Claims Procedure for an Ohio Worker's Comp Case
The Columbus, OH Workman's Comp Claims Procedure
Once an injury occurs, an application for workers' compensation must be filed to avail yourself of all the benefits the Ohio Workers' Compensation Law affords. Below is a discussion of some procedural issues of which you should be aware. If you have further questions about the claims process, then please contact a member of our legal team.
A Columbus workers' compensation attorney from Charles Zamora Co., L.P.A. can make sure that you take the right action.
Report the Injury to Your Employer
An injury may be the result of a sudden mishap at work. Or, an injury may be the result of repetitive work activity, such as a cumulative trauma disorder (for instance, carpal tunnel syndrome). The workers' compensation law recognizes that not all injuries occur due to a sudden mishap. An injury that occurs gradually over time may also be a compensable work injury. Once the injury happens, or you receive a medical diagnosis, notify your employer immediately and fill out an accident report. If you are a police officer, fill out an "injury packet."
File a First Report of Injury with the BWC
The application for workers' compensation benefits is called the First Report of Injury ("FROI"). Under the workers' compensation law, the FROI may be filed by the injured worker, an attending physician or health care provider, or the employer. Once filed with the Ohio Bureau of Workers' Compensation ("BWC"), a claim number is immediately assigned. The BWC will mail an identification card to the injured worker, which contains the claim number and other relevant information about the claim. The injured worker will use the BWC identification card similar to a health insurance card when obtaining medical services. Continue to see your doctor while the BWC begins to process your claim. Make sure your doctor treats workers' compensation patients before you begin treatment.
BWC Customer Service Specialist
In Ohio, employers are classified as either "state fund" or "self-insured." In both cases, the Bureau of Workers' Compensation will assign a customer service specialist ("CSS") to your claim. The CSS takes a direct role in state fund claims, but an indirect role in self-insured claims. For state fund claims, the CSS makes initial decisions concerning the allowance of the claim, the setting of the average and full weekly wage, payment of compensation, scheduling of medical examinations, the issuance of orders, and various other matters.
If the injured worker disagrees with a decision of the CSS, the remedy is to file an appeal. On the other hand, in self-insured claims, the self-insured employer has the right to make initial decisions concerning the claim. If the injured worker disagrees with a decision of the self-insured employer, the remedy is to file an administrative motion with the BWC and request a hearing before the Industrial Commission of Ohio. Once the CSS receives an appeal or a motion for hearing, it may take 1 to 3 months for a hearing to be scheduled.
Managed Care Organizations
In workers' compensation claims, there are two general forms of benefits: (1) medical benefits and (2) compensation. The payment of medical benefits in state fund claims is made by so-called managed care organizations ("MCO"). The MCO processes requests from the injured workers' attending physicians and medical providers for medical services, such as requests for treatment, diagnostic studies, physical therapy, consultation exams, medical appliances, and other treatment issues. Typically, treatment requests are submitted on a "C-9" form. If the MCO disapproves or modifies the C-9 request, the injured worker and/or the attending physician may appeal. If an appeal is filed, an alternative dispute resolution ("ADR") process begins. This process consists of medical "peer reviews" and additional decision-making by the MCO. Ultimately, if the injured worker is still dissatisfied with the MCO's decision, the BWC reviews the matter and issues an Order, which the parties may appeal to the Industrial Commission of Ohio.
For self-insured denials or modifications of C-9 requests, the injured workers' remedy is to file an administrative motion with the BWC and request the Industrial Commission of Ohio schedule a hearing. At the hearing, all parties may testify and present evidence in support of their respective positions. After the hearing, the Industrial Commission's duly assigned hearing officer will issue an Order by mail to all parties and their representatives. Further appeals may be available to the parties.
Duty of the Injured Worker to Cooperate
When a workers' compensation claim is filed, the self-insured employer may request the injured worker sign a medical release or submit to a medical examination. Generally, the self-insured employer has the right to compel one medical exam for each issue arising in the claim. For example, if the injured worker requests the payment of temporary total compensation, the self-insured employer has the right to have the worker examined the issue of entitlement to temporary total compensation.
If the injured worker requests authorization for a diagnostic test, such as a magnetic resonance image ("MRI") or electromyographic exam ("EMG"), the self-insured employer has the right to have the worker examined to determine if the MRI or EMG is necessary, reasonable, and related to the allowed conditions in the claim. If the injured worker fails to provide a signed medical release or fails to attend a medical exam, the self-insured employer will notify the BWC or Industrial Commission of Ohio. The BWC and Industrial Commission has the authority to "suspend" the claim until the injured worker cooperates. During the suspension, no compensation or benefits will be paid to the injured worker or medical providers.
Similarly, if the injured worker fails to attend an exam scheduled by the BWC or Industrial Commission, the particular application or request is "suspended" until the injured worker complies. In cases where temporary total disability compensation is being paid, the BWC may suspend further compensation if the injured worker fails to attend a medical exam seeking to determine whether the injured worker has reached maximum medical improvement.
The "Life" of Claims
The "life" of a workers' compensation claim is dependent upon several factors. For lost-time claims with injury or disease dates before August 26, 2006, the claim lasts for ten (10) years from the date of injury, the date of last payment of compensation, or the date of last payment of a medical bill, whichever is later. For medical-only claims with injury or disease dates before August 26, 2006, the claim lasts for six (6) years from the date of injury or diagnosis.
For lost time and medical-only claims on and after August 26, 2006, the claim lasts for five (5) years from the date of injury or occupational disease. The claim is extended five (5) years each time a bill or compensation is paid in the claim unless a period of five (5) years has passed without the payment of such compensation or medical benefits. There may be options available to you that will continue to extend the life of your claim so that it does not expire. It is advisable to discuss the specifics of your claim with an attorney to determine the date on which your claim will expire.
Definition of "Injury"
The Ohio General Assembly enacted legislation changing the definition of "injury." As a result of a failed referendum attempt, the Supreme Court of Ohio ruled that such legislation became effective August 26, 2006. The statute is R.C. 4123.01(C)(1)-(4) and defines the term "injury" as any injury, whether caused by external accidental means or accidental in character and result, received in the course of, and arising out of, the injured workers' employment.
The term "injury" does not include psychiatric conditions, except where the injured workers' psychiatric condition arose from an injury or occupational disease, or where the injured workers' psychiatric condition arose from sexual conduct in which the injured worker was forced by threat of physical harm to engage or participate.
The term "injury" also does not include injuries or disabilities caused primarily by the natural deterioration of tissue, an organ, or part of the body.
The term "injury" does not include injuries or disabilities incurred in the voluntary participation in an employer-sponsored recreation or fitness activity if the employee signs a waiver of his or her right to compensation or benefits under the workers' compensation law before engaging in the recreation or fitness activity.
The term "injury" does not include a condition that pre-existed the injury unless that pre-existing condition is substantially aggravated by the injury. A substantial aggravation must be documented by objective diagnostic findings, objective clinical findings, or objective test results. While subjective complaints may be evidence of a substantial aggravation, subjective complaints without objective diagnostic findings, objective clinical findings, or objective test results are insufficient to substantiate a substantial aggravation. Moreover, once that condition has returned to a level that would have existed without the injury, the claim essentially abates, since no further compensation or benefits are payable beyond that point.
Employer Retaliation is Prohibited
The workers' compensation law prohibits employers from retaliating against any employee who files, pursues, or testifies in a workers' compensation proceeding. If the injured worker suspects the employer has engaged in unlawful retaliation (such as a suspension, demotion, reduction in pay or status, failure to promote, disciplinary action, discharge, or other adverse job action), the worker must provide written notice to the employer of the alleged violation within 90 days of the adverse job action. The injured worker must then file the lawsuit within 180 days of the adverse job action. The time limits are jurisdictional; a lawsuit will be dismissed if it is filed outside the jurisdictional time limit. The injured worker should contact an attorney immediately.
Industrial Commission Hearings
If any party disagrees with a decision of the Bureau of Workers' Compensation or a decision of the self-insured employer, and the party has filed a timely appeal (or a motion has been filed in the case of a self-insured claim), the matter will be scheduled for a hearing before the Industrial Commission of Ohio.
Hearings before the Industrial Commission are informal. This only means the Ohio Rules of Civil Procedure and the Ohio Rules of Evidence (which apply to lawsuits in Ohio courts) do not apply to proceedings before the Industrial Commission. However, the Industrial Commission strictly follows the laws and rules governing workers' compensation claims. Also, the Industrial Commission has adopted Resolutions and a Hearing Officers Manual which govern hearings and claims procedures.
If your claim is scheduled for a hearing before the Industrial Commission, it is highly recommended you contact an attorney to represent your interests. Often, the employer attends with its attorney. Moreover, the BWC often has an attorney from its Law Department appear at the hearing. (Interestingly, this author has never had any hearing or claim where the BWC Law Department lawyer appeared and argued in favor of the injured worker). You should be aware, as the injured worker, you may have two (2) parties arguing against you at your hearing.
Appeals to Court & Mandamus Actions
Once the Industrial Commission of Ohio issues a final decision as to the injured workers' "right to participate" in the workers' compensation fund, the losing party has the right to file an appeal to the Court of Common Pleas. A clear example of the "right to participate" is the initial allowance or disallowance of the claim. Other issues involving the "right to participate" are not always clear. The injured worker should consult an attorney.
If an appeal is filed to the court of common pleas, the case proceeds de novo, meaning the injured worker bears the burden of proving (or re-proving) his/her right to participate in the workers' compensation fund, notwithstanding the previous decision of the Industrial Commission. The parties have the right to request a jury trial. However, the jury is not allowed to be told how the Industrial Commission ruled on the matter and/or whether the injured worker or the employer won at the administrative level.
For issues concerning "the extent of disability," the losing party has the option of filing an original action in mandamus from the Industrial Commission's final decision. The mandamus lawsuit is typically filed in the Tenth District Court of Appeals, Franklin County, Ohio. However, the mandamus lawsuit may also be filed in the court of common pleas, or the Supreme Court of Ohio. To be successful in a mandamus lawsuit, the "relator" must establish the Industrial Commission "abused its discretion" in reaching its decision, or in the explanation the Industrial Commission provided. Because the Industrial Commission is considered to be an expert in the area of workers' compensation, and mandamus is an extraordinary remedy, the Courts afford substantial deference to the Industrial Commission's decision. The injured worker should consult an attorney.
The above information is intended solely as an overview. It is advisable to contact an attorney to assess the merits of your claim.
Please call our Columbus workers' comp attorneys at (614) 344-6822 to discuss the specifics of your case.
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