Notices
Timeframes
Benefits
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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. |
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| Notices |
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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? |
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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. |
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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? |
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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. |
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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.) |
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What other
notices are required? |
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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).) |
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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. |
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| Timeframes |
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How long
does the insurer have to accept or deny a fatal claim? |
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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. |
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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. |
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Are interim
temporary disability or fatal benefits due prior to the insurer's notice of acceptance
or claim denial? |
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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. |
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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. |
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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. |
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| Benefits |
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Is the insurer
responsible for paying for the burial or funeral expenses? |
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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. |
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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.
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What are
the benefits for the surviving spouse and dependents? |
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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. |
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Beneficiary(ies)
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Maximum
monthly total
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| 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 |
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* 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. |
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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. |
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How do I
determine whether a dependent is eligible for benefits? |
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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.
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