(A) Numbering and
recording.
(1) Upon receipt, the bureau will
assign a claim number to each initial application for benefits. The bureau shall
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
shall
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,
shall
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 shall
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 shall have authority to
may approve such claim for payment of medical bills
and temporary total disability compensation or other appropriate compensation.
The approval of the claim must
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
shall
does not
apply. Upon approval of the claim the claimant shall
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
shall
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
shall
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 shall
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 shall
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 shall
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
shall
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
shall be applicable
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 shall
will be referred,
forthwith, 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
shall
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 shall
will be referred,
forthwith, to the appropriate district hearing officer for further
consideration. In cases of temporary total disability, a medical examination
performed within the past thirty days shall be
regarded as
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
shall
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, shall
will be referred,
forthwith, 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 shall
will be
adjudicated without a formal hearing.
(2) Disputed or contested claims
shall
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 shall
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
his or her
their designee is of the opinion that an emergency
exists which requires an immediate hearing of a claim,
he or she
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.
Such request shall be made in accordance with the
rule of the industrial commission on emergency hearings as defined in rule
4121-3-30 of the Administrative Code.
(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,
shall
will be given an opportunity to provide additional
evidence on questions pertaining to the claim pending before the bureau.
The evidence shall
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.
Notes
Ohio Admin. Code
4123-3-09
Effective:
12/1/2024
Five Year Review (FYR) Dates:
9/13/2024 and
12/01/2029
Promulgated
Under: 119.03
Statutory
Authority: 4121.12,
4121.121
Rule
Amplifies: 4121.121,
4121.43,
4123.651
Prior
Effective Dates: 10/09/1976, 01/16/1978, 12/21/1979, 08/22/1986 (Emer.),
11/17/1986 (Emer.), 01/10/1987, 02/10/2009, 11/05/2009, 04/01/2014,
07/01/2019
