2.02.2012

Self-insured Claim Certification and “Continuing Jurisdiction”

For self-insured employers, the decision to reject a claim will lead to a hearing with the Industrial Commission of Ohio, but the decision to certify a claim is seemingly absolute. Thankfully, though, a mechanism does exist for a self-insured employer to dispute a claim post-certification where certain grounds exist. A recent Ohio appellate decision, Lane v. Bur. of Workers’ Comp., 2012-Ohio-209, (2nd Dist. C.A. Jan. 20, 2012), does a good job of reviewing the grounds for “continuing jurisdiction.” 
The Lane case involved an injured worker who, on a Saturday, was arrested for a license suspension and, at the time of his arrest, complained of a left shoulder injury. On the subsequent Monday, the injured worker allegedly injured his left shoulder while pushing a vegetable bin at work. Although this was an unwitnessed incident, the injured worker immediately sought initial treatment and was diagnosed with a shoulder strain, and upon receipt of the initial treatment record, the employer certified the claim for left shoulder strain based on the available information. It should be noted, though, that claim certification was done without knowledge of the arrest that had occurred two days prior. Subsequent to the claim certification, the employer became aware of the arrest and the injured worker’s disclosure of his prior left shoulder injury. The employer filed a motion, alleging that the Industrial Commission had jurisdiction under O.R.C. 4123.52 to “correct a potential fraud and/or mistake of fact” regarding the certification of the claim. The Industrial Commission ruled in the employer’s favor on the basis that discovery of the arrest records constituted “new and changed circumstances” allowing for the exercise of continuing jurisdiction. The claim was denied in its entirety at a Staff Hearing.
Having exhausted his administrative remedies, the injured worker appealed the denied claim in common pleas court, and the trial court, following a bench trial, ruled in favor of the employer. In deciding that the injured worker was not entitled to participate in the workers’ compensation system, the trial court noted that the employer’s prior claim certification as a self-insured employer was no longer in effect after the Industrial Commission assumed jurisdiction, and concluded that the injured workers’ alleged injury was not in the course of, and arising from, his employment. An appeal to the court of appeals was then undertaken by the injured worker.
In its decision to affirm the judgment of the trial court, the appeals court cited O.R.C. 4123.52 and State ex rel. Baker Material Handling Corp. v. Indus. Comm., 69 Ohio St.3d 202, 1994-Ohio-437, regarding continuing jurisdiction. In Baker, the Ohio Supreme Court referenced the statutory provisions of O.R.C. 4123.52 and held that where there were instances of new and changed conditions, fraud, or clerical error, the Industrial Commission had jurisdiction to modify a certified claim. The appeals court also stated that subsequent cases have further expanded the grounds for continuing jurisdiction to include new and changed circumstances, mistakes of fact and law, and “error by an inferior tribunal.”  It is this comprehensive list of “exceptions” that a self-insured employer should be mindful of when managing its claims, as more often than not, new information is discovered post-certification.


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