|
|
| |
Effective
Jan. 1, 2010, Senate Bill 110 enhances death benefits for surviving
family members by expanding the scope of the burial benefit and doubling
it to 20 times the state average weekly wage; creating a new benefit
for college-aged surviving children; and clarifying that if the worker
has no surviving spouse or dependents, the insurer must pay the full
remainder of permanent partial disability payments to the worker's
estate. (See OAR
436-060-0012.)
We have included some helpful tips we've gathered from working with
the industry for processing fatal claims. These suggestions are intended
to help you process fatality claims; however, they are not a substitute
for following the requirements of statute and rules.
This document will be updated as we receive additional questions.
If you have questions about the information contained in this document,
please contact the Benefits
and Certifications Unit at 800-452-0288. |
| |
|
|
|
| Notices |
 |
When
a claim has been filed and the worker dies before a compensability
determination is made, is the insurer required to accept or deny the
claim? |
 |
Yes.
In all circumstances, the insurer is required to issue a Notice of
Acceptance or claim denial for all claims, regardless of the cause
of death. The Notice of Acceptance or denial should be addressed to
the worker's estate. |
|
|
If
the worker dies after the claim is accepted, but before a Notice of
Closure is issued, is the insurer required to close the claim? |
|
Yes.
If the claim has been accepted and classified as disabling, the insurer
must issue a Notice of Closure, regardless of the cause of death.
The Notice of Closure should be addressed to the worker's estate. |
| |
Tip:
All permanent partial disability awarded by the Notice of Closure
must be paid to the worker's surviving beneficiaries or estate. (See
ORS 656.218.) |
|
|
What
other notices are required? |
|
Other
notices required under Oregon Administrative Rules chapter 436 intended
for the worker are not required when the worker is deceased. (See
OAR
436-060-0013(3).) |
| |
Tip:
Consider the purpose of the notice. If the notice is intended for
the sole use of the worker, it may not be appropriate to send it. |
| |
| |
| |
| Timeframes |
|
How
long does the insurer have to accept or deny a fatal claim? |
|
The
insurer has 60 days from the date of knowledge to investigate the
accident or cause of death and issue a notice of acceptance or deny
the claim. |
| |
Tip:
The insurer has 60 days to accept or deny the worker's claim. However,
if there are no questions or concerns regarding the compensability,
the insurer may want to issue the acceptance notice early. This may
alleviate some of the stress the family is dealing with regarding
funeral bills and financial responsibilities. |
|
|
Are
interim temporary disability or fatal benefits due prior to the insurer's
notice of acceptance or claim denial? |
|
In
regard to instant fatality (within 24 hours of the injury), fatal
benefits payable to beneficiaries are not due while the claim is in
a deferred status. If the claim is accepted for a fatality, the initial
payment of fatal benefits to beneficiaries must be paid no later than
the 30th day after the notice of acceptance. (See OAR
436-060-0150(8).)
The initial payment must include any fatal benefits due for the deferred
period unless previously paid. Subsequent monthly payments to beneficiaries
must be made in a predictable monthly sequence. (See OAR
436-060-0150(9).) Fatal benefits are not paid in advance; they
are paid after they have accrued. |
| |
Tip:
An insurer may begin paying fatal benefits prior to accepting the
worker's claim (though it is not required). If compensability is not
in question and you're simply gathering additional information before
issuing the acceptance notice, you may begin paying fatal benefits.
This may be helpful to the worker's family, especially if the worker
was the primary or sole wage earner. |
| |
|
| |
In
regard to delayed fatality (more than 24 hours post injury), the insurer
should determine if interim temporary disability benefits are due
and payable. The first payments of interim temporary disability benefits
are due within 14 days of the date of knowledge. (See OAR
436-060-0150(5).) Subsequent interim temporary disability benefits
must be paid at least once every 14 days. (See OAR
436-060-0150(6).) Interim temporary disability benefits are due
until the date of death or denial. If death is determined to be compensable,
eligibility for fatal benefits begins on the date of death. |
| |
|
|
|
| |
|
| Benefits |
|
Is
the insurer responsible for paying for the burial or funeral expenses? |
|
If
the worker dies as a result of a compensable workers' compensation
injury or occupational disease, the insurer is responsible for paying
expenses related to the funeral and disposition of the body. The insurer
should pay the expenses up to 20 times the state's average weekly
wage. (See Bulletin
111 for current amount.)
Funeral establishments are not required to directly bill the insurer.
If the insurer receives direct billing for related expenses, it may
directly pay the establishment. If the insurer receives a reimbursement
request for related expenses, it may directly pay the requestor. Any
unpaid balance must be paid to the worker's estate no later than 60
days from date of acceptance. |
| |
Tip:
To avoid questions about what expenses have been paid and remain unpaid,
the insurer may consider sending a copy of the paid and unpaid bills
(invoices) to the worker's estate. |
|
|
What
are the benefits for the surviving spouse and dependents? |
|
Unlike
temporary disability benefits, fatal benefits are determined by the
state's average weekly wage, not the worker's average weekly wage:
The current total combined monthly benefit for all beneficiaries is
$4,643.36. The benefit amounts are adjusted annually, please consult
Bulletin
111 for up-to-date information. |
| |
|
| |
| |
|
|
Beneficiary(ies)
|
Maximum
monthly total
|
| Spouse |
$2,321.86 |
| *Child
(dependent on surviving spouse) |
$348.26 |
| *Child
(not dependent on surviving spouse) |
$870.65 |
| *Child
(no surviving spouse) |
$870.65 |
| Children
(age 18 to 23 without a living parent) |
$2,321.86 |
| *Other
dependents (combined max.) |
$348.26 |
|
| |
|
| |
*
Children (up to age 18 or 23 if attending higher education).
* Other dependents are persons that actually received at least
50 percent of average monthly support from the worker during the previous
12 months. |
| |
|
| |
Tip:
For high-wage earners, the spousal benefit may be less than 66 2/3
percent of the worker's average weekly wages. The insurer may want
to explain this to the surviving spouse so he or she can budget accordingly. |
|
|
How
do I determine whether a dependent is eligible for benefits? |
|
Ask
for the following documentation:
Spouse or domestic partner: Marriage certificate, certificate
of registered domestic partnership, or divorce decree.
Children: Birth certificate or adoption paperwork
Children in higher education: School records to confirm registration
and course load to confirm attending at least half-time status.
(see ORS
656.204(8)(c).)
Other dependents: Evidence that the dependent received at least
50 percent of their average monthly support from the worker during
the prior 12 months.
|
