Immediately after numbering and recording, all new claim applications, except applications of employees of self-insuring employers, 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.
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 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.
Immediately after numbering and recording, all applications for death benefits 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.
"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.
The employer may require a medical examination of the employee as provided in section 4123.651 of the Revised Code under the following circumstances:
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 applies to claims where the date of injury or the date of disability in occupational disease claims occur on or after August 22, 1986.
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 will be referred to the appropriate district hearing officer for further consideration. In cases of temporary total disability, a medical examination performed within the past thirty days 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.
The doctor's report shall be filed with the bureau immediately upon its receipt. Failure of the employer to comply with this rule will not delay further action in the claim, unless it is established that the omission was due to causes beyond the employer's control.
The evidence 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.
Ohio Admin. Code 4123-3-09
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