Source: https://www.bwc.ohio.gov/basics/PolicyLibrary/FileShell.aspx?file=%2FClaims+Policy%2FLongshore+and+Harbor+Workers'+Compensation+Claims+(aka+Marine+Industry+Fund).htm
Timestamp: 2020-06-03 10:42:11
Document Index: 751205332

Matched Legal Cases: ['§901', '§701', '§902', '§906', '§908', '§910', '§910', '§908', '§907', '§902', '§909']

Longshore and Harbor Workers’ Compensation Claims (aka Marine Industry Fund)
CP-12-05
R.C. 4131.11 to R.C. 4131.16; O.A.C. 4123-20-01 to O.A.C. 4123-20-07; 33 USC §901 et seq.; 20 CFR §701 et seq.
Ann Shannon, Chief of Claims Policy and Support
Policy CP-12-05, effective 07/22/16 and Procedure CP-12-05.PR1, effective 07/22/16
Longshore and Harbor Workers’ Compensation Claims Table of Contents
Marine Industry Fund (MIF)
A. BWC Role
C. Notice of a Longshore Claim
E. Rate and Payment of Compensation
The purpose of this policy is to ensure that when BWC is the authorized longshore carrier for an employer, qualifying claims are processed in compliance with the Longshore and Harbor Workers’ Compensation Act.
Longshore and Harbor Workers’ Compensation Act (LHWCA): A federal act, administered by the U.S. Department of Labor (DOL), that offers compensation and medical care to employees disabled from injuries (including occupational diseases) that occur on the navigable waters of the United States, or in adjoining areas customarily used in loading, unloading, repairing, or building a vessel. This act also offers benefits to dependents if the injury causes the employee’s death.
Marine Industry Fund (MIF): A separate State of Ohio fund for the payment of compensation and benefits under the Federal Longshore and Harbor Workers’ Compensation Act.
1. It is the policy of BWC that claims qualifying under the LHWCA (hereinafter referred to as “Longshore claims”) for which BWC is the authorized longshore carrier shall be:
a. Processed by BWC consistent with that act; and
b. Charged against the MIF.
2. BWC shall:
a. Represent the interest of the MIF in all proceedings pertinent to a controverted claim; and
b. Charge representation expenses, including travel, incurred by BWC to the MIF.
1. Longshore claims are not subject to the provisions of the Disabled Workers’ Relief Fund (DWRF).
2. There shall be no deduction from Longshore claims:
a. For family support orders; or
b. For the purposes of recoupment of overpayment in a BWC State Fund claim or from a different Longshore claim.
1. Claims services staff shall consult with the BWC attorney, as needed, regarding the handling of a Longshore claim.
2. The Special Claims Department shall process all Longshore claims unless otherwise assigned by claims services management.
3. Special Claims staff shall reference the “Longshore Procedure Manual” (available in the Special Claims Department) and the DOL Division of Longshore and Harbor Workers’ Compensation (DLHWC) website for additional information on federal requirements.
4. References to specific federal forms or other communications within this procedure are for the convenience of Special Claims staff. Special Claims staff shall always follow the direction of the DOL should any of the specific forms or other communications change.
a. Special Claims staff may locate Federal Longshore claim forms on the DOL DLHWC website.
b. Special Claims staff shall ensure that the federal forms used are current (by checking the DOL website or contacting the DOL, as needed).
5. Any written communication required by this procedure that is not identified as a federal form shall be drafted by Special Claims staff as off-line correspondence or generated through the claims management system, as available.
6. Special Claims staff shall ensure Longshore claims, where BWC is the insurer, are charged against the MIF and to the extent possible, provide guidance so that potential Longshore claims are not allowed in the State Insurance Fund.
7. Special Claims staff may reference the Longshore and Harbor Workers’ Policy COR page for links to websites referenced within this procedure.
8. Claims services staff may email the BWC Marine Fund email box with any questions.
1. Employer’s Reporting of an Employee’s Injury, Occupational Disease, or Death Upon receipt of an Employer’s First Report of Injury or Occupational Illness (LS-202) from an employer reporting an injury, occupational illness, or death under the LHWCA, Special Claims staff shall:
a. Obtain a claim number utilizing the following information:
ii. Social Security Number;
v. Date of injury;
vi. Employer name; and
vii. Employer policy number (claims services staff shall ensure the employer’s MIF policy number for Longshore claims is identified).
b. Initially identify the claim as “medical only” in the claims management system during investigation;
c. Confirm coverage by MIF for the applicable period with BWC Underwriting.
d. Send a “Medical Benefits Card” letter to the claimant advising the claimant of:
i. The BWC MIF claim number;
ii. The name and contact information of the assigned claims service specialist (CSS);
iii. Information on medical benefits; and
iv. Any other relevant information and/or requests appropriate at the time of sending the letter.
e. Send a copy of the LS-202 to the DOL.
i. If the DOL has not yet assigned a DOL claim number:
a) For new claims the initial notice is sent to the Case Create designated fax number, 202-513-6814; or
b) U.S. Department of Labor
ii. If the DOL has assigned a DOL claim number, the notice should be:
a) Submitted electronically through the SEAPortal and a copy of the proof of submission imaged in the BWC claim file; or
b) Sent to:
U. S. Department of Labor Office of Workers' Compensation Programs Division of Longshore and Harbor Workers' Compensation 400 West Bay Street, Suite 63A, Box 28
2. Filing of a First Report of Injury, Occupational Disease or Death (FROI)
a. If a Longshore claim is filed with BWC on a FROI and claims services staff have confirmed the existence of an MIF employer policy, claims services staff shall:
i. Assign the employer’s MIF policy number; and
ii. Reassign the claim to the Special Claims department.
b. If not yet received, Special Claims staff shall contact the employer and advise it to file the appropriate DOL forms for the claim.
3. If the proper assignment and/or processing of a claim is unclear, claims services staff or Special Claims staff shall consult with the BWC attorney.
1. While the Longshore claim is being investigated for compensability, Special Claims staff shall send a Notice of Controversion of Right to Compensation (LS-207) to the DOL, with copies to the claimant and the claimant’s representative, if applicable, and the employer and employer’s representative, if applicable.
2. If not already received, Special Claims staff shall contact the employer and request that an Attending Physician’s Supplementary Report (LS-204) be provided. Special Claims staff may also request an independent medical examination or a physician file review, as needed, for determination of the claim.
3. Special Claims staff shall review the claim documentation to determine if the status and situs test are met.
a. Status Test: Was the claimant engaged in maritime employment at the time of his or her injury (i.e., a job related to the loading, unloading, construction or repair of a vessel);
i. In general, the following maritime employees may file a claim for a job-related injury under the LHWCA:
a) Longshoremen;
b) Waterfront crane operators;
c) Longshore checkers;
d) Stevedores;
e) Terminal workers;
f) Shipyard employees;
g) Shipbuilders;
h) Marine Construction workers; and
i) Vessel repair workers.
ii. The following employees, if covered by state workers’ compensation law, are excluded from coverage under the LHWCA:
a) Employees hired exclusively to perform office clerical, secretarial, security or data processing work;
b) Employees of a club, camp, recreational operation, restaurant, museum or retail outlet;
c) Employees of a marina who are not engaged in construction, replacement, or expansion of the marina (except for routine maintenance);
d) Employees of suppliers, transporters or vendors that are temporarily doing business on the premises of a maritime employer and are not engaged in work normally performed by employees of that employer covered under the LHWCA;
e) Aquaculture workers;
f) Individuals employed to build any recreational vessel under sixty-five feet in length, or to dismantle any part of a recreational vessel in connection with the repair of such vessel; and
g) Small vessel workers if exempt, by certification of the Secretary of Labor, under certain conditions.
iii. Other employees excluded from LHWCA coverage are:
a) Masters or members of a crew of any vessel;
b) Individuals engaged by a master to load or unload or repair any small vessel under eighteen tons net; and
c) Employees of the U.S. government or of any state or foreign government.
b. Situs Test: Did the injury occur upon the navigable waters of the United States, including any adjoining:
i. Pier;
ii. Wharf;
iii. Dry dock;
iv. Terminal building way;
v. Marine railway; or
vi. Other adjoining area customarily used by an employer in loading, unloading, repairing, dismantling or building a vessel.
4. Special Claims staff shall not allow a claim for compensation if the injury was caused solely by:
a. The intoxication of the employee; or
b. The willful intention of the employee to injure or kill him/herself or another.
5. If the status and situs tests are met, Special Claims staff shall review the medical documentation in the claim to determine if the medical documentation supports any one or more of the following, as defined by the LHWCA:
a. Temporary total disability (TT);
b. Permanent total disability (PTD);
c. Temporary partial disability (TPD);
d. Permanent partial disability (PPD); or
e. Death benefits.
6. If the Special Claims staff determines that the claim is compensable, Special Claims staff shall send the claimant an “IW Introduction” letter to notify the claimant of the allowance, and as applicable:
a. Identification of the specific allowed conditions;
b. Information related to medical benefits;
c. The address for submission of medical invoices;
d. The compensation to be paid, if applicable; and
e. Other information pertinent to the claim.
7. If Special Claims staff receive an Employee's Claim for Compensation (LS-203) or other notice that the claimant is off work, the claim shall be identified as “Lost Time” in the claims management system.
1. Special Claims staff shall staff an allowed claim with the BWC attorney to determine the appropriate compensation, consistent with 33 USC §902, §906, and §908-§910 (Be aware these statutes are similar, but vary in detail, from BWC law and rules). General provisions of those statutes include:
a. Time for commencement - No monetary compensation shall be allowed for the first three days of the disability unless the disability extends beyond fourteen (14) days, then the compensation shall be allowed from the date of the disability.
b. Determination of Average Weekly Wage-Factors considered under §910 include whether the employee is a five or six-day worker and whether they were employed substantially the entire year.
c. PTD and TT - Compensation is two-thirds of the claimant’s average weekly wage, subject to a maximum amount. The maximum rate for PTD and TT is adjusted every October 1, based on the current National Average Weekly Wage (NAWW) for the affected period. PTD is subject to a maximum adjustment of 5%.
d. Permanent Partial Disability- Compensation is payable for the permanent loss or proportionate loss as a percentage associated with certain parts or functions of the body. Compensation is payable as specified in 33 USC §908.
e. Temporary Partial and Non-scheduled Permanent Partial Disability - Compensation is two-thirds of the employee's weekly wage loss or loss of wage-earning capacity.
f. Permanent Partial Disability for Retirees - If the claimant suffers the onset of a latent occupational disease after retirement, compensation is two-thirds of the NAWW multiplied by the percentage of impairment resulting from the disease.
g. Maximum and Minimum Payments:
i. Compensation may not exceed 200% of the NAWW, applicable at the time of injury, or the claimant’s full average weekly wage, whichever is less.
ii. Compensation for total disability may not be less than 50% of the NAWW except if the average weekly wages are less than 50% of the NAWW, then the compensation rate equals the average weekly wage.
2. Special Claims staff may locate the NAWW maximum and minimum rates and annual increase percentage on the DOL DLHWC website.
3. Special Claims staff shall request wages using the “Request for Wage Information” letter.
4. Special Claims staff shall not apply family support deduction orders or provisions for the Disabled Workers’ Relief Fund (DWRF) to Longshore claims.
5. Special Claims staff shall not recoup an overpayment in a BWC state fund claim from a Longshore claim.
6. Special Claims staff shall ensure the first payment of compensation is made no later than fourteen (14) days from the date the employer has been notified or has knowledge of the injury or death.
a. Special Claims staff shall send a Payment of Compensation Without Award (LS-206) to the DOL, the claimant, and the claimant’s representative, as applicable, and the employer and employer’s representative, as applicable, on the same day the first payment is made.
b. If the first payment of compensation is not made timely, a significant penalty will be assessed.
c. If for any reason the first payment of compensation may be late or is already late, Special Claims staff shall consult with the BWC attorney.
7. When the claimant ceases to be eligible for compensation, Special Claims staff shall send a Notice of Final Payment or Suspension of Compensation Payments (LS-208) to the DOL, the claimant, and the claimant’s representative, as applicable, and the employer and the employer’s representative, as applicable.
a. The LS-208 shall be sent no later than sixteen (16) days after the date of final payment.
b. If the LS-208 is not sent to the DOL timely, BWC is subject to a civil penalty.
c. Special Claims staff shall consult with the BWC attorney if for any reason the LS-208 may not be sent in the required timeframe or is already beyond the required timeframe.
1. Special Claims staff shall receive, review and approve or disapprove all medical invoices submitted on behalf of the claimant, in accordance with 33 USC §907.
2. In general, Special Claims staff shall approve:
a. All medical, surgical, and hospital treatment and other medical supplies and services required due to the claim-related injury or occupational disease; and
b. The cost of travel and mileage incidental to the medical treatment.
i. Travel expenses shall be paid at the federal reimbursement rates available on the U.S. General Services Administration (GSA) website and the DOL DLHWC website.
c. Special claims staff shall notify the physician of C-9 treatment approvals using the “Treatment Approval” letter.
3. Special Claims staff shall ensure, prior to approval, that the medical treatment is provided by one of the following physicians within the scope of his/her practice, as defined by Ohio law:
a. Doctor of Medicine;
b. Surgeons;
d. Dentists;
e. Clinical psychologist;
f. Optometrists;
g. Osteopathic practitioners;
h. Chiropractors, but only to the extent that the treatment is for the manual manipulation of the spine to correct a subluxation (dislocation).
4. Special Claims staff shall authorize the treating physician initially selected by the claimant and shall send that physician the “Ohio Marine Industry Fund Provider” letter.
a. Special Claims staff shall not permit the claimant to change the treating physician without good cause.
b. Special Claims staff shall consult with the BWC attorney, as needed, if the claimant makes a request to change the treating physician.
5. Special Claims staff shall refer a Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) or equivalent to the medical services specialist (MSS) for review. Based upon the review by the MSS, Special Claims staff shall:
a. Approve or deny the C-9 or equivalent request or recommendation;
b. Fax the decision to the medical provider’s office; and
c. Notify the claimant by letter of the decision.
d. Significant requests for additional conditions should be staffed with BWC attorney.
6. In addition to the provisions of section V.F.2-3, above, Special Claims staff shall review a medical service invoice to ensure:
a. The HCPCS, CPT, and ICD codes are included;
b. The provider is an enrolled and active BWC provider, and the provider number is included. If the provider is not enrolled, Special Claims staff shall:
i. Pend approval of the medical service invoice; and
ii. Send the provider the Application for Provider Enrollment and Certification (MEDCO-13).
c. If the medical service invoice is approved, Special Claims staff shall:
i. Place the date, initials and his or her “A” number on the invoice;
ii. Indicate if the invoice is approved or denied and if denied, the reason for the denial; and
iii. Send the invoice to BWC Medical Billing and Adjustments (MB&A).
d. If the medical service invoice is disapproved, MB&A will send notice and the reason for disapproval to the provider and parties to the claim.
7. Vocational Rehabilitation: Special Claims staff shall consult with the BWC attorney if the claimant makes a request for vocational rehabilitation or for a Functional Capacities Evaluation (FCE).
1. Special Claims staff and the BWC attorney shall determine death benefits and rates in accordance with 33 USC §902 and §909. General provisions of those statutes provide that:
a. The following survivors may be eligible for death benefits in a Longshore claim:
i. A surviving spouse;
ii. Children of the decedent;
iii. Parents;
iv. Siblings;
v. Grandparents.
b. Reasonable funeral expenses may be paid up to a maximum of $3000.
2. When notified of the death of the injured worker/claimant, Special Claims staff shall identify the claim as “Death” in the claims management system.
2. Disputes in Longshore claims shall not be referred to the Industrial Commission or to the Alternative Dispute Resolution (ADR) process.
3. Special Claims staff shall refer claimant inquiries regarding appeal rights under the LHWCA to the Office of Workers’ Compensation Programs website for national and/or regional Longshore office phone numbers.