Claims Procedure

Claims Procedure for an Ohio Worker's Comp Case

Understanding the Worker's Comp Claims Process in Ohio

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.

Our Columbus workers' compensation attorney from Zamora & Hogan Co., L.P.A. can make sure that you take the right action. Call us today at (614) 344-6822.

Steps to Report Your 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."

How the Workers' Compensation System Operates in Ohio

Workers' compensation in Ohio is a system designed to benefit employees who suffer work-related injuries or illnesses. The Ohio Bureau of Workers' Compensation (BWC) is the state agency responsible for administering workers' compensation in Ohio.

Here's an overview of how the workers' compensation system works in Ohio:

Coverage: Most employers in Ohio are mandated to carry workers' compensation insurance. This includes private employers with one or more employees and public employers.
Employee Eligibility: Almost all employees are covered under Ohio's workers' compensation system. This includes full-time, part-time, seasonal, and temporary workers.
Injury Reporting: Employees must report work-related injuries or illnesses to their employer immediately. Employers may have specific procedures for reporting injuries.
Employer Responsibilities: Once an employer is notified of a workplace injury, they must report the incident to the Ohio BWC. Employers are also responsible for providing injured workers with necessary medical treatment.
Medical Treatment: Injured workers are qualified for medical treatment for work-related injuries. The BWC may have a list of approved healthcare providers, and workers typically need to seek treatment from these approved providers.
Compensation Benefits Available in Ohio: Workers' compensation benefits in Ohio may include medical benefits, compensation for lost wages, and disability benefits. The amount and duration of benefits rely on the nature and severity of the injury.

Temporary Total Disability (TTD): TTD benefits are provided to workers who cannot return to work due to work-related injuries or illnesses. These benefits generally cover a percentage of the employee's average weekly wage.
Permanent Partial Disability (PPD): If a worker sustains a permanent impairment but can still work, they may be eligible for PPD benefits. The amount is determined based on the type and extent of the permanent impairment.
Vocational Rehabilitation: In matters where an injured worker cannot return to their previous job, vocational rehabilitation services may help them re-enter the workforce in a new capacity.
Settlements: In some cases, workers may settle with the employer's workers' compensation insurer. This could involve a lump-sum payment in exchange for giving up future benefits.
Appeals: If there is a dispute over a workers' compensation claim, the employer or the employee can appeal the decision. The Industrial Commission of Ohio handles these appeals.

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 Columbus, Ohio 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 Ohio 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.

Pen to Paper - workers' comp claims procedure

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.

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THE OPINIONS THAT MATTER MOST

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“Up front and honest”
Abbie has been nothing but amazing with my workman's comp claim. She is up front and honest about everything regarding my claim. She is down to earth and very approachable. She made sure they approved and paid for everything within my claim. If I ever needed her again I would absolutely choose her. I will also refer others to her as well.

- F. Towns
“Fantastic”
Wish I had contacted Chuck Zamora earlier in the workers comp process. Him and his group were fantastic, can't thank them enough.

- Daniel S.
“Highly recommended”
Mr Chuck helped me with a worker compensation claim,they worked with me throughout the process from day one until the end. He is respectful,knowledgeable on what he does and always open to answer your questions or concerns.....highly recommended

- Former Client
“Extremely knowledgeable”
Mr Zamura was extremely knowledgeable with all phases of my Ohio Police and Fire disability claim. He followed up on all aspects and made sure I was informed and up to date with everything going on. He was prompt at returning calls and emails if needed. His application paperwork was done very thoroughly which helped the process go much easier with the OP&F review board. His staff was great also. I would recommend him to anyone looking into a possible disability claim. I am from Akron and he is in Columbus. I only made 2 trips down to see him face to face. Everything else was done electronically or by phone.

- Steve H.
“A professional with high ethical standards”
I hired Mr Zamora and could not have been happier. He was a professional with high ethical standards and represented me well, gave me excellent legal advice, peace of mind through the process and handled everything efficiently and effectively! I would highly recommend him to any of my fellow police officers or fireman!

- Don M.
“ALWAYS treated me with kindness, dignity, & respect”
If I had to go through such a situation with BWC I’m forever grateful it was with these people walking through it together...Charles & his secretary Iesha & Danielle. They ALWAYS treated me with kindness, dignity, & respect. They treated my situation as if it just as important to them as it was to me. They ALWAYS made me feel like I was their only one... trust me they have many & for good reasons. It makes my heart happy knowing there are still hardworking wonderful people out there doing what they do & fighting for the right reasons because they genuinely care. I’ll always feel fortunate to have met them. 🙏❤️🙏

- Erica
“If you've been injured at your job then you need Abbie from Zamora & Hogan Co., L.P.A. She is the best!”
If you've been injured at your job then you need Abbie from Zamora & Hogan Co., L.P.A. She is the best! She is smart, patient, and hard working. Attorney Abbie Hogan will get you the maximum compensation you deserve.

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“I would highly recommend to my family and friends.”

- Trish R.

What is the 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.

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Appeals to Court & Mandamus Actions in Columbus

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.

How Our Workers’ Compensation Lawyer Can Help You

We can assist you by:

Comprehensive Case Evaluation: We conduct an initial assessment of your injury and medical records to determine eligibility and outline your options. By reviewing your case in detail, we help ensure that all necessary documentation and evidence are submitted accurately.
Documentation and Filing Support: Filing an error-free claim is essential for a smooth process. We assist with gathering medical records, accident reports, and other documentation to build a solid foundation for your case.
Medical and Financial Benefit Advocacy: We work closely with healthcare providers to ensure you receive the necessary treatments and that your medical benefits are honored. In addition, we negotiate with the BWC and your employer to maximize your financial compensation, helping you secure the wages and benefits you’re entitled to under Ohio law.
Appeals Representation: If your claim has been denied or disputed, we can help you prepare for the appeals process, gather additional evidence, and represent you at hearings. Our legal experience with the Ohio Industrial Commission ensures that your appeal is handled strategically, increasing your chances of a favorable outcome.
Long-Term Support for Complex Cases: Navigating the complexities of ongoing benefits can be difficult for injuries that result in permanent or long-term disability. We help handle your case over the long term, ensuring that any change in your medical condition or work status is accounted for in your benefits.

Contact Us Today

If you’re facing a workplace injury or occupational illness, it’s crucial to have knowledgeable legal support. The workers’ comp claims process can be very challenging, but with the right guidance, you can focus on healing while knowing that experienced professionals are managing your case.

At Zamora & Hogan Co., L.P.A., we are here to help you confidently navigate the system. We offer a personalized approach, understanding that each case is unique and requires tailored attention. Whether you’re in the early stages of filing a claim, need help understanding your benefits, or wish to appeal a denied claim, we are here to advocate for you. With our guidance, you can secure the workers' compensation benefits to support your recovery and protect your financial future.

The above information is intended solely as an overview. It is advisable to contact our Columbus, Ohio worker's compensation attorney to assess the merits of your claim.

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