4121-3-13. Disputed self-insuring employers' claims

(A) In the event there is a dispute or disagreement between the employee or an eligible applicant and the self-insuring employer that concerns a contested claims matter, the claim shall be referred to the commission for hearing.

(B) Upon receipt of a notice of a dispute or disagreement that concerns a contested claims matter, the bureau of workers' compensation shall immediately notify the parties of existence of the dispute or disagreement, and shall within seven days refer the matter to the commission as a disputed claims matter.

(C) In the event that the self-insuring employer fails to respond to a request for compensation and benefits made by an injured worker within thirty days of such a request, or pursuant to paragraph (B) of this rule the self-insuring employer disputes an application for compensation or benefits, the commission shall schedule the contested claims matter for hearing.

(D) Prior to the hearing in a contested claims matter the parties or their authorized representatives shall file the information necessary to comply with the provisions of paragraph (A)(1) of rule 4121-3-09 and paragraph (A)(2) of 4121-3-09 of the Administrative Code. Such information shall include, but not be limited to, medical reports received by the parties or their authorized representatives from the treating physician and physicians who have seen the injured worker in consultation for the allowed injury or occupational disease for which the claim has been filed.

(E) Notwithstanding paragraph (D) of this rule, a self-insuring employer, or its authorized representative, shall provide to the commission and to the injured worker, or the injured worker's representative in claims where the injured worker is represented, the following information in writing, prior to the date of hearing of a contested claims matter:

(1) A copy of the first report of injury, occupational disease, or death, or an equivalent document; and

(2) A statement listing the specific conditions that are recognized in the claim by the self-insuring employer, including conditions that were originally recognized as related to the injury or occupational disease for which the claim has been filed, as well as any conditions that are subsequently recognized by the self-insuring employer as being related to the injury or occupational disease; and

(3) Where the contested claims matter concerns a dispute as to the full weekly wage or average weekly wage, the information used to calculate the full weekly wage or average weekly wage, depending on which is at issue, shall be submitted unless the full weekly wage or average weekly wage had been previously established by a final order of the commission; and

(4) A statement setting forth the date of last payment of compensation and the date of the last payment of a medical bill where the employer intends to raise the issue of the statute of limitations pursuant to section 4123.52 of the Revised Code.

(5) A statement setting forth the date of last payment of a medical bill where the contested claims matter concerns a dispute over entitlement to, or extent of, medical benefits.

(6) A statement setting forth the date of last payment of compensation where the contested claims matter concerns entitlement to compensation.

(F) The information in paragraphs (D) and (E) of this rule is not to be provided to the commission or to the injured worker if the injured worker is unrepresented, or to the injured worker's representative in cases where the injured worker is represented, by the self-insuring employer if the information was previously filed with the commission or the bureau of workers' compensation, and the information is part of the claim file folder within the possession of the bureau of workers' compensation.

(G) Except as herein provided, the processing of contested claims matters where the employer is a self-insuring employer shall be in conformity with rule 4121-3-09 of the Administrative Code.

(H) Nothing in this rule shall inhibit or diminish the authority, and attendant powers, as provided in Chapters 4121. and 4123. of the Revised Code and agencies 4121 and 4125 of the Administrative Code, of the commission and its hearing officers to fully adjudicate contested claims matters.

Five Year Review (FYR) Dates: 11/09/2016 and 02/01/2021
Promulgated Under: 119.03
Statutory Authority: 4121.30, 4121.31, 4121.36
Rule Amplifies: 4121.36 , 4123.35
Prior Effective Dates: 10/17/1968, 12/11/1978, 4/1/2004, 6/1/2008, 12/16/2012

Prior History: (Effective: 12/16/2012
R.C. 119.032 review dates: 09/07/2012 and 02/01/2017
Promulgated Under: 119.03
Statutory Authority: 4121.30, 4121.31, 4121.36
Rule Amplifies: 4121.36, 4123.35
Prior Effective Dates: 10/17/1968, 12/11/1978, 4/1/2004, 6/1/2008 )