimant Authorized
Representative" form or equivalent. There shall be a separate
authorization filed with the bureau for each claim to which the authorization
is to extend. When the authorization is on behalf of the employer, a blanket
authorization may be filed with the bureau. (B) An authorization may be cancelled by the filing of a notice
to that effect with the bureau or by filing a new authorization by another
representative. In either event, the party should notify the former
representative of the party's action. (C) The inspection of claim files shall be limited
to: (1) The parties and/or
their duly authorized representatives as outlined in paragraphs (A) and (B) of
this rule; (2) Any other person
authorized, in writing, by either the employee or the employer; such
authorization having been executed within one year prior to its
use; (3) Members of the
general assembly when in the course of their duties as such; (4) The governor, a
select committee of the general assembly, a standing committee of the general
assembly, the auditor of state, the attorney general, or the designee of any,
in the pursuance of any duty imposed by Chapters 4121. and 4123. of the Revised
Code. (5) Duly authorized
employees of governmental agencies whose official duties require the
information contained in the claim files; (6) Such other persons as
are specifically authorized by a member of the commission or the administrator
pursuant to the provisions of section 4123.88 of the Revised Code.
Last updated October 7, 2024 at 12:02 PM
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Rule 4123-3-23 | Limitations on the filing of fee bills.
Effective:
December 1, 2024
(A) Except as otherwise provided in this
rule, fee bills for medical or vocational rehabilitation services rendered in a
claim shall be submitted to the bureau or commission for payment within one
year of the date on which the service was rendered or one year after the date
the services became payable under division (I) of section 4123.511 of the
Revised Code, whichever is later, or shall be forever barred. (B) A self-insuring employer may, but is
not required to, negotiate with a provider to accept fee bills from the
provider for a time period other than as set forth in paragraph (A) of this
rule. (C) Paragraph (A) of this rule does not
apply to the following: (1) Requests made by the
centers for medicare and medicaid services in the United States department of
health and human services for reimbursement of conditional payments made
pursuant to section 1395y(b)(2) of title 42, United States Code (commonly known
as the "Medicare Secondary Payer Act"); (2) Requests made by the
Ohio department of medicaid, or by a medical assistance provider to whom the
department has assigned its right of recovery for a claim for which it has
notified the provider that it intends to recoup its prior payment for a claim,
for reimbursement under sections 5160.35 to 5160.43 of the Revised Code for the
cost of medical assistance paid on behalf of a medicaid recipient; (3) Requests made by the
department of veterans affairs (VA) pursuant to section 1729 of title 38,
United States Code for reimbursement of medical treatment provided to an
injured worker in or through any VA provider or facility; (4) Fee bills submitted outside the
timeframe set forth in paragraph (A) of this rule due to MCO or bureau error;
however, division (A) of section 4123.52 of the Revised Code still
applies; (5) Fee bills submitted outside the
timeframe set forth in paragraph (A) of this rule because the fee bills were
initially submitted to a patient, different third-party payer, or state or
federal program other than medicare, medicaid, or the VA that reimburses for
medical or vocational rehabilitation services and that patient, payer, or
program has determined it is not responsible for the cost of the services;
however, division (A) of section 4123.52 of the Revised Code still
applies. (D) Except in cases involving MCO or
bureau error, requests for additional payment on fee bills that were initially
timely submitted under this rule shall be submitted within one year and seven
days of the adjudication of the initial fee bill by the bureau or shall be
forever barred. In cases involving MCO or bureau error, requests for additional
payment on fee bills shall be submitted within one year and seven days from the
date the provider knew or should have known of an MCO or bureau error impacting
payment or shall be forever barred. No medical or vocational rehabilitation
provider shall bill a claimant for any request for additional payment that is
barred under this paragraph. (E) Paragraphs (A) to (C) of this rule
apply to bills with dates of service on or after July 29, 2011. Paragraph (D)
of this rule applies to bills with dates of service on or after September 12,
2011.
Last updated December 2, 2024 at 8:58 AM
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Rule 4123-3-24 | Fee controversies.
Effective:
December 1, 2024
When a controversy exists between a party and the
party's representative concerning fees for services rendered in industrial
claims, either the party or the representative may make a written request to
the industrial commission to resolve the dispute, the matter being within the
exclusive jurisdiction of the industrial commission. The bureau will refer any
such request filed with the bureau to the industrial commission for further
consideration.
Last updated December 2, 2024 at 8:58 AM
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Rule 4123-3-25 | Application for change of occupation allowance.
Effective:
December 1, 2024
(A) Eligibility for a change of
occupation allowance. (1) Where it is found
that a change of occupation is medically advisable for an employee suffering
from silicosis, coal miners' pneumoconiosis, or asbestosis contracted in
the course of employment, but the employee is not totally disabled therefrom,
and any other diseases which may be specified by law for which the statutory
allowance for change of occupation may be granted, or (2) Where it is found
that a change of occupation is medically advisable for a fire fighter or police
officer suffering from a cardiovascular and pulmonary disease contracted in the
course of employment, but the employee is not totally disabled
therefrom, (3) Pursuant to the
provisions of section 4123.57 of the Revised Code, such employee may file a
motion in accordance with paragraph (A) of rule 4123-3-16 of the Administrative
Code requesting the approval of the statutory allowance for such change of
occupation, in order to decrease substantially further injurious
exposure. (B) This rule is applicable to public
employees, employees of employers contributing to the private fund, employees
of self-insuring employers, and employees of amenable but non-complying
employers. (C) If there is no conflict in the
medical or the matter is not contested or disputed, the bureau will adjudicate
the request. If a conflict in the medical exists or the request is contested or
disputed, the bureau will refer the request to the commission for further
consideration. (D) To qualify for an award, the employee
must establish by appropriate evidence that the employee has discontinued
employment or has changed his or her occupation to one in which the exposure is
substantially decreased. The fact that the employee continues employment with
the same employer will not preclude the granting of the award so long as the
employment subsequent to the change is such that the exposure is substantially
decreased and the change of occupation is certified by the claimant as
permanent. (E) An award for change of occupation in
excess of the initial thirty weeks must be supported by evidence of employment
in an occupation in which the exposure is substantially decreased or evidence
of reasonable attempts to secure employment in an occupation in which the
exposure is substantially decreased.
Last updated December 2, 2024 at 8:59 AM
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Rule 4123-3-29 | Informing the claimant of the right to representation and status of the claim.
Effective:
December 1, 2024
(A) Whether a claimant is or is not
represented in an industrial claim is a matter of the claimant's free
choice. No employee of the bureau or of a self-insuring employer shall directly
or indirectly convey any information in derogation of this right. (B) Upon receipt of a claim, the bureau
shall notify the claimant and the employer of the number assigned to the claim
and inform the claimant of his or her right to representation or to elect no
representation in the processing of the claim. It is the responsibility of the
bureau to aid and assist a claimant in the filing of a claim as provided in
division (A) of section 4123.511 of the Revised Code. (C) Upon request, the bureau shall inform
the claimant of the status of the claim and of any action necessary to maintain
the claim.
Last updated December 2, 2024 at 8:59 AM
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Rule 4123-3-31 | Disabled workers' relief fund: claimant's payments.
Effective:
December 1, 2024
(A) On and after August 22, 1986, all
persons, without regard to date of injury, who are receiving compensation for
permanent and total disability which, when combined with disability benefits
received pursuant to the Social Security Act, is less than three hundred
forty-two dollars per month adjusted annually as provided in division (B) of
section 4123.62 of the Revised Code, are eligible to participate in the
disabled workers' relief fund. For purposes of this rule, this amount is
the "DWRF qualifying figure." (B) Each person who has satisfied the
requirements of paragraph (A) of this rule shall receive from the disabled
workers' relief fund a monthly amount equal to either the difference
between the DWRF qualifying figure and such amount as the person is receiving
per month as disability benefits from the social security administration or the
difference between the DWRF qualifying figure and such amount as the person is
receiving under the workers' compensation laws for permanent total
disability, whichever calculation results in the lower DWRF
payment. (C) For purposes of this rule, in the
case of individuals who have received a commutation of permanent total
disability benefits pursuant to section 4123.64 of the Revised Code, payments
from the disabled workers' relief fund are calculated as if such
commutation had not been made.
Last updated December 2, 2024 at 8:59 AM
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Rule 4123-3-32 | Temporary total examinations.
Effective:
December 1, 2024
(A) Pursuant to section 4123.53 of the
Revised Code, the bureau of workers' compensation shall schedule an
examination, for a date not later than thirty days following the end of the
initial ninety-day period of temporary total disability compensation, to
determine the employee's continued entitlement to temporary total
disability compensation, the employee's rehabilitation potential, and the
appropriateness of the employee's medical treatment. The bureau will mail
a copy of the bureau's determination to schedule the examination to the
employee, employer, and their authorized representatives, except where the
bureau has determined the employer is out of business. (B) If the result of the medical
examination is that the employee continues to receive temporary total
disability compensation, the bureau shall determine a date for the employee to
be scheduled to be reexamined, based upon the recommendation of the medical
examiner or other available evidence. If at the date the bureau has determined
to schedule the employee to be reexamined the employee is receiving temporary
total disability compensation, the bureau shall schedule the employee for the
examination. The bureau will continue to determine dates to schedule the
employee for subsequent examinations as long as the employee continues to
receive temporary total disability compensation. (C) The bureau, for good cause, may waive
the scheduling of the employee's medical examination under section 4123.53
of the Revised Code. "Good cause" is determined at the discretion of
the bureau, but generally is for a reason that the medical examination is not
feasible, such as the employee's medical instability. The bureau shall
contact the employer or the employer's representative if the bureau
determines that a waiver of the examination is advisable. If the employer
objects to the bureau's waiver of the medical examination, the bureau
shall schedule the medical examination. If the employer does not object to the
bureau's waiver of the examination, the bureau will notify the employee,
employer, and their authorized representatives of the waiver of the
examination, except where the bureau has determined the employer is out of
business. If the bureau has waived an examination, the bureau shall determine a
date for the employee to be scheduled to be reexamined pursuant to paragraph
(B) of this rule. (D) An employer of an employee scheduled for an examination by
the bureau under section 4123.53 of the Revised Code may waive the
bureau's scheduling of any such examination. The employer shall notify the
bureau of its intent to waive the examination, and indicate whether the waiver
is temporary or permanent, the reason for the waiver, and, if applicable, a
recommended subsequent date upon which the employee should be reevaluated for
scheduling the examination if the employee is receiving temporary total
disability compensation. The waiver shall indicate the name and title of the
person waiving the examination for the employer. The bureau may schedule the
examination even if the employer waives the examination where the bureau
determines that an examination is necessary. The bureau shall cancel the
examination if the bureau had scheduled the examination and agrees with the
employer's waiver of the examination. (E) The bureau shall conduct ninety day examinations for
employees of self-insuring employers upon the request of the self-insuring
employer. A self-insuring employer may determine that a ninety day examination
is not necessary, and in that instance may decide not to request such
examination be conducted by the bureau. At the appropriate time thereafter, the
self-insuring employer may request that the ninety day examination be
conducted. The self-insuring employer shall pay for the ninety day examination,
as well as all reasonable expenses associated with the ninety day
examination. (F) Medical examinations scheduled under this rule shall not
limit medical examinations provided for in other provisions of Chapter 4121. or
Chapter 4123. of the Revised Code.
Last updated December 2, 2024 at 8:59 AM
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Rule 4123-3-34 | Settlement of state fund claims.
Effective:
October 8, 2021
(A) The procedures of this rule shall apply to the settlement of state fund injury and occupational disease claims. (B) The employer or the claimant shall file an application for approval of settlement agreement on the appropriate form with the administrator of workers' compensation. Each application shall include the signature of the claimant and the employer, or their authorized legal representative, except as follows: (1) A claimant may file an application without an employer's signature in the following situations: (a) The employer is no longer doing business in Ohio; (b) The claim no longer is in the employer's industrial accident or occupational disease experience as provided in division (B) of section 4123.34 of the Revised Code and the claimant no longer is employed with that employer; or, (c) The employer has failed to comply with section 4123.35 of the Revised Code. (2) If a claimant files an application without an employer's signature, and the employer still is doing business in this state, the bureau shall send written notice of the application to the employer immediately upon receipt of the application. If the employer fails to respond to the notice within thirty days after the notice is sent, the application need not contain the employer's signature. (C) Each settlement application shall: (1) Include a list of the claim numbers and body parts affected in all claims filed by the claimant with the administrator of workers' compensation or the industrial commission. (2) Set forth the reason the proposed full and final settlement is deemed desirable by the claimant and state the amount of the requested settlement. (D) Settlement may be requested for a portion of a claim, one or more claims, or a combination of claims, provided that the claimant is not required to enter into a settlement agreement for every claim that has been filed with the bureau by the claimant. (E) The administrator shall utilize whatever methods the administrator determines to be appropriate, consistent with general insurance principles, to evaluate a claim for settlement. When a settlement agreement has been approved by the administrator, a notice of approval shall be sent to the claimant, the employer, and their representatives, informing them of their rights to withdraw consent to the settlement agreement within thirty days. . An employer shall not deny or withdraw consent to a settlement application filed under this section if both of the following apply to the claim that is the subject of the application: the claim is no longer within the date of impact pursuant to the employer's industrial accident or occupational disease experience as provided in division (B) of section 4123.34 of the Revised Code; and, the employee named in the application is no longer employed by the employer. Supporting evidence indicating that the claim remains within in the date of impact or that the claimant continues to be employed with the employer may be filed with the employer's withdrawal of consent. If written notice of the withdrawal of consent is not filed within the thirty day period, the settlement agreement is final. A claimant's refusal to endorse a settlement check issued as a result of an agreement reached pursuant to these procedures does not alter the finality of the settlement. The administrator may reopen a settled claim for purposes of conducting a fraud investigation. (F) The administrator shall also send the notice of approval to the industrial commission within five days from the date of the bureau order of approval. The staff hearing officer shall determine, within the time set forth in paragraph (E) of this rule, whether the settlement agreement is or is not a gross miscarriage of justice. If the staff hearing officer determines within that time period that the settlement agreement is clearly unfair, the staff hearing officer shall issue an order disapproving the settlement agreement. If the staff hearing officer determines that the settlement agreement is not clearly unfair, or fails to act within the time limits, the settlement agreement is approved. (G) The effective date of the settlement is the date the notice of approval of settlement agreement is mailed. Once the thirty day waiting period has passed as set forth in paragraphs (E) and (F) of this rule, the agreed settlement shall be final and cannot be appealed to the industrial commission or to court. (H) When a settlement application is filed in a claim in which an application for violation of specific safety requirement has been granted or is pending, the administrator shall refer the claim to the industrial commission for disposition of the application for violation of the specific safety requirement. If the application for the specific safety requirement has been granted and the employer is no longer doing business, or is otherwise not making the payments required by any award for violation of any specific safety requirement, the administrator may approve a final settlement without referring the claim to the industrial commission, provided the administrator identifies any settlement amounts that may be attributed to the award for violation of specific safety requirement. The administrator need not refer to the industrial commission any claim in which the claimant has voluntarily withdrawn an application for violation of a specific safety requirement, provided no portion of the settlement amount is attributed to any violation of a specific safety requirement. (I) The administrator may offset settlement amounts due the claimant by overpayments owed by the claimant or, where the claimant is also an employer, unpaid premiums owed by a claimant, as the administrator determines appropriate. (J) The representative's signature for either the claimant or the employer satisfies the requirements for paragraphs (B) and (C) of this rule. (K) A settled claim may be used as a defense to a claim for the same or similar conditions. A self-insuring employer shall not settle disabled workers' relief fund liability in state fund claims without the administrator's approval. (L) An employer or claimant who files a notice of intent to settle authorized under section 4123.512 of the Revised Code shall file on the appropriate form with the administrator of workers' compensation prior to filing an application for approval of settlement agreement. If the opposing party does not object within fourteen days of receipt of the notice, the administrator will proceed with the settlement process under this rule.
Last updated October 7, 2024 at 12:03 PM
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Rule 4123-3-35 | Employer disability relief.
(A) For the purposes of disability relief
under section 4123.343 of the Revised Code, an "employee with a
disability" means an employee who is defined as having one or more of the
conditions listed in division (A) of section 4123.343 of the Revised
Code. (1) With respect to the
condition defined in division (A)(4) of section 4123.343 of the Revised Code,
degenerative disc disease, spondylosis, spondylolysis, and spondylolistheses do
not constitute evidence of arthritis for purposes of satisfying the
statute. (2) With respect to the
condition defined in division (A)(14) of section 4123.343 of the Revised Code,
the employee must have inpatient treatment and admission for the
psycho-neurotic disability in a recognized medical or mental institution.
Outpatient treatment does not satisfy the statutory definition. (3) With respect to the
condition defined in division (A)(25) of section 4123.343 of the Revised Code,
an employer is not eligible for disability relief in the same claim in which
the employee participated in a rehabilitation program. The employee must suffer
a subsequent compensable injury or occupational disease claim, and any rights
to disability relief would be in the subsequent claim. (B) Under division (B) of section
4123.343 of the Revised Code, the administrator specifies the following grounds
upon which the administrator may charge claims costs to the statutory surplus
fund. (1) The administrator
will consider disability relief under section 4123.343 of the Revised Code only
in claims satisfying all of the following prerequisites: (a) The claimant is an employee with a disability as defined in
division (A) of section 4123.343 of the Revised Code and paragraph (A) of this
rule. (b) The employer has filed an application for disability relief
while the claim is within the employer's claim experience period, as
referred to in division (B) of section 4123.34 of the Revised
Code. (i) For a claim involving a private state fund
employer: (a) If the date of injury
is between January first and June thirtieth, the application shall be filed by
June thirtieth of the year no more than six years from the year of the date of
the injury or occupational disease. (b) If the date of injury
is between July first and December thirty-first, the application shall be filed
by June thirtieth of the year no more than seven years from the year of the
date of the injury or occupational disease. (ii) For a claim involving a public employer taxing district
employer, the application shall be filed by December thirty-first of the year
no more than six years from the year of the date of the injury or occupational
disease. (iii) For a claim involving a private state fund employer or
a public employer taxing district employer participating in a retrospective
rating plan, the application shall be filed within the time provided in
paragraph (B)(1)(b)(i) or (B)(1)(b)(ii) of this rule, as
applicable. (c) The bureau has awarded compensation to the claimant for
temporary total disability, disabilities described under division (B) of
section 4123.57 of the Revised Code, permanent total disability, or death
benefits, or the claimant has received wages from the employer in lieu of
compensation. (2) For an employer
granted relief, all or such portion as the administrator determines of the
amount that otherwise would be charged to the employer's experience will
be deducted from each claim arising from injury or occupational disease to an
employee with a disability for the purpose of premium or assessment adjustment,
in accordance with the following principles and paragraphs (E), (F), and (G) of
this rule: (a) All amounts deducted from the experience of the employer will
be charged to the statutory surplus fund. (b) The bureau will calculate the amount of the cost of the claim
to remain in the employer's experience by applying the complement of the
disability relief percentage to the reducible costs contained within the claim
cost as limited by the maximum value of a claim chargeable to the
employer's experience, as determined by the employer's credibility
group under rule 4123-17-05.1 of the Administrative Code. (c) The bureau will apply disability relief in a claim to only
the following claims awards and reserves: (i) Temporary total
disability; (ii) Disabilities
described under division (B) of section 4123.57 of the Revised
Code; (iii) Permanent total
disability; (iv) Death
benefits; (v) Lump sum settlements
under section 4123.65 of the Revised Code or a settlement agreement approved by
a court of competent jurisdiction in this state; (vi) Medical payments; and (vii) Claims reserves. (d) If the actual cost of a claim exceeds the maximum value of
the claim chargeable to a particular employer's experience, the ratio of
the nonreducible costs of the claim to the total cost of the claim will be
maintained in the maximum value chargeable to the particular employer's
experience, so that when the disability relief percentage is applied, it will
be applied only to that portion of the maximum value that is reducible in
accordance with division (B) of section 4123.343 of the Revised
Code. (e) The bureau will apply the disability relief in a claim for
lump sum settlements as provided in paragraph (B)(2)(c)(v) of this rule as
follows: (i) Where the disability
relief determination is made on or after September 29, 2017, the bureau will
apply disability relief to a lump sum settlement effective before, on or after
September 29, 2017; (ii) Where the lump sum
settlement is effective on or after September 29, 2017, the bureau will apply
the disability relief to a disability relief determination made before, on or
after September 29, 2017; (iii) Where both the
disability relief determination was made and the lump sum settlement was
effective prior to September 29, 2017, the provisions in paragraph (B)(2)(c)(v)
of this rule do not apply and the bureau will not apply the disability relief
to the lump sum settlement. (C) The administrator of workers'
compensation may delegate the authority granted to the administrator under
Chapters 4121. and 4123. of the Revised Code for determining the amount to be
charged to the statutory surplus fund in connection with an employer's
employees with disabilities. The decision of the administrator's designee
is the decision of the administrator. (1) An employer which
seeks a disability relief award must file a complete and timely application and
attach copies of all relevant medical evidence which the employer believes the
administrator should consider when determining the appropriate
award. (a) The administrator may dismiss without prejudice an incomplete
application. The administrator may dismiss without prejudice an application at
the employer's request. Within the time limits and provisions of this rule
the employer may refile an application that was dismissed without
prejudice. (b) The administrator may deny an application not filed within
the employer's experience as provided in division (B) of section 4123.34
of the Revised Code and paragraph (B)(1)(b) of this rule. (c) The administrator may dismiss an application which fails to
meet the provisions of paragraphs (A) and (B) of this rule. (d) The administrator may dismiss an application if the initial
allowance of the claim is being contested before the bureau, industrial
commission, or a court of competent jurisdiction at the time the application is
filed. Upon a final administrative or judicial determination allowing the
claim, the employer may refile an application dismissed under this
provision. (2) The administrator may
issue a disability relief order based on a review of the application and any
information contained in any relevant claim file or any other relevant bureau
or industrial commission records. (3) The administrator
will afford an employer the opportunity for an informal conference if the
application meets the provisions of this rule. (a) If the administrator conducts an informal conference, the
administrator will send a notice of conference to the employer and its
representative by regular mail or email, setting forth the date, time, and
place of the conference. (b) The administrator will notify the employer by mail or email
not less than fourteen days before the date of such conference, unless the
employer waives this notice. (c) At the request of the employer or another party, the
administrator may conduct an expedited or an informal telephone
conference. (4) The
administrator's decision will be reduced to writing and mailed to all
interested parties. The order will state the evidence upon which the
administrator based the decision. (5) The administrator
will keep a record of disability relief applications received, conferences
scheduled, orders issued with publication dates and any waiver of appeals, and
appeals to the industrial commission. (D) The burden of proof is upon the
employer to establish entitlement to the relief under section 4123.343 of the
Revised Code by appropriate medical evidence or other evidence as may be
indicated (1) With respect to any
credit under division (D)(1) of section 4123.343 of the Revised Code, the
administrator will grant full disability relief credit if the employer
establishes that the injury or occupational disease would not have occurred but
for the employee's pre-existing qualifying condition. (2) With respect to any
credit under division (D)(2) of section 4123.343 of the Revised Code, the
administrator will determine the degree of relief to be granted based upon the
following: (a) The degree to which medical evidence or other evidence
indicates the pre-existing condition has affected the cost of the
claim. (b) The employer shall establish the relationship between the
pre-existing condition and subsequent injury by way of aggravation or delayed
recovery by proof on file but the condition need not be recognized by an order
of allowance for such condition or aggravation of the condition. (c) In determining the appropriate per cent of relief in the
claim, the administrator will consider the effect of the pre-existing condition
on the past claims costs, and also account for the effect of the condition on
the anticipated future costs of the claim. (E) A non-complying employer is not
entitled to relief under section 4123.343 of the Revised Code. If the employer
had active coverage on the date of the injury but was a non-complying employer
on the date of the application for disability relief, the administrator may
dismiss the application. (F) No employer in any rating year may
receive credit under section 4123.343 of the Revised Code in an amount greater
than the premium it paid. (G) An order issued by the administrator is appealable under
section 4123.511 of the Revised Code. (1) If the administrator
holds an informal conference, the employer and the administrator may agree upon
the amount of disability relief in a claim, and the employer may waive its
right to appeal. (2) Upon waiver of the
employer's right to an appeal or the expiration of the appeal period, the
administrator's order is final, and the bureau will immediately process
the award. (3) If no agreement is
reached at the informal conference and the employer files a written appeal
within fourteen days of the employer's receipt of the administrator's
decision, the administrator will forward the claim file to the industrial
commission within seven days of the administrator's receipt of the notice
of appeal for a hearing before a district hearing officer. (4) The employer and the
administrator are parties at any hearing conducted by the industrial commission
or its hearing officers. (5) Upon a final
industrial commission order which grants disability relief, the bureau will
immediately process the award. (H) Since pursuant to paragraph (D)(2)(c) of this rule the
administrator is to consider the effect of the qualifying condition on the past
and future costs of the claim in determining disability relief, the employer is
not entitled to consideration of a subsequent application for disability relief
for a condition in a claim in which the administrator has made a previous
determination on the condition, regardless of whether there has been a change
in circumstances such as allowance of the condition or payment of compensation.
A subsequent application cannot substitute for an appeal of the
administrator's order. The administrator will dismiss or deny any
subsequent application for an increase in disability relief in a previously
determined claim.
Last updated October 7, 2024 at 12:04 PM
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Rule 4123-3-36 | Immediate allowance and payment of medical bills in claims.
Effective:
December 1, 2024
(A) In accordance with division (A) of section 4123.511 of the
Revised Code the administrator has established a program to immediately allow
specific medical conditions which have a historical record of being allowed
whenever included in a claim and having low medical costs. The medical conditions the administrator has
determined to be included in the program are indicated in the appendix to this
rule. (B) Upon the initial filing of a claim, the administrator will
investigate the claim and issue an order on the claim pursuant to section
4123.511 of the Revised Code. For any medical condition identified in the
appendix to this rule, however, the administrator may grant immediate allowance
of the medical condition and may make immediate payment of the medical bills
relating to that condition, regardless of the receipt of the medical reports
for that medical condition or the employer's certification of the
claim. (C) The employer retains the right to contest the immediate
allowance of a medical condition in a claim under this rule. If the employer
appeals the allowance and the claim is disallowed, the payment for the medical
treatment provided prior to the date of the disallowance of that claim shall be
charged to and paid from the surplus fund created under section 4123.34 of the
Revised Code. The administrator will not seek reimbursement of the payment from
the claimant or the provider.
View Appendix
Last updated December 2, 2024 at 8:59 AM
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Rule 4123-3-37 | Lump sum advancements.
Effective:
September 15, 2023
(A) The administrator of the bureau of
workers' compensation, under special circumstances, may commute an award
of compensation to a lump sum payment when the administrator determines the
advancement is advisable for the purpose of providing the claimant or the
surviving spouse financial relief or for furthering the claimant's
rehabilitation. (1) The bureau may grant
a lump sum advancement to a claimant only from an award of compensation made
pursuant to section 4123.58 of the Revised Code or from division (A) or (B) of
section 4123.57 of the Revised Code. (2) The bureau may grant
a lump sum advancement to a surviving spouse only from an award of death
benefits made pursuant to section 4123.59 of the Revised Code. However, the
advancement cannot exceed the amount of death benefits payable to the surviving
spouse over a two-year period. (3) The bureau will not
grant a lump sum advancement to a surviving dependent from an award of
compensation made pursuant to division (B) of section 4123.57 of the Revised
Code. (4) The bureau will not
grant a lump sum advancement in a claim where the allowance of the award of
compensation made pursuant to section 4123.58 of the Revised Code or from
division (A) or (B) of section 4123.57 of the Revised Code is on appeal under
section 4123.511 of the Revised Code or an appeal to court. (5) The industrial commission has
exclusive jurisdiction over an application for a lump sum advancement for the
payment of attorney fees incurred in securing an award. The bureau will refer
such applications to the industrial commission to adjudicate. (B) A claimant or the surviving spouse
requests a lump sum advancement by filing a fully completed application with
the bureau. (1) (a) The claimant or surviving spouse is to provide proof that
there are special circumstances for the lump sum advancement and that the lump
sum advancement is advisable for the purpose of providing financial relief or
for furthering the claimant's rehabilitation. (b) The bureau may dismiss an application for a lump sum
advancement where the claimant or surviving spouse has not provided proof of
special circumstances and proof of financial relief or for furthering the
claimant's rehabilitation. (2) The bureau will
review the application and utilize whatever methods the bureau determines to be
appropriate, consistent with general insurance principles, to evaluate the
claim for a lump sum advancement. (3) For a lump sum
advancement from an award of compensation made pursuant to section 4123.58 of
the Revised Code or from an award of death benefits pursuant to section 4123.59
of the Revised Code, if the bureau determines the lump sum advancement is
advisable, the bureau will calculate the net present value of the lump sum
advancement on the remaining compensation payable to the claimant or benefits
payable to the spouse. The bureau will determine the amount of the biweekly
rate reduction and the terms of such reduction. The administrator will fix a
specific time for the reduction of the biweekly rate of compensation to offset
the lump sum advancement depending upon the time period the claimant or
surviving spouse has selected for the offset of the lump sum advancement, when
applicable. Once a claimant or surviving spouse has selected a time period for
the offset of the lump sum advancement, the claimant or surviving spouse cannot
change the time period. The bureau will include the net present value of the
lump sum advancement in determining the reduction of the biweekly rate of
compensation. (4) For a lump sum
advancement of an award made pursuant to division (A) or (B) of section 4123.57
of the Revised Code, if the bureau determines the lump sum advancement is
advisable, the bureau will calculate the net present value of the lump sum
advancement on the remaining weeks of compensation payable to the claimant and
in determining the amount to be paid to the claimant for the lump sum
advancement. (5) In determining the
net present value of a lump sum advancement, the bureau will use the discount
factor as periodically established by the bureau. (6) The bureau will issue an order
approving or disapproving the application. If the bureau approves the
application, the order will advise the claimant or surviving spouse of the
amount of reduction of compensation and the terms of the lump sum
advancement. (C) Maximum rate reduction in
compensation. (1) No lump sum
advancement will be approved that will result in a rate reduction of more than
one-third of the biweekly rate of compensation, except where the advancement is
for compensation under division (A) or (B) of section 4123.57 of the Revised
Code. The bureau will not include an advancement for attorney's fees in
accordance with section 4123.06 of the Revised Code in the calculation of the
maximum rate reduction limitation. (2) The bureau may
approve no more than two concurrent lump sum advancements in a claim in
addition to an advancement for attorney fees that the industrial commission has
granted in accordance with section 4123.06 of the Revised Code. (3) Upon the recoupment
of the lump sum advancement in accordance with the terms of the order and
agreement, the bureau will remove the rate reduction due to the lump sum
advancement and reinstate the claimant's rate of compensation or the
surviving spouse's benefits. (D) The lump sum advancement warrant will
include the claimant or the surviving spouse as a payee, except where the
warrant is for the payment of attorney's fees in accordance with section
4123.06 of the Revised Code, in which case the attorney will be named as the
only payee on the warrant.
Last updated October 7, 2024 at 12:04 PM
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Rule 4123-3-38 | Surplus fund charge of qualified motor vehicle accident claims.
Effective:
December 1, 2024
(A) Pursuant to section 4123.932 of the
Revised Code and when an employer satisfies all of the requirements of this
rule, the bureau shall charge to the surplus fund created under division (B) of
section 4123.34 of the Revised Code any compensation and benefits related to a
compensable workers' compensation claim based on a motor vehicle accident
involving a third party. This rule applies only to claims arising on or after
July 1, 2017. (B) Eligibility
requirements. (1) This rule does not
apply to self-insuring employers, state agencies, or a state institution of
higher education, including its hospitals. (2) This rule applies to
private state fund employers and public employer taxing district employers that
pay premiums into the state insurance fund. (a) The employer must have had active workers' compensation
coverage on the date of injury of the claim. (b) The employer must be current with respect to all payments due
the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the
Administrative Code. (c) The employer must be current on the payment schedule of any
part-pay agreement into which it has entered for payment of premiums or
assessment obligations. (C) If an employer believes the bureau
should charge a claim to the surplus fund under this rule, the employer may
file an application with the bureau requesting the bureau determine whether the
claim is to be charged to the surplus fund. The bureau will not review or
consider charging a claim to the surplus fund under this rule unless the
employer files an application in accordance with this rule. (D) The employer's application to
charge a claim to the surplus fund will include all of the
following: (1) Evidence that the
claim is based on a motor vehicle accident involving a third party. "Motor
vehicle" has the same meaning as in section 4501.01 of the Revised
Code. (2) Evidence that either
of the following circumstances apply to the claim: (a) The third party involved in the motor vehicle accident was
issued a citation for violation of any law or ordinance regulating the
operation of a motor vehicle arising from the accident on which the claim is
based and that any form of insurance maintained by the third party or uninsured
or underinsured motorist coverage as described in section 3937.18 of the
Revised Code covers damages caused by the motor vehicle accident which gave
rise to the claim. (i) The employer does not
need to prove that the third party was convicted of the citation. (ii) The employer does
not need to prove that the insurance accepts complete liability for the motor
vehicle accident, but only that the insurance accepts liability for some
portion of the accident and pays costs associated therewith. (b) If there is evidence that the third party was not issued a
citation arising from the accident, the employer is to provide evidence that
the third party involved in the motor vehicle accident was primarily liable for
the accident on which the claim was based and that any form of insurance
maintained by the third party or uninsured or underinsured motorist coverage as
described in section 3937.18 of the Revised Code covers damages caused by the
motor vehicle accident which gave rise to the claim. (i) "Primarily
liable" means that the third party involved in the motor vehicle accident
is more than fifty per cent liable for purposes of section 2315.33 of the
Revised Code. (ii) The employer does
not need to prove that the insurance accepts complete liability for the motor
vehicle accident, but only that the insurance accepts primary liability for the
accident and pays costs associated therewith. (E) Within one hundred eighty days after
the bureau receives the employer's application, the bureau shall determine
whether the claim shall be charged to the surplus fund under this
rule. (1) If the bureau
believes the employer has not provided all of the information necessary for the
bureau to make the determination, the bureau will contact the employer for the
employer to provide the additional evidence required prior to denying an
application. (2) If the bureau
determines that the employer failed to establish that the bureau should charge
the claim to the surplus fund under this rule, the bureau will deny the
application with an explanation of the reasons for the denial. (3) If the bureau fails
to make a determination within the time required, the application will be
deemed approved and the bureau shall charge the claim to the surplus
fund. (F) If the bureau determines that the
employer's claim meets the criteria of this rule, or if the application is
deemed approved because the bureau failed to make a determination within the
time provided for in paragraph (E) of this rule, the bureau shall charge all of
the costs of the claim to the surplus fund created under division (B) of
section 4123.34 of the Revised Code. If the bureau previously included the costs of
the claim in the calculation of the employer's experience in any prior
policy year, the bureau will adjust the employer's experience in the prior
policy years the costs of the claim were included. (G) The bureau's denial of an
employer's application to charge a claim to the surplus fund under this
rule is appealable to the adjudicating committee under section 4123.291 of the
Revised Code.
Last updated December 2, 2024 at 9:00 AM
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