The best system in the country.
That’s the assessment of Ohio’s workers compensation program from a prominent Columbus attorney. Ohio is one of four states that has a private system, i.e. state-run monopoly. The major benefit: Without third-party insurers, the profit motive is removed from the program.
“I’ve always called it the workers compensation bargain,” said Phillip Fulton of Columbus-based Phillip J. Fulton Law.
High praise indeed, and a feeling shared by other attorneys in the state.
“I agree with that assessment,” Frank Gallucci of Plevin and Gallucci in Cleveland said. “But it is not a perfect system. I think as a state we need to be careful that we do not let the system be subject to political swings. We are not always using the system in the best ways.”
One way to gauge the strength of the system is the solvency of the trust fund from which claims are paid. The state had so much money in the fund in 2020 that it paid dividends to employers as a way to help offset the sting of COVID-19 shutdowns.
In three separate payments, the Bureau of Workers Compensation (BWC) sent a total of $7.88 billion to Ohio employers. Gov. Mike DeWine asked for the disbursals, and the BWC could do it thanks to some wise investing. Between July 1 and Sept. 30, 2020, the fund earned $902 million in investment income.
“There have been a few times where there have been attempts to change the system, but it’s always failed because people have a general positive view of the state monopoly,” said Thomas Schaffer of Schaffer and Associates in Toledo, a firm that has 60-plus years of experience in workers comp and social security work. “I’ve heard people say it would be possible for the bureau to not take any more premiums for 10 years and still have enough money to cover all the injuries.”
Gallucci’s firm has offices in Cleveland, Columbus and outside Cincinnati. He praised DeWine’s move, but also wondered if the money couldn’t have been used to set up a fund that would been “self-funded in perpetuity,” he said.
Fulton, who represents injured workers and who has written the main treatise on Ohio Workers Compensation Law (the fifth edition was recently published), said the fund’s large stash is not an indication that claims are not paid.
“We have our battles when it comes down to trying to make sure that benefits are fair and equitable to injured workers,” Fulton said. “Even with that I still think we have the best system.”
From 2017 to 2019, Ohio’s total benefits paid decreased from $1.491 billion to $1.463 billion to $1.406 billion in 2019. Ohio, North Dakota, Wyoming and Washington are the only states to privatize workers compensation insurance.
How to File a Workers Comp Claim in Ohio
If injured on the job, it’s vital to notify the employer immediately – or as soon as reasonably possible.
“What goes a long way toward getting a claim found legitimate is how well it’s documented,” Schaffer said. “The importance of documenting an injury can’t be stressed enough. You’ve got to document, document, document. If you have an injury, immediately report it. If there’s a witness, get the name of the witness. Tell at least a co-worker right away that you were injured.”
Schaffer suggests the following steps to take when you’re injured on the job:
- Inform your supervisor or employer immediately.
- Prepare an incident report that includes as much detail as you have available.
- Seek immediate medical treatment, even if you have to go to a company’s occupational health clinic; it documents the fact you were injured.
- File a claim with workers comp. It can be done online.
- When filing an incident report or claim, make sure you include every part of the body you believe was injured.
- Take photographs with your phone, if you’re capable of doing so.
“Sometimes injuries occur at night when there’s no foreman or boss in charge,” Schaffer said. “At a minimum tell a co-worker. Text your boss. ‘This happened, and I want to confirm this happened.’ Employers often will fight because they don’t know what happened. This all helps make things clear.
A claim can be filed within one year of the occurrence of an injury, and it’s important to follow the procedure set up by the state. It can be filed by one of three parties: The injured worker, the doctor treating the injury, or another interested party, such as the employer or spouse.
An injured worker or interested party can file the First Report of Injury (FROI) claim, either online or with a paper form. To fill the form out online, go here and click on “Complete FROI” on the right side of the page.
The FROI can be printed, filled out and filed via mail or fax (1-866-336-8352). Mail can slow the process. A claim can also be filed over the phone at 1-800-644-6262 from 7:30 a.m. to 5:30 p.m. The BWC then has 28 days to determine if a claim is legitimate.
Other than typically required information – social security number, name and address, date of injury/disease, occupation – workers must describe the accident, the body parts affected and the employer policy number when filing a claim. Medical providers must provide a causality indicator, employers the job title, date of hire and date the employer was notified.
Workers also can file a claim as an injury develops – say in the back or neck or shoulder due to repeated lifting – without a specific incident taking place.
“Document the injury as soon as the realization comes to mind that you have an injury,” Schaffer said. “Even though it may not have happened on a certain day and time, if you feel the work is causing the injury, be sure to document it. Say over two or three years you’ve been doing repetitive lifting over your head and your shoulder started bothering you. Carpal tunnel is another injury like that that happens over time.”
Survivors of a worker killed due to a job-related accident can file a claim to request death benefits.
Employer’s Responsibility for Claim
All employers are required to carry workers compensation insurance, even for part-time workers. Exceptions are present for home workers who earn less than $160 per quarter, and most volunteer workers. Businesses with more than 50 employees can self-insure, and single-member LLCs make their own decision.
Claims are paid from the state insurance trust that is funded by premiums paid by employers. The BWC works with Managed Care Organizations to coordinate care of an injured employee. When a clam is approved, the MCO takes charge and the state fund pays medical bills.
Once an employer is notified of an injury and claim, the employer can reject the claim or dispute the BWC’s decision. If disputed, a claim is heard by the Industrial Commission of Ohio (ICO), a state agency empowered to resolve workers compensation disputes.
Bureau of Workers Compensation Responsibility for Claim
The BWC will investigate the claim and determine if it is valid. It is required to respond in 28 days and attorneys say the state typically meets that deadline. The BWC website says claim decisions are made, on average, 11.1 days after the claim is received.
The BWC then pays claims, and pays the medical costs that are accepted by a state-approved medical group, called Managed Care Organizations, that has responsibility for overseeing the medical aspects of the claim.
Though Ohio has several categories for workers’ comp claims (listed below), the typical payment falls under the category of Temporary Total Disability, which means the worker cannot work for a short period of time due to an injury incurred on the job, with the amount based on the wages earned.
All medical costs are covered in a valid claim. As for benefits paid, for the first 12 weeks, workers with a valid claim receive 72% of pre-injury wages. After 12 weeks, the benefit is reduced to two-thirds of pre-injury wages. However, the figure is capped at either the statewide average weekly wage (SAWW) or the worker’s take-home pay before the injury, whichever is less. If the statewide average is higher than your weekly pay, your benefit will be capped at your weekly pay.
The minimum amount of temporary disability benefits is one-third of the SAWW, or your actual wages, whichever is lower. In 2020, the maximum benefit was $980, the minimum $316 – though workers who earned less than that amount receive the amount of wages (workers comp is not designed to give people a raise).
If you are receiving Social Security retirement benefits, the maximum allowed workers’ compensation benefit is two-thirds of the SAWW – $653 in 2020.
Ohio’s Managed Care Organizations
An Ohio worker is entitled to see his own doctor after an injury, Gallucci said. But an employer can ask the employee to go to a Managed Care Organization (MCO) as well. This is a part of the program that receives mixed reviews
The MCO is a private medical facility that the state has agreed can handle workers’ compensation cases and manage the medical portion of a claim. There are understandable concerns about seeing a doctor the worker may not know well or even be familiar with. The levels of paperwork needed also can seem intimidating.
The process for paying an approved claim works this way:
- The patient sees an approved provider, or his or her doctor if the physician is willing to take on a workers comp claim.
- The provider bills the BWC.
- The BWC sends the bill to the MCO.
- The MCO approves the cost and sends it back and the bureau pays the MCO, which pays the provider.
- Medications can be reimbursed, but the injured worker must give the pharmacist a form that will be sent to the BWC.
“That sounds a little bureaucratic, because it is,” Schaffer said. “Many people find that the time period for the claim to be processed and approved gives them a less than regular incentive to file a claim. Someone injured on a job may have heard stories from co-workers where they had to wait months, sometimes years, to get a claim approved.”
That would lead to an individual relying on his or her private health insurance to remedy an injury as opposed to workers compensation. Schaffer said that he’s read a study where only 40% of workers compensation claims nationally are pursued through workers comp as opposed to private health insurance.
It is important for all injured workers to notify any medical professional that they see that they were injured at work and are being treated for a work-related injury. The bureaucracy has led to some medical professionals to decide not to take part in workers compensation. If possible, make sure before the physician will do so ahead of time. Employers can refer workers to occupational care facilities for treatment.
“The MCO in my mind is a major flaw,” Gallucci said.
“They’re doing what they think is best,” Fulton said. “I’m OK with it.”
The state provides an MCO Report Card that evaluates every MCO’s performance in quality of medical management, return-to-work strategies and service timeliness. It can be found here.
Filing a Claim with a Self-Insured Employer
In Ohio, business with 50 or more employees may choose to administer their own workers’ comp programs, using Ohio laws and regulations. The state gives the business the option of self-insuring or using the state system. Most prefer the state system.
If a company self-insures, the claim is filed with the employer, who then makes the determination requiring medical treatment and procedures as well as benefits. Though prior authorization is usually required, the employers will pay health-care fees, and are required to pay within 30 days of receipt. This form should be used to determine where to file a self-insured claim. If there are disputes, either the employer or worker can file a Motion C-86 form to request a hearing in front of the Industrial Commission (IC).
Deadlines for Ohio Workers Comp Claims
Anyone injured on the job should notify their employer, in writing, as soon as possible. Keep a copy of the notice. Workers who have been injured while working have one year to file a claim. Those with an occupational illness have two years to file. The one year seems like a long time “until you’re the person hurt trying to deal with the system,” Gallucci said. The state bureau has 28 days to make a determination on the validity of a claim.
How to Appeal a Claim Denial
A denial of a claim does not end the process. Read the letter notifying you that your claim was denied, and try to understand the medical evidence used. If you don’t agree with the assessment, you have the right to appeal.
However, pay close attention to when you received the letter and to dates. Ohio gives you 14 days to file, so don’t waste time. If there is any confusion or concern, it may be wise to consult a workers comp attorney, who can help sort through the complex issues and bureaucracy.
An appeal can be filed online through the Industrial Commission Online Network. Just follow the login instructions and those that follow. An appeal can also be filed in writing by using the Notice of Appeal paperwork. A hearing will follow, and will be set up by the Bureau of Workers Compensation. The Industrial Commission will notify you of the time, date and location. A decision will be made within seven days.
“That means there is another body separate from the BWC that is there to make a determination as to the disputes in the claim,” Schaffer said. “That process of getting the hearing, especially during COVID, can take months.”
The first hearing is before a district officer within 45 days of the filing of an appeal. If the worker or employer appeals the decision, a second hearing is in front of a staff hearing officer. If that decision is appealed, it goes in front of the Industrial Commission Commissioners’ Panel. Workers and employers also can use the Ohio court system if they feel strongly about an issue, though that can be expensive and has no guaranteed outcome.
Eligibility for Workers Comp in Ohio
By law, all employers are required to carry workers comp insurance, even if they only have one employee. The only exception is for domestic workers (housekeepers, babysitter, gardeners) who earn less than $160 in a quarter. Even part-time employees must be covered – though their benefits would be prorated according to the number of hours worked. Self-employed also must carry coverage, though if there are no employees the self-employed individual can decide if he or she wants to carry the coverage.
An employee is defined as “an individual who is employed to provide services to an employer for compensation that is reported as income from wages.”
Ohio’s BWC monitors and enforces workers’ compensation law, and has penalties for businesses that fail to comply or allow coverage to lapse. If an incident occurs when coverage has lapsed, the employee can sue the employer for all damages and expenses, or file a workers compensation claim and the BWC would require the employer to reimburse the entire cost of the claim.
Benefits: What Does Workers Comp Cover in Ohio?
Ohio offers several types of compensation via benefits. Those whose claim has been allowed may qualify for benefits even if they have not lost time from work due to the injury.
Medical care typically covers expenses related to the injury. Wage replacement kicks in when employees miss seven days of work. These payments are usually made on a weekly basis, and depend on individual circumstances described below.
Eligibility for benefits begin after a worker misses more than seven days of work. The first seven days are only payable if a worker missed 14 consecutive days of work.
Benefits typically cover all expenses for the medical care an employee receives for the injury. These costs include doctor visits, hospital stays, medications, surgeries, rehab, home and vehicle modifications and more.
In addition, Ohio offers several different types of compensation based on the injured workers’ circumstances. These are listed below.
Temporary Total Compensation
This benefit compensates an injured worker who is totally disabled from work for a short period of time. TT is generally the initial award of compensation paid for lost wages. Typically the award pays 72% of pre-injury wages for 12 weeks, then two-thirds. The first seven days are not eligible for benefits. The awards are subject to maximums and minimums, described previously.
Workers in Ohio receive benefits until they are:
- Able to return to work, either at their actual job or another position the worker can fill.
- Your doctor reports your conditions has improved as much as it can
- You receive claims for the maximum 200 weeks.
Medical benefits typically cover all reasonable expenses related to the injury. The Managed Care Organization has significant input in determining the validity of medical assessments, and charges. A workers who sees a private doctor must tell the physician the assessment is a work-related injury. Some doctors do not want to participate in the state system due to the bureaucracy and requirements. Employers can refer a worker to a care group, or the employee can go to an MCO.
Wage Loss Benefits
Working wage loss is payable when the injured worker takes a job other than his or her former position. Non-working wage loss is payable when the injured worker is released to return to work with restrictions but finds work at a lower income level. Ohio pays two-thirds of the difference between pre-injury weekly wages and earnings at the new job or position. If, for example, you were earning $1,000 per week and because of injury had to take a job that pays $700, the difference would be $300. The benefit would be two-thirds of $300, or $200. These benefits are payable for up to 200 weeks.
Workers also are entitled to wage loss benefits while they seek work that accommodates the partial disability. These benefits last up to 52 weeks; if the worker finds a job, half of those weeks could be added to the 200-week limit for benefits after the worker has found a job.
Permanent Total Disability Benefits
Workers are considered permanently disabled if they have lost use of both hands, arms, legs, or eyes, or any combination of those body parts, or it they can’t hold long-term jobs due to injury. With permanent disability workers receive weekly payments at the temporary disability rate for the rest of his or her life.
Permanent Partial — Scheduled Loss Benefits
This is paid for severe injury such as amputations, sight or hearing loss. Applicants must apply with a Motion (C-86) and provide supporting medical evidence. Consideration is based on the nature of the injury as well as when it occurred. The weekly amount is equal to the statewide average weekly wage. A state schedule determines how long the benefit is paid. These determinations sound cold and bureaucratic. Loss of a hand, for instance is paid for 175 weeks, a leg for 200 weeks. The schedule even prorated weeks for each finger, toe, eye and hearing loss. If the injury occurred in 2020 when the average wage was $980, total benefit for amputation of a leg would be $196,000.
Permanent Partial Benefits – Percentage Loss
When permanent damage other than loss of one of the scheduled body parts lingers after an injury, a benefit for residual loss would be available. In Ohio, these are typically called C-92 awards. Examples: Lost sight if an eye is injured, inability to lift an item over a certain weight after a shoulder injury, not being able to fully extend an arm after it is broken. A doctors assigns a percentage of disability and benefits are calculated at two-thirds of the worker’s weekly wage, with a limit of one-third of the statewide weekly average wage. Benefits are prorated to last the number of weeks equivalent to the percentage of disability, times 200 weeks. If a disability is considered 25%, payments last 50 weeks. If the disability is 90% or more, payments last all 200 weeks.
Ohio also offers a death benefit to the survivors of a deceased worker whose death was caused by an incident at work, either instantly or as a result of injury or disease. Accrued compensation – the unpaid portion of a benefit – is paid to an injured worker’s dependents at the time of his or her death. Claims must be filed within one year of the worker’s death. The benefit is equal to two-thirds of the deceased workers’ wages or salary, subject to a minimum or maximum weekly amount that changes annually. The death benefits may include money for funeral expenses up to $7,500.
Returning to Work in Ohio
The worker, the employer and the state all want people back to work as soon as they safely can. Ohio tries to treat each case individually, because all are different. As the state web site points out, a construction worker with a broken leg will be off work longer than office worker with the same injury.
The state will determine an optimal return-to-work date as part of the claims process. Medical providers – including a physician and an MCO — play a key role in determining treatment and a targeted date to return. The doctors will provide guidance on restrictions, or if a worker needs to temporarily do a different job or work less than full-time.
The goal is for the MCO, physician and employer to design a return-to-work program personally tailored to each individual, and his or her injury.
- N.A. (ND) What Benefits Does the Ohio Bureau of Workers’ Compensation Pay? Retrieved from https://www.ohiodisabilitylaw.com/workers-compensation-lawyers/workers-compensation-benefits/
- N.A. (2020, July 7) Understanding workers’ compensation. Retrieved from https://info.bwc.ohio.gov/wps/portal/gov/bwc/for-employers/workers-compensation-overview/understanding-workers-compensation