Supreme Court of Ohio and the Ohio Judicial System...3033 Kettering Blvd. Suite 201 Dayton, Ohio...

IN THE SUPREME COURT OF OHIO

tate ex. ReL Laura Baker649 Stone Ridge Drivepringboro, OH 45066

Relator,

S.

teven Buehrer, Adniinistrator)hio Bureau of Workers' Compensation0 West Spring Streetolumbus, OH 43215

Respondent.

^ ^..^. ^

Case No.

ORIGINAL ACTION SEEKING A WRITOF MANDAMUS OR ALTERNATIVEWRIT

(Affidavit Attached)

RELATOR'S COMPLAINT FOR WRIT OF MANDAMUS

HOCHMAN&PL:fJNKEITCO., L.P.A.

3033 Kettering Blvd.Suite 201

Dayton, Ohio 45439

IOCHMAN & PLUNKETT CO., L.P.A.iary D. Plunkett (0046805);rett R. Bissonnette (0076527) (COUNSEL OF RECORD)033 Kettering Boulevardoint West, Suite 201layton, Ohio 4543937/228-266637/228-0508 (Fax Number)

eys for RelatorBaker

....... ......... -^;

- ------- ------

^ ,., .

„'. . >..l. 1 ^^ 1 r ^i

1

COMPLAINT FOR WRIT OF MANDAMUS

Relator Laura Baker hereby files her Complaint for a Writ of Mandamus, seeking an Order from

Court directing Steven Buehrer, Administrator of the Ohio Bureau of Workers' Compensation, to

out his statutory duty to consider the settlement application pertaining to Relator Laura Baker's

' compensation claim. For her Complaint in Mandamus, Relator Laura Baker ("Relator") states as

JURISDICTION

1. This Original Action is brought pursuant to Section 10 of the Rules of Practice of the Supreme

Court of Ohio and Article IV, Section 2 of the Ohio Constitution.

2. Nomandamus action is pending in this or any other court regarding the actions that are the

subject of this Complaint.

3. Relator Laura Baker is a workers' conlpensation claimant with an injury occurring on November

10, 2008.

4. Respondent Steven Buehrer is the Administrator of the Ohio Bureau of Workers' Compensation

("BWC"), which is a state agency authorized by various provisions of the Ohio Revised Code to

administer workers' compensation claims, pay workers' compensation betlefits, and settle state-

funded workers' compensation claims.

STATEMENT OF FACTS

5. Relator incorporates all facts set forth in the preceding paragraphs 1 through 4 as if fully re-

written llerein.

6. Relator suffered an injury on November 10, 2008 which arose from, and which occurred in the

course of, employment with Advance America Cash Advance Center, when she was struck on the

head by a gunman in the midst of a robbery.

Relator filed a workers' compensation claim, which was recognized for the physical conditions

"contusioil scalp (head);" and "sprain of neck."

HOCHMAN&PLUNKMCO., L.P.A.


Dayton, Ohio 45439

8. Subsequently, Relator's claim was amended to include the additional diagnosis of "post-traumatic

stress disorder" and "major depressive disorder single episode severe without psychotic features."

9. Relator has been unable to return to work since November 10, 2008.

10. Relator was examined by Dr. Charles Walters on August 8, 2012, and Dr. Walters concluded that

Relator had continuing severe psychological symptoms, and that she was permanently and totally

disabled as a result of the allowed psychological conditions.

11. Relator filed an application for permanent and total disability benefits. Following the filing, the

Industrial Commission of Ohio scheduled an examination with Dr. Giovanni Bonds on December

14, 2012. Following the exatnination, Dr. Bonds issued a report which included his opinion that

she was incapable of work activity due to the severity of the psycliological symptoms.

12. Following the issuance of Dr. Bonds report, the Industrial Commission of Ohio issued a tentative

order on January 25, 2013, which granted Relator's application for permanent and total disability

compensation, to commence effective August 8, 2012.

13. Relator has continued to receive permanent and total disability compensation benefits since the

aforementioned date, at a rate of $613.20, bi-weekly, and will likely continue to receive such

benefits for the remainder of her life.

14. The Bureau of Workers' Compensation evaluates settlements using a publicly-issued life table

(the "BWC Life Table"). The BWC Life T'able discounts a stream of permanent and total

disability compensation benefits to present value for evaluation and settlement purposes, using a

discount rate publislied annually by the BWC. Currently, the discount rate is four percent (4%).

'I'he BWC Life Table additionally provides for a factor which considers the injured worker's

present age, for purposes of estimating a life expectancy, for settlement purposes.

15. Additionally, Relator is entitled to continue to receive medical benefits, in the forin of the BWC's

payment for treatment which is reasonably, necessary, cost-effective, and related to the allowed

conditions in her workers' compensation claim (also known as the "Miller criteria").HC)Cf3MAN&PLi JNKh; IT

CO., L.P.A.3033 Kettering Blvd.

Suite 201

Dayton, Ohio 45439

16. Relator continues to receive medical benefits paid for by the BWC, and will likely continue to

receive such benefits for the extended future.

17. On February 19, 2013, Relator filed a BWC Form C-240 application for settlement with the

BWC. Included in the settlement demand were the Relator's calculations of the present value of

the stream of future permanent and total disability compensatiorz benefits, as well as a demand for

settlement which encompassed the value of future medical treatment likely to be paid for by the

BWC. The settlement application did not require the signature of the employer, as Relator is no

longer employed by the employer, and the employer's "experience period" llad passed as of the

date of the filing of the application for settleinent. Relator included all forms and affirmations

required by the BWC to settle a claim under which an injured worker was currently receiving

permanent and total disability compensation benefits.

18. On July 17, 2013, the BWC dismissed Relator's C-240 application for settlement, finding that

"settlement of this claim is not in the Ohio Bureau of Workers' Compensation's best interest at

this time." The BWC did not further elaborate on the reasons for the failttre to make an offer.

HOCHMAN&PLUNKEITCO., L.P.A.


Dayton, Ohio 45439

19. Relator, through counsel, submitted a letter to the BWC in response to the settlement application

dismissal, and deinanded that the BWC reconsider the dismissal and make an offer. The BWC

refused, without elaborating on the reasons for the dismissal.

20. Thereafter, Relator continued to receive workers' compensation benefits in the form of medical

coverage, prescription medication, and permanent and total disability compensation benefits,

21. On May 2, 2014, Relator filed a second C-240 application for settlement, including similar

calculations to those submitted with the first C-240 application for settlement.

22. Seventeen days after the filing of the second C-240 application, on May 19, 2014, the BWC

dismissed the application for settlement, without elaborating further as to the reasons why. The

dismissal indicated that simply "the BWC does not wish to settle this claim at this time."

4

23. Relator, through counsel, sent a second demand upon the Administrator of the BWC to carrv out

his statutory obligation. The Bureau of Workers' Compensation reinstated the settlement

application.

24. Respondent, Bureau of Workers' Compensation, dismissed the settlement application a third time

on July 11, 2014. Relator's counsel submitted another demand to reinstate the settlement

application, but Respondent has refused to reconsider its dismissal of the settlement application

and consideration of the same.

25. Claimant continues to receive benefits, but desires to settle her workers' compensation claim

notwithstanding the multiple disrnissals of her settlement applications.

COUNT ONE - WRIT OF MANDAMUS

26. Relator incorporates all facts set forth in the preceding paragraphs 1 through 24 as if fully re-

written herein.

27. Respondent Administrator, BWC, has a clear legal duty to consider applications for settlement of

workers' compensation claims, as set forth in R.C. 4123.65, a statute which lias previously been

enforced in similar situations by this Court in State ex. rel. Johnston v. Ohio BWC, 92 Ohio St.3d

463, 475, 751 N.E.2d 974, 2001-Ohio-1284.

28. The disniissal of a settlement application is not appealable, pursuant to R.C. 4123.65.

29. Respondent Administrator, BWC, has failed to execute his lawful duty to consider multiple

settlement applications filed by Relator, without justification or excuse.

30. Relator has no adequate remedy at law. The only remedy available to Relator to address the

improper and unlawful actions of the Administrator of the BWC is tllrough an action in

mandamus, seeking a writ of mandamus from this Court directing Respondent, Administrator of

the BWC, to consider Relator's settlement application.

31. Pursuant to S.Ct.Prac.R. 10.4(B), a memoranduni in support of Relator's Complaint seeking a

writ of mandamus is attached hereto and incorporated by reference as if fully re-written herein.HOC'.IIMAN&PLUNC=

CO., L.P.A.

3033 Kettering Blvd.Sitite 201

Dayton, ohio 45439

WHEREFORE, Relator liaving shown a right to relief, Relator prays for all appropriate relief,

but not limited to, a`Vrit of Mandamus from this Court directing the Administrator of the BWC

consider Relator's settlement application.

Respectfully submitted:

HOCIIMAN & PLUNKETT CO., L.P.A.

Gary D. Plunkett (0046805)Brett R. Bissonnette (0076527)3033 Kettering BoulevardPoint West, Suite 201Dayton, Ohio 45439937/228-2666937/228-0508 (Fax Number)brettbissonnettena hochmanplunkett.com

Attorneys for RelatorLaura Baker

CERTIFICATE OF SERVICE

I certify that a true and accurate copy of Relator's Complaiirt for Writ of Mandamus and;companying Memorandum in Support of Complaint for Mandamus was sent to the foregoing onugust _2, 2014:

Administrator, Bureau of Workers' Compensation30 West Spring StreetColumbus, OH 43215

v.^: - -1 ^•...^"

Brett Bissonnette

HOGIMAN&.PLUNI^TrCO., L.P.A.


Dayton, Ohio 45439

IN THE SUPREME COURT OF OHIO

,tate ex. Rel. Laura Baker Case No.649 Stone Ridge Drivepringboro, OH 45066

Reiator, ORIGINAL ACTION SEEKING A WRITOF MANDAMUS OR ALTERNATIVEWRIT

Steven Buehrer, Administrator . (Affidavit Attached)Ohio Bureau of Workers' Compensation30 West Spring StreetColumbus, OH 432] 5

Respondent.

RELATOR'S MEMORANDUM IN SUPPORT OF HER COMPLAINT FOR WRIT OFMANDAMUS

HOCHV1AN&PLUNKksFrCO., L.P.A.


llaytorr, Ohio 45439

HOCHMAN & PLUNKETT CO., L.P.A.Gary D. Plunkett (0046805)Brett R. Bissonnette (0076527) (COUNSEL OF RECORD)3033 Kettering BoulevardPoint West, Suite 201Dayton, Ohio 45439937/228-2666937/228-0508 (Fax Number)brettbissoiinetteg.hochmanplunkett.cornAttorneys for RelatorLaura Baker

MEMORANDUM IN SUPPORT OF COMPLAINT FOR WRIT OF MAIdbAMUS

This Original Action for a Writ of Mandamus is being filed to direct Respondent, the Bureau of

orkers' Compensation ("BWC"), to process Relator Laura Baker's Lump Sum Settlement Application,

make an offer to settle her workers' compensation claim, pursuant to the BWC's statutory obligation

R.C. 4123.65.

Relator Laura Baker was employed by Advanced America Cash Advance Center on November

10, 2008, when she was injured in a robbery, (Relator Aff. par. 1). Her workers' compensation claim was

for physical conditions, initially. (Id., par. 2). She later developed psychological difficulties as a

suit of her work injuries, and her claim was ultimately recognized for the psychological conditions of

`post-traumatic stress disorder" and "major depressive disorder, single episode, severe without psychotic

features." (Id., par. 3 - 4). Relator Baker's workers' compensation claim was ultimately allowed for

and total disability compensation benefits, at a rate of $375.50 per week. (Id., par. 5 - 7).

Relator's claim allows her to receive permanent and total disability compensation benefits for the

rest of her life. (Id., par. 7; R.C. 4123.58). Respondent, Bureau of Workers' Compensation, is required to

pav these benefits, bi-weekly. Relator desired to settle her workers' compensation claim, and submitted a

settlement demand on February 19, 2013. (Id., par. 7). The settlement demand was for $560,000.00,

which took into account the net present value of the future permanent and total disability compensation

benefits, cotnputed to be $337,199.00. (Id.) Relator was not required to obtain the etnployer's signature,

as the claim fell outside the employer's experience. (Id.; R.C. 4123.65).

On July 17, 2013, after having the settlement application on file for nearly five months without

making an offer, Respondent BWC dismissed Relator's settletnent application. (Id., par. 8). Relator

continued to receive permanent and total disability compensation benefits in the meantime. (Id.) The

settlement disapproval order simply indicated that settlement was "not in the Ohio Bureau of Workers'

Compensation's best interest at this time" without elaboration. (Id.)

Relator's counsel submitted a letter in response to the Bureau of Workers' Compensation,

HOCF-IMAN&PLUNKEITco., L.P.A. demanding that the BWC consider and make an offer, in good faith, on July 26, 2013. (Id., par. 9).


Dayton, Ohio 45439 1

After failing to receive a response, on May 2, 2014, Relator filed a second settlement application,

the same documentation and demand. (Id., par. 10). Thirteen days later, on May 15, 2014, the

WC once again dismissed the settlement application, simply indicating that "The Bureau of Workers'

ompensation does not wish to settle this claim at this time." (Id., par. 11). Counsel for Relator sent

letter to the BWC on May 22, 2014, demanding that the BWC perform their statutory obligations

process the settlement demand in good faith. (Id., par. 12). During this time, she continued to receive

substantiating the value in the claim, (Id.)

After initially reinstating Relator's settlement application, the BWC once again dismissed the

settlement application for a second time on July 11, 2014. (Id., par. 13). Relator's counsel

submitted an additional letter delnanding that the application be reinstated, and an offer made. Relator's

attached numerous exbibits documenting the value of the claim for ongoing medical and

permanent and total disability compensation benefits. (Id., par. 14). The BWC has failed to respond to the

letter; instead, the BWC has completely and deliberately failed to consider her settlement application,

despite the fact that the BWC is responsible for continuing to pay workers' compensation benefits.. (Id.,

par. 15 - 16). LAW AND ARGUMENT

The Workers' Compensation Act requiresthe BWC to consider settlement applications filed by

FiOC'IiMAN&PLUNKLTT

CO., L.P.A.3033 Kettering Blvd.

Suite 201

Dayton, Ohio 45439

injured workers, R.C. 4123.65. This statutory duty has been recognized to entail an obligation imposed on

the BWC to determine the appropriateness of settlement applications, in good faith. This Court stated in

State ex. rel. Johnston v. Ohio BWC, 92 Ohio St.3d 463, 475, 751 N.E.2d 974, 2001-Ohio-1284:

"While this provision does not require the Administrator to approve asettlement application on demand or accept the terms agreed to by theparties, nor does it give the Administrator the unfettered discretion toreject settlements out of hand. There is nothing in the statute to supportthe notion that the Administrator can properly reject an application thathe determines to be appropriate. Semantics aside, the Administrator hasan affirmative statutory duty to determine the propriety of settlementapplications, the performance of which can be enforced by proceedingsin mandamus."

This Court granted the relator's application for a writ of mandamus in Johnston, and required the

WC to consider the settlement application that was filed before the claimant's death, providing an

to the rule that a settlement application normally abates at the time of a claimant's death,

the fact that Respondent BWC had refused to settle the workers' compensation claim.

In this claim, Relator Laura Baker has an allowed workers' compensation claim, and is entitled to

largest benefits in the workers' compensation system in Ohio - permanent and total disability

i compensation benefits under R.C. 4123.58. 'The Bureau of Workers' Compensation is required - and is

lcurrently fulfilling their obligation - to make payments under R.C. 4123.58. As such, the claim cannot be

isaid to have no value. Yet, the BWC bas refused to make an offer to resolve the claim.

Under previous precedent from this Court in Johnston, the BWC is prohibited from rejecting

settlement applications out-of-hand. The BWC has a statutory obligation to review a settlement

application and nlake an offer in good faith where warranted, under Johnston. Without question, in this

case, with regular benefits being paid, Relator's claim has value which requires the BWC, in good faith,

to process the application and make an offer. As the BWC has refused to do so - despite repeated

demands by Relator - this Court should order Respondent BWC to process Relator's settlement

application in good faith and make an offer to settle Relator's workers' compensation claim.

Respectfully submitted:

HOCfLMAN & PLUNKETT CO., L.P.A.rw"-" ^ fe

s

Gary D. Plunkett (0046805)

Brett R. Bissonnette (0076527)3033 Kettering BoulevardPoint West, Suite 201Dayton, Ohio 45439937/228-2666937/228-0508 (Fax Number)brettbissonnette(cr^hochmanblunkett.com

HOCFIN1ANBcPLUNKMCO., L.P.A.


Dayton, Ohio 45439

Attorneys for RelatorLaura Baker

3

CERTIFICATE OF SERVICE

certify that a true and accurate copy of Relator's Complaint for Writ of Mandamus and accompanyinglemorandum in Support of Complaint for Mandamus was sent to the foregoing on August 7, 2014:

Ldministrator, Bureau of Workers' Compensation0 West Spring Street'olumbus, OH 43215

Brett Bissonnette

xoc.'HNtAN&PI:Lrv'KITrrCO., L.P.A.


Dayton, Ohio 45439

AFFIDAVIT OF LAURA BAKER (SIZEMORE)

STATE OF OHIO )

)COUNTY OF MONTGOMERY )

1. My name is Laura Baker (Sizemore) and I have reached the age of majority of 18 years. Iani testifying herein based upon my own personal knowledge.

2. On November 10, 2008 I was employed by Advanced Ainerica Cash Advance Center. Onthat date, I was a victim of a robbery and was struck on the head by a gunman. I filed aWorkers' Compensation claim which was originally recognized for the conditions ofscalp contusion and neck sprain. A true and accurate copy of the Industrial Commission'sRecord of Proceedings from January 25, 2013 setting forth these facts in addition to mytestimony is attached hereto at pages 1-3.

3. As a result of my injury, I developed psychological difficulties. On January 20, 2009, theattorneys working on my behalf filed a motion to amend my Workers' Compensationclaim to include the additional condition of Post-Traumatic Stress Disorder. On March30, 2009, The Industrial Commission's District Hearing Officer granted this motion andadditionally allowed my claim for the condition of Post-Traumatic Stress Disorder. Atrue and accurate copy of the Record of Proceedings is attached hereto at pages 4-5.

4. I continued to suffer from psychological difficulties. On October 26, 2011, the attorneysworking on my behalf filed a motion for my claim to be recognized for the additionalcondition of "major depressive disorder, single episode, severe without psychoticfeatures." On June 11, 2012, the Industrial Commission's Staff Hearing Officer grantedthis motion to amend my claim. A true and accurate copy of the Industrial Commission'sRecord of Proceedings is attached hereto at pages 6-7.

5. I subsequently filed an application for permanent and total disability compensationbenefits. The Industrial Coinmission scheduled me to be evaluated by an independentpsychologist as part of the filing process. Dr. Giovanni Bonds agreed that I waspermanently and totally disabled from all employment as a result of the allowedpsychological conditions in my Workers' Compensation claim. A true and accurate copyof Dr. Bonds' December 14, 2012 report is attached hereto at pages 8-15.

6. After considering Dr. Bonds' report, the Industrial Commission of Ohio granted myapplication for permanent and total disability compensation. A true and accurate copy ofthe Industrial Commission's Record of Proceedings is attached hereto at pages 1-3.

7. As a result of being found perrnanently and totally disabled from all employment, Ibecame entitled to compensation at the rate $375.50 per week. Additionally, I continuedto receive medical benefits paid by the Bureau of Workers' Compensation. Using

formulas dictated by the Ohio Bureau of Workers' Compensation, the attorneys workingon my behalf calculated a factor using Bureau of Workers' Compensation life expectancytables that took in to account my status as a permanent and total disability recipient aswell as my age. Using a discount rate, the attorneys working on my behalf submitted asettlement demand of $560,000 which took in to account the 100% net present value ofmy benefits was equal to $337,199. I submitted a form C-240 (settlement agreement andapplication for approval of settlement agreement) on February 19, 2013. Because myclaim was outside the experience period of my employer, and I was no longer employedby my employer, it was not necessary for me to include my employer's signature. A trueand accurate copy of the settlement application and attachments is attached hereto atpages 16-21.

8. I continued to receive permanent and total disability compensation benefits and medicaltreatment from the time my settlement application was filed. Nonetheless, the Bureau ofWorkers' Compensation failed to consider my settlement application. On July 17, 2013,the Bureau mailed an Order to me which disapproved my settlement agreement simplyindicating that "settlement of this claim is not in the Ohio Bureau of Workers'Compensation's best interest at this time." A true and accurate copy of the Bureau'sdismissal of my settlement application is attached hereto at pages 22-23.

9. On July 26, 2013, the attorneys working on my behalf sent the Bureau of Workers'Compensation a demand to reconsider my settlement application. They indicated that Icontinued to receive permanent and total disability compensation and pointed out theBureau's obligation to consider the appropriateness of settlement applications in goodfaith. Even the Bureau of Workers' Compensation's own claims representative did notunderstand why the Bureau of Workers' Compensation would not make an offer. A trueand accurate copy of the letter sent by the attorney s working on my behalf sent to theOhio Bureau of Workers' Compensation, together with the attachment consisting of thenotes of the Bureau of Workers' Compensation, is attached hereto at pages 24-28.

10. On May 2, 2014, the attorneys working on my behalf, at my direction, refiled a second C-240 (settlement agreement and application for approval of settlement agreement). Theyattached the same documentation as before. Once again, the signature of my employerwas not necessary. A true and accurate copy of the settlement application andattachments is attached hereto at pages 29-34.

11. On May 15, 2014, the Bureau once again dismissed the settlement application. Onceagain, there was no rationale documenting the fact that the Bureau has thoughtfullyconsidered my application. The disapproval of settlement agreement simply indicated"The Bureau of Workers' Compensation does not wish to settle this claim at this time." Atrue and accurate copy of the settlement disapproval is attached hereto at pages 35-36.

12. On May 22, 2014, the attorneys working on my behalf sent an additional letter to theBureau of Workers' Compensation requesting them to consider my settlementapplication. My attorneys pointed out the fact that between July 23, 2013 and March 31,2014 the Bureau of Workers' Compensation paid out $2,920.24 in medical benefits in

addition to the $375.50 per week payments for my pertnanent and total disabilitycompensation. My attorneys even included calculations from the Bureau of Workers'Compensation's own website showing the payments involved. Clearly, my claim hasvalue. A true and accurate copy of the letter my attorneys sent, as well as the attachmentsincluded, including the previous letter referred to, is attached hereto at pages 37-48.

13. The Bureau of Workers' Compensation reinstated my settlement application, but

dismissed it once again without addressing the reason why, in a dismissal on July 11,

2014. A true and accurate copy of the letter is attached hereto at pages 49 - 50. This wasthe third dismissal of my settlement application.

14. My attorneys once again sent a letter on July 18, 2014 to the Bureau of Workers'

Compensation, demanding that my settlement application be reinstated. A true and

accurate copy of the letter and attachments are attached at pages 51 to 81. The letter

outlined the costs to the Bureau of Workers' Compensation of leaving the claim open, and

requested the Bureau of Workers' Compensation reinstate my settlement application toconsider the same.

15. The Bureau of Workers' Compensation has not responded to the letter demanding that

they reverse their decision to dismiss my settlement application for a third time.

16. The Bureau of Workers' Conlpensation has completely and deliberately failed to consider

my settlement application. Given that I currently receive paynients of $375.50 per week,

together with additional medical benefits that are paid for by the Bureau, I believe my

claim has value and the Bureau should consider my settlement application. The Bureau of

Workers' Compensation should be ordered to consider my settlement application and

extend an offer to resolve my Workers' Compensation claim.

Further Affiant Sayeth Naught.

Laura B er (Sizemore)

Sworn to and subscribed before me on this ^,^ 2014.day of

Notary Public

BRECf' Bi NNEITE, ft" atUwMiy NOc,St* ofabieMy ComMisaion ha so 8*90 ,Secfim 147.03 ft R. C^

Ohio Industrial ComBiission

RECORD OF PROCEEDINGS

Claim Number: 08-382336 Claims Heard: 08-382336

LT-ACC-DSIF-COV

PCN: 2122631 Laura Baker

LAURA BAKER

506 THOMPSON DP.

FAIRBORIJ OH 45324-2163

Date of Injury: 11/10/2008 Risk ]Otumber: 1244253-0

TSNTA7.'IV8 ORDER

This claim has been previously allowed for: CONTUSION SCALP (Ha.AD);

SPRAIN OF PTSC,B; POST-TRAI7MATIC STRESS DISORDER; BJAJOR DEPRESSIVE DISORDER

SIISGLS EPISODE SEVERE WTTFTOI7T PSYCHOTIC. FPsATIIHES.DISALLOWED: SPURRING AT C6 • 7.

This claim aame before Staff Hearing Officer Elizabeth Fox pursuant to R.C.

Sections 4121,35 and 4123.58 on:

10-2 A.pp For Fermanent Total Disability Compensation filed by TnjuredWorker on 09/18/2012.

Issue: 1) Permanent Total Disability

The Snjured Worker suffered this injury on 11/10/2009 when she was employedwith a cash advance business as a manager. On the date of injury, she wasa victim of a robbery and was struck on the head by an gunmen. The claimwas recognized for a scalp contusion and a neck sprain and then forpsychological conditions, including post traumatic stress disorder and

major depressive disorder, single episode, severe without psychotic

features. The Injured Worker bas not returned to work since the in7ury inthis claim.

The Injured Worker was examined at the request of the Tndustrial Commission

for the recognized physical conditions by Dr. James Lutz on 12/17/2p12.

Dr. Lutz performed a physical examination of the Injured Worker andreviewed selected medical records from the claim file. Dr. Lutz noted thatthe in_iured Worker is no longer treating for the physical conditions

recognized in her claim. Be stated that the injured Worker has no worklimitations as a result of the eZlowed physical conditions in the claim.

In support of her application, the Injured Worker submitted a report fromDr. t'..harles Walters dated 08/08/2012. Dr. wa.lters noted continuiaig severe

symptoms as a result of the allowed psychological conditions in the claim.

F3e concluded that the Irijured Worker is permanently totally disa3led as a

result of the allowed psychological con.ditions.

The Injured Worker was examined at the request of the Tndustrial Commission

for the allowed psychological conditions in the ciaim by Dr. Giovanni Bonds

on 12/14/2012. Dr. Bonds was provided selected medicall records from the

claim file and she performed an examination of the Injured Worker which

inclsded a mental status examination and an interview of the lnjured

Worker. Dr. Bonds stated that the Injured Worker experiences severe

psychological symptoms including depressed mood, lack of energy and drive,

social withdrawal and difficulties with concentration. Dr. Bonds concluded

that the Injured worker has a mild impairment in her activities of daily

living, a moderate impairment in her social funationing, concentration,

Page 1 of 48

PTTO01 Page 1 sn/sn

Ohio Industrial Comrnissimn

RECORD OF PROCEEDINGSClaim Nuu$ser; 08-382336

persi_stence and pace, and in her adaptation. Dr. 3onds concluded that the

Injured vaorker has reached maximum medical improvement and her symptoms are

stabilized. However, she concluded that the prognosis for further

improvement was poor given the length of time since the industrial injury.Dr. Bonds stated that the Irjured Worker was incapable of work activity dueto the severity of the psychological symptoms.

The Hearing Officer finds that the Injured Worker has reached maximum

medical improvement for the allowed conditions in this claim. The Hearing

Officer finds that the allowed phvsical conditions in the claim do not

prevent a retnrn to the Injured Worker's former position of employment or

to other types of work. However, the Hearing Officer finds that the

allowed psychological conditions restrict the Injured Worker's residual

functional capacity to such an extent that she is unable to perform the

duties of sustain.ed remunerative employment.

2`he Hearing Officer concludes that the injured Worker is permanently andtotally disabled. Permanent total disability benefits are to commence

effective 08/12/2012, the date of the report from Dr. Walters, and to

continue without suspansion unless future facts or circumstances should

warrant the stopping of the award. The Hearing Officer finds that the

start date of Dr. Walter's report is appropriate because Dr. Walters is the

earliest credible opinion on permanent total disability.

Because the Hearing Officer finds that the medical evidence along supportsthe conclusian that the Injured worker is permanently and totally disabled,no consideration of the vocational factors is warranted.

This order is based upon the report of Dr. Walters dated 08/1212012, the

report of Dr. Bonds dated 12/1.8/2012, and the report of Dr. Lutz dated12/17/2012.

P-n objection may be filed with the Industrial Coit¢nissionk*ithin fourteen

(14) days of the receipt of this order. If a timely objecti.on is filed,

the IC-2 Application for Permanent Tota1 Disability will be scheduled for

hearina.

Typed By: sn

Date Typed: 01/22/2013

F'indings Mailed: 01/25/2013

Elizabet..h Fox

Staff Hearing Officer

Electronically signed byElizabeth Fox

The parties and representatives listed below have been sent this record of

proceedings. If you are not an authorized representative of one of the

partias, please notify the Industrial Commission.

08-382336

Laura Baker

506 Thompson DrFairborn OH 45324-2163

ID No: 20516-91Hochman & Plunkett Co. I.pA

3033 Kettering Blvd Ste 201

Moraizae OH 45439-1948

Risk No: 1.244253-0 ID No: 150-80

Advance America Cash Advance Cent.er ***Careworks Consultants, Inc***

Advanceamerica Cashadvance Centers 5500 Glendon Ct Ste 300

135 N Church St Dublin OH 43016-3290

Spartanbu'rg SC 29306-5138

PTT001 Page 2 sn/sn

Page 2 of 48

Ohio Lndastrial Commission Page 3 of 48

RECORD OF PROCEEDINGSClaim Nurabe.r; 518-382336

IL^ No: 20428-91

Taft Stett imius Hollister

425 hialnut St Ste 18o0

Cincinnati OH 45202-3948

ID Na. 4040-05

-**SWC - DWRF Section-

30 W Spring St

Columl3us OH 43215-2216

BT7C, LAW DIRECTOR

NQ'I"E. INSURED YdORKEItS, EMpLOYERS, AND THEIR AUTHORIZED REPRESENTATIVES MAY

P.EITIEW THESR ACTIVE CLATIKS IISFORMATION THROUGH THE INDUSTRIAL COMNIISSION T4E'B

SITE AT www.onioi.C.com. ONCE ON THE FIOME PAGE OF THE WEB SITE, PLEASE CLTCTC

ANL1 FOLLOW THE INSTRUCTIOC3S FOR OBTAINING A PASSF7ORD.ONCE YOU HATTE

OBTAINED A FASOWORI'i, YOU SHOULD BE ABLE TO ACCESS YOUR.ACTIVE CI.Ii.IM ( S) .

PTT401 Paqe 3 sn/sn

Ac, £cfuai Opportunity Etipioyer

aud Service Prbvider

The Inc3eestrial. Commission of Ohio


Claim Number: 08-382336LT-ACC-OSIF-COV

PCN: 2090551 Laura Sizemore

Claims Heard: 08-382336

LAURA SIZEMORE506 THOMPSON DRFAIRBORN OH 45324-2163

Date of Injury: 11/10/2008 Risk Number: 1244253-0

This claim has been previously allowed for: CONTUSION SCALP ( HEAD); NECKSPRAIN;.

This matter was heard on_03/30/2009 before District HearingC}fficer RichardMalone pursuant to the provisions of R.C. Sections 4121.34 and 4123.511 onthe following:

C-86 Motion filed by Injured Worker on 01/20/2009Issue: 1) Additional Allowance - POST TRAUMATIC STRESS DISORDER

2) Additional Allowance - ANXIETY REACTION

Notices were mailed to the Injured Worker, the Employer, their respectiverepresentatives and the Administrator of the Bureau of Workers'Compensation not less than fourteen (14) days prior to this date and thefollowing were present for the hearing:

APPEARANCE FOR THE INJURED WORKER: Mr. SnyderAPPEARANCE FOR THE EMPLOYER: No AppearanceAPPEARANCE FOR THE ADMINISTRATOR: No Appearance

It is the order of the District Hearing Officer that the Injured Worker'sC-86 Motion, filed 01/20/2009, be granted to the following extent:

First, prior to hearing and before discussion of merits, counsel for theInjured Worker submitted a document to the Industrial Commission, dated03/30/2009, withdrawing that portion of the Injured ldorker's Motion, filed01/20/2009, that had requested that the claim be additionally allowed forthe following condition: ANXIETY REACTION. Accordingly, it is the order ofthe District Hearing Officer that the Injured Worker's request that thisclaim be additionally allowed for ANXIETY REACTION be DISMISSED.

Next, it is the order of the District Hearing Officer that this claim beADDITIONALLY ALLOWED for the following condition: POST-TRAUMATIC STRESSDISOtOER. This District Hearing Officer finds that the Injured Worker hasestablished by a preponderance of the medical evidence that she suffersfrom POST-TRAUMATIC STRESS DISORDER as a result of the industrial injury of11/10/2008.

In support of this decision, the District Hearing Officer relies upon thereport of Dr. Flexman, dated 02/03/2009, and the report of Dr. Howard,dated 02/09/2009, as they relate to the requested additional condition,PtIST°TRAUMATIC STRESS DISORDER.

All evidence was reviewed and considered in arriving at this decision.

An IC-12 Appeal from this order may be filed within fourteen (14) days ofthe receipt of the order. The IC-12 may be filed online at www.ohioic.comor the IC-12 may be sent to the Industrial Commission of Ohio,Dayton District Office, 3401 Park Center Drive, 3rd Floor,

Page 4 of 48

DHOSFCT2 Page 1 dgw/dgw 11

The Industrial Commission of Ohio

RECORD OF PROCEEDINGSClaim Number: 08-382336

Dayton OH 45414-2ra80.

Typed By: dgwDate Typed: 03/30/2009 Richard MaloneDate Received: 02/20/2009 District Hearing OfficerNotice of Contested Claim: 02/19/2009Findings Mailed: 04/01/2009

Electronically signed byi2icha.rd Malone

The parties and representatives listed below have been sent this record ofproceedings. If you are not an authorized representative of either theinjured worker or employer, please notify the Industrial Commission.

08-382336Laura Sizemore506 Thompson DrFairborn OH 45324-2163

Risk No: 1244253-0Advance America Cash Advance CenterAdvance America135 N Church StSpartanburg SC 29306-5138

IO No: 20516-91Hochman & Plunkett Co. LPA3077 Kettering Blvd Ste 210Moraine ®H 45439-1949

BWC, LAW DIRECTOR

NCiTE: INJURED WORKERS, EMPLOYERS, AND THEIR AUTHORIZED REPRESENTATIVES MAYREVIEW THEIR ACTIVE CLAIMS INFORMATION THROUGH THE INDUSTRIAL COMMISSION 41EBSITE AT www.ohioic.com. ONCE ON THE HOME PAGE OF THE WEB SITE, PLEASE CLICKI.C.O.N. AND FOLLOW THE INSTRUCTIONS FOR OBTAINING A PASSWORD. ONCE YOU HAVEOBTAINED A PASSWORD, YOU SHOULD BE ABLE TO ACCESS YOUR ACTIVE CLAIM(S).

DHQSFCT2 Page 2 dgw/dgw

:PO @guai OF*Pgrtunity Fmplayer

alefl 9^i.cQ PrOVif]CeC

Page 5 of 48

^

Ohio Industrial Comtnission


Claim Number: 08-382336

LT-ACC-OSIP-COV

PCN: 2120971 Laura Baker

Claims Heard: 08-382336

LAURA BAKER

506 THOMPSON DR

FAIRBORN Ofi 45324-2163

Date of Injurg: 11/10/2008 Risk Number: 1244253-0

This claim has been previously' allowed for: CONTUSION SCAL3 (F3EATi) ; D7SCIC

SPRAIN; PQST-TRADR'IATIC STRESS DISORDER; MAJOR DEPRESSIVE DISORDER SINGLE EPISODE

SEVERE 'NtITE€O7P3' PSYCHOTIC FEATaRES- DISliLLOWEDe SPURRING AT C6-7.

This matter was heard on 06/11/2012 before Staff Hearing Officer Vicki C.

Singleton pursuant to the provisions of R.C. Sections 4121.35(B) and 4123.511(D)on the followingo

APPEAT, of DHO order from the hearing dated 05/01/2012, filed by injured Workeron 05/17/2012.

Issue: 1) Additional Allowance - MAJOR DEPR.ESSSVE DISORDER SINGLE EPISODE SEVER'4TITHOIIT PSYCHOTIC FEA?'LPRES

2) Fiddit.ional Allowance - SPURRING AT C6-7

Notices were mailed to the injured uorker, the Employer, their respective

representatives and the Administrator of the BiLreau of Workers' Compensat.ion not

fewer than fourteen (14) davs prior to this date, and the following were presentior the hearing:

APPEARANCE FOR THE IITJQRED WORKER: Iir. Miller

APPE_ARP.NCEFOR THE EMPLOYER: Ms. O'Brien

Al'PEF3RFNCE FOR THE ADA2IT.d'ISTRATOR: No appearance

It is the finding and order of the Staff Hearing bfficer that the DistrictHearing Officer order from the dated 05/01/2012, is affirmed.

It is the finding. and order of the Staff Hearing Officer that the Injured

SiorkerFs C-86 motion filed 10/261/2011, requesting allowance of the additional

conditions: Major depressz.ve disorder, single episode, severe without psychotic

features; spurring at C6-C7 i-s granted to tYie extent that i?A<70& DEPRESSIVEDISORS78R, SINGLE EPISODE, SEVERE WITHOL7°-r PYSCHDTIC FEATURES is found to becausally r_elated to the industrial injury of 11/10/2008 and is GRANTED as anadditional condition in this claim. The Staff Hearing Officer finds thatSPURRING AT C6-C7 is not directly or causally related to the industrial injuryof 11/10/2008 and therefore is DSN28D as an additional condition in this elaim.

This order is based upon medical Pawlarzcyk dated 03/20/2012 and Dr- David dated01/20/2011.

A POWER OF ATTORNEY IS ON FILE FOR T}lE' ABOVE LISTED INJURED WORKER.

An IC-12 Appeal from this order may be filed uithia fourteen t14) days of the

receipt of the order. The IC-12 mav be filed online at srwra.ohioic.com or the

IC-12 may be sent to the Industrial Commission of Ohio, Dayton Distriat Office,

1242 E.Davton-Yellow Springs Rd, Fai.rborn, OH 45324-6326.

Typed Bg: rdg

Date Typed: 06/11/2012 Vicki C. Singleton

SH01 Page 1 rdg/vcs

Page 6 of 48

Ohio Industrial Comrnission

RECORD OF PROCEEDINGSClaim Nuniber: D8-382335

Staff Hearing OfficerFindings Mailed: 06/1312012

Elecfzonicaily signed byVicki C. Singleton

The part.ies and representatives listed below have been sent this record of

proceedings. IiE you are not an authorized representative of one of the

parties, please notify the Indnstriai Commission.

08-382336

Laura Baker

506 Thompson Dr

gairhorn OH 45324-2163

Risk No: 1244253-0

Advance AmericH Cash Advance Center

Advanceameraca Cashadvance Centers

135 N Church St

Spartanburg SC 29306-5138

ID No: 20516-91

HocYunan & Piunkett Co. LPA

3077 Kettering Blvd Ste 210

Moraine OH 45439-1949

ID NO: 150-BD

***Careworks Consultants, Tnc***

5500 Glendon Ct Ste 300

Dublin OH 43016-3290

BWC, LAW DIRECTOR

NOTE: INJtTRM WORKERS, ENIPT.OYERS, AL+ID 9.'IiESR A17THORTZED REPRESENTATIVES MAY

REVIEW T1LEIR ACTIC7E CLAIMS INFORMFTIOL3 THROIIGH TI3E INDUSTRIAL COWISSION ti+TEE

SITE AT www.ohioic.com. ONCE ON THE HOME PAGE OF TF3E WEB SITE, PLEASE CLICK

AND FOLLOW THE INSTRIICTIOATS FOR OSTASISING A PASSWORD. ONCE YOU HAVE

OBTAINED A PASSWORQ, YOU SHOULD BE ABLE TO ACCESS YOUR ACTIVE CLAIPI(S). .

vH01 Page 2 rdg/vcs

An Bgual Opporttmiti• Fanployer

aIId Sei2vice PlovidPS'

Page 7 of 48

^

i

From:9372776057 To:9372643760 T-ime:Deceantrer 20, 2012 2:16:46 PM EST J oStPage 8 of 48

Dec 20 2012 02:52PNi 5onds Ma'^his & Assodates 9372776057 page 2

BONDS, NIATHIS & ASSOCIATES, INC.PSY+GHOL®GICAL HEALTH SERVICES

lQ9 WHITE ALLEN AVENUEDAYTON, QIiIt? 45405PHQ^.'+E (937) 277-7962

GIOVANNI M. BONDS P'h.D., PRESME?'F'I"

PSYGTIQLC7GYCAi, EVALUE1TIEfN

NAME: Laura Bai:erCi,AfMh-3MBER: 08-392336DATE OF EXAIVIINATIC3N: I2f 1412012

IZEASCIN FOR REFERRAL

vL:i" y i av:

cwrwjg d_

^^^ ®_ ° ^_ .. . _.._. ...^^ ^: _.3 . _

S.S._#. 259-49-1312I?ATE OF INJUR.Y:11 /1 f il2(tf l i{AGE: 43-1

Laura Baker was referred by the Industrial Commission of Ohio for a psychologicalevaluation to detemtine the percenta.ge of Percna.nent Total Disability. The examiner wasasked to address the following questions:

. It has been dctermined by the Industrial Commission order that th.is injuredwsrker has zeached maximum znedical improvement (M1vll). If you believe theInjured Worker is stiit at IvIMl, based on the AMA f.suid.es, Second and FifthEditions, and with reference to the Inchis°srial Cumm.ission Medical ExanninationManual, provide the esti:ntated percentage of whote persorz impairment arisingfrom each allowed psychotogicalliasychiatric condition separatcly, and. thenprovide a combined whole person impai.rtnent. If there is no impairment for anallowed cond.itian indicate zero percent.

• If you believe the Injured Worker is still at MML cornplete the enclosed()cc^tionnt ActiNity Assessment In your narrative report provide a discussicsnsetting forth mental limitations resulting from the allowed condition (s).

• If ,you do not believe the Ita1ttred Worker is still at NM, note the following andanswer accordingly:Irx order for an Injured Worker to be found no longer A^4I, there must beworsening of the allowed condition since the determisxation of NM accompaniedby the prognosis #.hai the Evorseni.n.g is temporary. The mere prospect ofimprovement in the allowed condition beyond a level previously declared MMIwitkr a proposed treatment will ztot,justify change in the NTM determination.

What is the rationale for your opinion that the Injured Worker is no louger at:Nf1VLI?

*^ From:3372775457 To:937264376t? Time:December 202012 2.16:46 PM EST I oir

Dec 20 2012 0252PM Bonds f^'iathis & Assodates 9372776067 page 3 --A G'age 9 of 48

Page 2 of 7Baker, Laura S4VC # 08-382336

Ugderststuding of Evalua.txon Purpose, CtanficlentaaIity, Cousenf ta ]Ev2lnatiort &Autbvrization to Release Test Results

Prior to stariarig the evaluation Laura was provided a written statement detailing thepurpose of 1he evaluation, confidentiality lianits atxd #o whom the results would bereleased. 'I'b.is form was discussed with Laura. She verbalized an understanding of thisinfarrua.tion and agreed to proceed with the evaluation and the release of infarnaafinn tothe Inciustria! Cornmission..

B ACKGR QU" INC+` C1RM4'I7[ ClN

The 7ndustrial Commission provided the following background reports:1. Statenment of Facts2. Application for Compensatian Permanent Total Disability3. Evaluation for Perrnanent Disability Report Charles Walters MD , 08f 12J124. Psychological Evaluation Report Douglas Pawlarcyzk, PhD. 03/2().1125. Psychological Evaluation Report Jennifer Stoeckel PhD. 07106J116. Psychological Evaluation Report Roberto Madrigal PhD. 09110f107. Psycholggical Evaluation Report Kenneth Manges PhD. 04126/10R. Psvehological Evai ►Wion Report Lee Howard PhD 021041d99. First Report of an In_j ury, Cflccupa¢i onal Discase or Death 11f 131(3$10. Percentage of Permanent Partial Disability Report Paul Deardorff PhD. I00-5l12

The background records indicate that Laura Baker was izajtred on 11/101200$ whileworking as a m.a.nagerr for Advanced America Cash Advance Center. The business wasrobbed and the gunman hit her on the side of back and head, Her claim has been allowedfor Contusion Scalp (Heacl), Sprain of Neck, Posttra.urrcatic Stress Disorder, and MajorDepressive Disorder Sixtgle Episode Severe Without Psychotic Featuies.

Lau•ia Baker is 43 years old, married and living in Fairborn, Ohio with her hwband andtwo children ages 13 and 2. Laaara w-as rnarried once previously for 10 years and t.hatrnarcia.ge ended by divorce. She has been married to her preserzt husband for 17 years.She stated that he is ]oval and patient, and has integrity. Laura thinks that her healthproblems are affecting her zxzarriage and that he.r husband arust be tired of them. Inaddition to the two children at home she has a 23 year old daughter on her o-wn.

Laura -w-as born in San Pedro, California and grew- up in different places. Her father wasin the U.S. Air Porce_ Her mother was an NCO Club manager. Both parents are iiving.They divorced when she was 15 and she resided with her mother rsfter the ciivorce.Laura's mother lives in Geor,gia and her father lives here in this area. She reported. thatgrowing up her relationship with her parents was clQse arid supportive but both parentsworked and were gone a great cleal. Laura has a ycrunger brother that also lives inPairborn and she has a good relationship wit3h hirn.

' From:9372776067 To_9372643760 T°ime:®ecember 20, 2012 2:16:46 Pm EST oze

Dec 20 2012 02.53PNr Bonds Maths & Assodates 9372776067 page 4 Page 10 of 48

Page3of7Baker, Laura BWC # D8-38Z335

She reported no family hustDr,y of mental illness, alcvholism, drug abuse; suicide ormental re#ardatioxs_ She stated that she was not physically, menta.lly or sexnally abused asa chiid.

Laura stated that she no longer has fi-ie:ncLs with whom s6e talks about her prol.}lenns arspends time. Sinoe h--r work injury she has decreased socializing with friends. Shereported no cmrent recreational activities, hobbies or interests. She used to loveswimming, reading and shopping. Laura stated that her b.uslsand put in a swimming poolat home to encourage her to swim but she still does not swim very often. She used to reada book a day but now she cannot get one started. As a child and teenager, Laura hadfriends with whom she played and socialized. Tlge people she has felt close to in. ii.feinclude her mother, her husband and some friends. I.,a.um has a religious members`r ►ip andshe attends church weekly. She stated that for a while she was participating in the churchchoir but it became too stressftrl for her s'.a.ndi.ng up in front of people skping so she nolonger does that. Laura stated that she goes to a church in her neighborhood regularly.She has found "a family there and [she] feels wmfortable there." Laura ccammexited thatbefore she was assaulted she used to be very active and was hardly ever home. She feelsuncomf6rt,.able w-hen she goes out and especially if she sees young black males in hoodiesand black pantS, whiah is the attire that was worn by those that assaulted her. She statedthat she will start having panic attack symptoms if she sees someone dressed in thatmanner.

Laura reported ncs history of arrests. She is not on probation or parole. She has never f.leda ldwsuit for damages in a civil case. She is currentiy having $nancia.l and creditproblems. She has never filed bankruptcy.

Laura stated that she completed the 12"` grade in 1997. She attended. Wright StateUniversitg.- in the 1990s and studied Sociology. She did not graduate, howeveT she reportsneeding only a few more credits to get her degree. In school her grades were usuallyaverage. She has not had any vocational or technical skill training. Laura garticipated inchov in school. She was never suspended or ex.pelled from school. At the t-iene of herinjury, Lauxa was working as a manager for Advanced America She was employed therefrom 2007 to 2008 when slae was robbed and assau3ted. Laura has not returned to worksince she was injured. Other _previosie employrnent included being an accounts managerfor Long's Candle, sales for Party Light and c3erk for Money Back.. She did not reporthaving any problems on the job or ever having any discipiinary actions taken against her.I..aura has no history of ni%l.itary service.

Laura stated that she is five feet, four inches tall and weighs 150 pomd.s. Her physicalccrrnplas.nts are of pain in her neck, hands, knees and everywkrere. She stated that she ha.sdiabetes an.ti osteoartltritis. She has nat lhad any hospitalizations. She controls her diabetesby diet. Laura stated that she does not cnrre.n.tly have a faimily physician.

^ ^^.

Ti: rom: 9372776067 To: 9372F4376t} Ti me: December 20, 20I2 2:16:46 Pm EST I ozcPage 11 of 48Dec 2Q 2Ct12. 02a4PM Bonds P1att^es & Assodates 9372775067 Pa^ 5

Page 4 of 7Bxker, Laura BWC # 0$-382336

Laura is receiving mental heatt3i treatnient at TC^T where she sees a psyehia#rist Dr.A1khativaga aud therappist Jack Atkins for treatinent of Posttrsumati c Stress Disorder anddepressiQn. She curren.tiy takes Buproprion 100 mg, Cyrnbalta 60 mg BID, Ttuodone150 mg bedtime and Ativan 05 mg prn, She stated that sbe goes to t?nerapp sessionsbiweek3y. She stated that she talks about what she has be^en doing and her-therapist triesto get her to get out of the house. She feels that she has not m,acie progres.s in therapyduring this past year. When she taites the Ativan it helps her to stay caEm. She stated thather other medications have a side effect of demaseci sex drive. Laura stated thatsometimes she does not feel comfortable going to TCN because she sees people there thatnza.ke her uncomfortable.

Laura stated that sbe drinks maybe once a week and has one or two drinks. She starteddrinking when she was 18. She did not report ever liaviszg work, school, 1ega1, health,financial problems related to alcohol -use. Laura reported no use of illicit drugs ordependence on prescription medications. She quit smoking for a couple of years butrestarted a year ago and now smokes about half a pack of cigarettes a day.

MENTAL STATUS

La:ura was brQught to the evaluatic ►n by her ex-busband and she arrived on time. She hadcornpleted the background histor}r form that had been mailed to her hozne. Laiuraunderstood fne p-arpose of the evaluation and she was cooperative. She seemed willing totalk about herself.

La.t.tra, was clean and casually dres.sed.. Her speech was clear and un:dorstandable. lt was ofnormal rate and tesne. Thought processes were logical, coherent and goal directed. Lauradid not cry or have a.n emotional outburst. She reported that she feels depressed mostdays all day. She expressed feelings of low self esteem and helplessness. Lau,ra rergcal-k.edthat she feels like she is a weak person now. She has no suicidal thoughts, plans orhistr}ry of attempts. She stated that she becssmes agitated and angry often. Sometimes sheis snappy and argues witlr her Ezusband. She gets angry quickly and sometimes she willthrow or break things. Laura stated that sbe has mood swings, which she described aseasil^ becoming angry over stupid things. She did not describe any periods of eleva.fedmood or a sense of grandiosity. No psychomotor retardaion or agitation was observed.

Laura displayed a nervous habit of tlA2stirzg her hair. She stateed that she olten is nervousand anxious. She is fearfiil of not seeing what is going pn lrehind her. Sometimes she haspanic a.itac}:s. Laura stated that she startles easily. Her anxaet3 and fearfulness is triggeredby seeing people in hoodies ar by TAking about the robbery and her asss.ult. She st:Il hassome nightmares about it but now thexl occur less frequently, maybe once a month. Laurastated that she does not feel comfortable going into public places and being aroundp:;ople, especially people that remind her of the robbers. Laura reported that she oftenfeels fidgety and restiess and sometimes she gets "cabira fever from staying in the houseso -much." She reported having sleep problerits.

rom:9372776067 1"o,9372643760 Time_Decemaer 20, 2012 2:16_46 PM EST ^ oIe ^Page 12 of 48

Dec 20 2092 02:.54PP1 Basds NEathis & Assodates 9372776067 page 5

Page snf7Baker, Laura BWC W 0&-382336

Scmetinzes it 'ss hard for her to go to sleep at night and she may nap in the day. She oftertfeels tired and does n©t have arzy energy or motivation to do things. She reportett havingdifficulty with oaDccntetion and inemory. She is no longer able to read and a^^y focusedon ,.vhnt she is reading. Laura stafed that she is obsessive com.pulsive aboiut the way thatshe shtswers. She has a certaut routine that she has to follow when she takes a shower.There was no indication of haIluciiaations, delusioats, paranoia or any dissociaticee^.•perienccs.

Laura was alert and oricrcted to person, place, date and situation. She could state hername, age, birth date and Social Security number. She could narne the curren.t presidentof the tI: sa and the last three previous presidents. She said the rnontLis of the yearbackward carrecily. On digit span, she recalled seven digits forward and five digitsbackward. She remembered one of three items aiter a ,$ve minute delay and she correctlyfigured out bow much change she should get back if she bought an item for $10_5{} andgave the clerk $20.00. She cnutd not figure out how much a dozen cookies would cost ifthey were priced three for $ l.50 or how much an item would cast that A-as originally$600 and on sale for 25 percent off. Hez expiaDataon of the sa-ying "Don t judge a book byits cover," -was "First impressions, don't go by them. Get to kmow the persffn before youjudge them." She answered tl= "Birds of a feath.er flock together," zneans "People of thesame interest are usually friends.." GGeneral cognit7ve abilities seem to be in about theaverage range (90-100). She did not need questions repeated or simplified for her and herattention and concentratian wcre satisfactory during this evaluation.

ACTIVITIES OF DAILY LIVr,.'^'G

Laura stated that she gets up at 9:00 a.m. She gets on the computer and checks pacebook.She feeds her son, takes care of him and ivatches TV. Sometimes she calls ber neighborand invites her and her children over. Soinetimes she may cook if she feels well cnaugh..She does the Ia.undry. She goes grocery shopping with ber husband. Laura drives and hasa car. She pays bi11s though sometimes she forgets. SQmetirnes she goes to her daughter'ssoft' ball games.

S U15!1]!IA RY AND FL"tir DIN GS

Laura Baker's claim has been allowed for Prolonged Pr,sttraumatic Stress Disorder and.Major Depressive Disorder Single Episode Severe without Psychotic Features. La.ura waspsychologically tr 3atamatized as a resuii of being assaulted during a robbery at her place ofernplQynlent in 2008. She has never returned to work.. I aura continues to be bothered bymemories of the traumatic event, being vigilant, easily startled and sensitive to things thatremind her of the people that assaulted her. She is also d.epressed on a nearly daily basisbut she is not suicidal and has no history of suicide attcmpts. Laura's depressionmanifests as depressed mood, lack of energy and drive ar interest in doing things. She hasbecome socia.tiy vtirithdrawn. She also reports having difficulties with her can.centr.a.tion,and being unable to attend and focus, to read or to do any concenfrated act.ivities.

From:3372776067 To:937Z64375D Time:December 20, 2012 2:7:46 P h t EST pTC ^Cec 20 2012 02'55PM 8onds Mathis & Assoclates 5372776067 pagQ 7 Page 13 of 48

Page 6 of 7

Bnker, Laura BWC # 08-382336

According to her report before this ii-ijury she was an outgoing person who had frieYadsand social interests and aciivities She fun.ctianed well on the job and had no historv ofmental illness or subsrance abta.se problems.

She has had several years now of individual psychotherapy and treatment withmedication to address her a.nxieip and depression but despite these treatments, littleimprovement has beea rriade in the reduction of symptoms and improved fimctionalabilities.

ASSESSMENT OF SEVERITY IN TERMS OF FUNCTIONAL LIMrTATIQI+iSIILIE TO TH1E ALL43W`ED PSYCHOLOGICAL CC.INDMaN

l. Activities of daily living: Laura reported that she does some basic hygiene andIaouschold tasks. She has two children, one of whazn is still a toddler that shetakes care of during the day. She caan, drive and but seldom leaves the house orgoes any place alone. She reported being somewhat n.egiceffirl of hex appearra,nceand sometimes needing prompts and reminders even to shower and clsange herclothes. Fian.ctioning in this area is rated mild Class two, 20 .pcrcen.t.

2. Social Fu.p.cd.onaug: Laura continues to limit her social activvities oht of featfulnessand anxiety about potential harm that could come to her. She has only one currentsocial outlet and that is with her church and her involvem.ent there is r.ninirnal. Sheremains afraid to go into public plaoes or do any activities alone. Functioning iQthis area is rated moderately impaired Class Three, 30 percent.

3. Cor{cen:iration, persistence and pace: Laura reported that she has difficulties nowwith being able to focus in order to read or perform sustained actiArities. She isoften depressed and has a great deal of difficulty motivating herself to initiate andcarry out daily activities. Functioning in this area is rated Class Tfu-ee, moderate25 percent.

4. Adaptation: Because of the PTSD and Major Depressive Disorder, Laura's abilityto handle day to day work stress is significantly imisai:red. 5he would havedifficulty meeting work demands for speed and productivity, working around avariety of people, dealing with the public, performing multiple tasks and havingresponsibility for other people. Functioning in, this area is cansidered raod.eratelyimpaired and rated Class Tkzree, 40 percent_

In response to the Industrial Comtnission's questions:

1. The injured worker has reached maacimum medical itnprovement. She has Iaadapprop.r.iate treatment with psychotherapy and medication. Her symptoms arestabilized and the prognosis for further funetiona.t iinprovement is poor given thelength of time since the injury _

^ °''

** Fram:9372776067 To:9372643760 Time:Decenlber 20, 2012 2:16:46 Pflf ESTPaqe 14 of 48Dec 20 2012 02:56P^1 8mds Mathis & Associates 9372776057 page 8

Page 7 of 7Baker, Laura BWC 4 08-382336

2, The percentage of permanent total impairment due to the allowed canditions,Posttraumatic Stress Disorder and Major Depressive Dasorder, severe vnthoutpsychotic featums, is 29 percent of the body as a. whole based upon the AMAGuides to rhe Evaiuation of Permanent Impa.irment, riftffi Ed.ition, Talrie 14-1,AMA Guides Second Edition, C , b a p t e r 1 l,`f able 1.

Giovanni M. Bonds 1'la. D.Clin%cai Psychologist

cjm

^ ^^

of 48

OCCUPATIONAL ACTI^ ASSFSSMENTMenU & Behavioral k ` .-don

INJC7RED WORKER: Laura Baker ^_.'= .^;_r: Iv U? ^^? ^;}. g 3- 38 2 3 3 6_ .

13asad solely on impaii-xnent resulting from ; he allowed meatwl and b°hwvioral:!ondition ( s) in this claim within zny specialty, and wi_th no corsa.deration ofs.he Irjured Worker's age, education, or work trairing:

^_ (s

This Injured Worker has no work limitations.

This Injured Worker is incapable of work.

This injured Worker. is capable of work with the lzmitation (s) /modification(s) noted below:

1^i

l.,,P

J •^^

/, t^f} 3̂^

^^t Ayo-Psyi^^^`h^-atrist/Psycho oyist Signature

Gin,.anni M s^>r^dsP^^rch_atrist/Ps^rchoioa,ist Ryame

SPECP-PT

/2 -/^.-f2-Bat_e

of 48

I Bureau of Workers' Settlement Agreement and App^ca^tiean forO

°^ Compensation Apgaroval of Setttem®at Agreemmt

{Por state-trmd c]®iuxa only)[Self-9raratvd cla= jaa SI-921

Fiie thiaepp3ication toaattle workers' companaatian alairns s3sdr etststurnl ernployers. Ohio Revlsed Cade 4123.Fi5 requires the injuced worker andttre amployer tosign aettlemerrr appttcations unless the employer Is no longertloing buelrieaa in ohiu. lf dte claim to be setded is a smle-fund claim, andthe emplayer ic now salf-ircuring, f6WC eharpes 1he self-insuring employer doRar for doltar for any ponion of the setilemant attributed to paac, pres®ntor future Disabted Wofkere Aelief Fund tflWffrl Gahiroy.

By fiCing this applicaiion, the iniuredworksrand the emp)oyer agree all unresohed issues will he suspended. All ongoing compensation and medicatpayments, howevgr, ae'9l ecrninne untif the etFeciire setttemarrt dsta The bfteetive setdemeni date is the mailing date of B1h7C's uppmfai d sottlemeruagraoment.

PM9w Notat: The persons lertroivod with fil trv,1 this settlaee+n agree if any other clairn(s} or part of any claumisl beDng sartled hss been recognixad orallowed, then the cnat of all medu:ai senikes, RpaFutat higs, druga and mad'rclnes wilh date(si of a®rvico or flling of related presanptions 6notto ezeaeda 34day suppl'y) provided to the injured worker 5efom the affecBVe sett9ernetd datt:, shati bafire r®6pons6tiility of the ciate insurance fund, providadsuch casts rasulttiom the a9•iowed condidony at the aialma and cra properlY payabie under q,rrent rnedieal paymeMgufdelines. The costs of aYf madicalservice„ haspital hiRs, drugs and mad'ic'mewith the date(s1 of aaruiw ofiifEing of rolated presraiptliens (not to exz®ed a 30-daysupph) pmvidDd tu theinlur vmrker on oraf>Hrtha etfective setttemem date arethe r9sponsi4l4 af doe injured wnrker.

Ily fnftiating this hux, the injuredworicer amknawkrdgas ha or she has read and understands the abnve stalemard.

Special Rlotlrae tu (llfedrears Benet-ioiariesMedicere does not pay medlcai hdls far' cond-rtions covererl by yaur wdrkers' comparmetion cialrn. If a sattlenient of your workeri compensat;onci-a'un israaehed, and the sottiemenr allocstes cerain amountcfor fwuro mad ical expe+rses, Madir.are does nat pay for tkroae sorvices until mediealezpsnses related to yaur workers oampi3nsation elaim aqusl the amouRt of the lurnp sum setllornent allocated to tuture mad ical ezpgnsos- €madditi^ral irdannafion, please call the MedicarU coordination of bgnafrts carIIrar,tnrat[8goi 999-Tt1&

Insrruciiros

- Forlast-timeantlmetrcal-anlyclaims,mailthiscompletedapp4cationtoyournearestcustorftrsoroiceofftcs.• Csitt-BgROirlOBlfYCfortheaddressofymarlocalcusiamersorvicooKiae.

- Tosedaaclaimwithaaak-FnauringamploYar.pteasocompleteandiorwardfomZ51-d2,nrcontactyoursaff-6asurin6emplayerloeolherfermssattingout thaagraernent benrraen the infured worker and salf-insur'mg employer.

• Tofacditatesettlemenlofthisclaim,pleaseiprvrardanyunpaidbdlstoyourmanagedcare organ'vation.tnciude a Bat of arty unpeid itills you are awure of or attach onpies of any unpaid hills or state® ents.

App4ication for Approval o¢ $ettlanNntt AgrpecnantThe iniuradworket and employsr,as agreed to below, makeabpifcation to SWC for approval of a finat eet9tameatia tha inju n:d worker's daimisk.

name

LAURA9AKER

5063H(t$iP5lalN OR

resentaNre name

tSOCHfdAN S PLUta47

3033 KETTt3dIH8 BLVD S i 204

loyar momeApYAh.'CEA1,E3iIC.A CASH ADVAPfGE CBVTERS IHC

aA

135 N CHU1tCH ST

iayer repe®smrsttatima naane

rtiuo aa 01b8F rntevant empioysrs fs attached U Yps I

^.8ifrt{S) to'CfsFm Nurrdêr' .. Hequestedamanntfor

e&naxaas

°Ust any claims specificaAy excludod from cetttament

**Plasa expiain arcv rgqVest fvr a Dardal ssttlement

?SB-48-tgt2

FAIRBOFW

ID ni

DAYTGN

h®r

L244Z53-D

SPARTAN®URG

$+0J,DOg-oo

or nrrar fhona numb®r

tk?fOEdtgfiB Es371878-7182

state zIP cada

ON 4^2^71gg

PhamenumtprL12n5rEL93 (837) 228-2655

4N

sc

d6438

ntan5ar(a641342-564

Ie

293D6-st3a

narnber

aocation of rnqasatadsattismerrt etnd:ait

Ilochrnan & F'1[umkeft3033 Fiettering $1vcI.

Suite 201

1)a3't0n, Ohio 45439'D# 2051 6-91 -

i.sr'230A-TTACHCrAj -

Gwrkp sat forltt tha cirptnrstantes by tancon of whidt the prppused seitiemmst k doamed 6asirar,le,

laimar^t wishes to recezve the benefits from a'7ump sum settlement to assist in recovering fromthe diffi.culfies the andustrial injury has caused.

ias infarmatiwr on athar reievantclahns baan attachetl? Aro you reWvln8, or heve yoa appllsd far htedicare be^Yac ®fHo . qt. ®N

irryukreukrangme trundrtentatth'rs afsvarr ' g bysici s1? gasrtt' .rin .lme'F Yess kVa '^ r r7f

trqyûn•antôrking7 rfyetwkaityatarpreaentrmpf}'^kqy.r_7 A isyrarrp^^rrrrtacqrpationT Whatwyutpreseutrryac No ^ 1

PAGE 11131 RCYD AT 2F2612043 10:24:77 AM lEastern Standard Time] t 5VR:lMf39FXPDA4175 1 DNiS:144564756° CS1I1:143747D4585" DURATION (mm-ss):02•44

^t ^

of 48

Employer SignaturetRequired by ORC 4123.65 unless the employer is no lonQvr doing businexs in Oftio}

fnstructaons• Pkass cheek ane af the farawving bmons and sip bebez Yeir signamra does nat wafva ttra enptayars riphrm wiArdraw eonranius the setdeqrenr by previdinq

writtan nadoe ta tlie ampuyaa arrd U,e aWC admatutrawaithbs36 days after the adminlsACtnr iasuesthe approralef the seteamant aprvamert

13 A. The employer is supportive of and agroeabie tc a settiement up ta th¢ asnourrt Fistod on tha front of ths appricatiort,

E3 B. 7he employer does not ageee with tha requestod acrtfernent terrna but wi6t perticipate with the $WC in the neeotiation procea&

[3 C. TheempFoyerissuppuc@veofandapreeaMetaSMlementofthec6aims65tetfanthefrpn[of?huappiication.Howevor,theemptoyerwill not partioipate in the seafeancnt negflxiations and teilsaste tho BVslC to negotiatsttieseitiement on behalf of the eppto}r&r.

E.^ D. lheemployerisnoia®rcaabiatosettietpentoftheclairrdsYtistedunthefrontofthisapPiicafion.

®y sfgning rieiF apreemertL, an empJayer thet i.a turratltly are#-insurad aotnawfadges im rs6figarion ar norreburse 6VJG hir the porfton o3 Uea aettlemenfemouMat}arated toQVURi- c®cts af ihe ebove-reJ^eersx^icinhnlst. eINC wilf 5ifr3he ©W1tF portrop ot thasetaemeettv the setFinsuringernproyer, evwrit iNa injured rtivrirerhas rmi yset6ean datermined to be permanenCry end mra)iy disebkd orc,r,rrenrdp eBpibfe for D1YqF jrarm6ra

aranber

Settiamortt ,oigreement and Release

As set forth in this agreeanent, the inj ured worker for and in consideration otth e receiptofthe setttement amountapprovedby the BWC, which sum wig be paid from the appropriate fund on behag of the empioyer aftar approval by the BWCadministrato r, unless within 30 days after such approval the a dm[nistrator; the employer or the injured worker, withdrawsconsent to, or unless the industriel Commission of Ohio ([CE disapproves the agreement, does hereby tQr hlnt1hersalfand far anyone claiming by through or under him/her, forever release and discharge the above referenced employer,its officers, employees, agenCS, representatives, successors and assigns, the IC, the BWC,the appropriate fund, end allpersons, firms or corporations from atay or ali cfaims, demands, actinns or causes of action incurred on or prinr te thedete ofthe a pproval of this agreamerd; arising outof Ohia Revisad Code Chapter 4121. or 4928., which hefshe now besor which he/she hereafter claim to have, whether known or unknown by reason of or in any manner grovoing out of theclaims or partsthereof set forih above. The injured worker further understands and agrees that anyamount paid pursuantta this agreement is subject to any valid court-ordered child supporL The parsons iavolved with fifrng this seitlementagrae that if any claim(s) or part of any claim(s) being sattled has been racognized or allowed, thenthe cast p€ a[l medicalselvices, hospital brTls, drugs and medicines wth ffate(s} af service orfil[ing of related prescriptions(not to excaed a30-daysupply} provided to the injured worker beforethe effeetive settlement date, shall be the responsibility of the stateinsurance fund, provided such costs result from the allowed conditions of the claims and are praperiy payable undarcurrent madica[ payment guidniines. The eosts of inedica[ services hospital bilis, drugs and medicines (notto exceed a34-day suppiy) provided to the injured worker on or after the effective date of the sattlament date are the responsibilityofthe injured worker.

By initiaiing this box, the injured worker acknowfedges he or she has read and understands the abavostatemelttL

Also as setforth above, the injured worker understands that any setttament amounts allocated for future medicalservicesmustbe used formedicaCservices before Madicarewil( considerpaymentfors:efvicesfarghe conditions of the workers'compansation e[aim.

5atitamentof any claimfsj included in this agreementin no way impairs BVttC's statutory rights to subrogation recovery.Also, be advised that upon a fintling of iraud,the adnunistrator retains the right to rescind this setdement agreentent andre-open the claim for an administrative overpayment hearing and referral for criminai prosecution.

Power of Attorney

By signinp below the injured worker grants a rnnited powbr of attorney to the atiomey of recard forihe purpose of receivSng the warrant"rsssrsd becauee af thie -ttiement agreament Date

PRGE 71t3 r RCYD AT 212612043 10:24:117 AM [Eastern Sr:tndard Tdmej"SVR:Iat]p9FXPOQ4115 ` DPI3S:144564756 * CS9D:4 5 3 74 1 04565 • DlJltaTlOrd (mmss}:0244 ^

of 48

Laura Baker 418-352335

Caleulativn of Setdement Dentand

PAGE 3113' RCVD AT 2I2812013 10:24:47 Am! [Eastern Standard Time]' SVl2:tlilI09FXFD44115 ` DAlIS:144584756 x CSID:193741n4565 " DURATION (mm-ss):62-44

of 48

Laura Baker 118-382336

F'I IID Calculations (considering DWRF entitiement)

Regular PTD Benefits _

Week-ly PTD Rate (irom worksheet } 375.50ninus LSAsI

equals Weekly PTD Rate (adjusted for LSAs) 375.50x Factor from BWC Life ExpectancyTables 89$

]Eqoofs 100% NPV of regufar P'TD benefits

Pluss DWRF benefitsCurrent weekly DWRF floor

minus Weekly SSD benefitsminus PTD payments allocated to other cimsminus Weekly PTD Rate

equals Current weekly DWRF entitlemen.tx Factor from BWC Life Ecpect^ncy Tables

En®afs 100% NPV ofDVVRF benefits

Equals Fu11 PTI3 Value

I S 337,199i10

^ 337,199.00

PAGE 4153' RCVL7 AT 2126I201310:24:'!7 AM [Eastern StanBard'iBmej * S11k:INt09FX.PD04145 " DNIS:144564756' GSlD:19374704365 ° pCRiqTiON (mm-ss):02-44 ^cy

I ^I

- I

of 48

B G D F G F6 { ^ f LI:aurm 8aker 08-3S2336.-

-- -CAL.C{JLATIIYC PT7? RATES WHEN CONSiDERING SSD BENEFfI•S-.___...rr_^.._ -----

.. . ^1. Ca[culvtingtbe weekiy workers' comliensatinn amount p9rsuant to Uhio 1tevlted Cede 4I".3,5${A).4 Variabfms oired - - :

-- - --- - _ __ - _- ;AWW 3---37530 5U% SA. W W iqriaimn m PTD from Ita[e Char[ for DO1)

286.13 2^ AW W500-67 2!3 SAWW ("PTD ofZcet" amount £rom Ra#e Cbart for DEDI)

Na a) f 2 13 ofAWW 286.13 >=213 SAWW - -- SOk.67 d^en vl`WAC

25 atSAW{M1' 506,67-T (

-I-No rb} FfA[;'W r+29201<50"/oSAYrrW 37550 L1=U1'WAC

AWW ^ 42920

Yes cj ICAWW R2924 .>= 50"l^ SA'4YW 375,50bat2(3 AWW 2$6.T3 <50%SAWW 375.50 :thep C--^50°la SA9V4V 375-50_._. ..^ -

! - ------ ^ - •_

t3To t3} 1f213 afAUW 286.13 >5tl9'oof SA^S'W 375.50

but 2(3 AW W-- 286,13 i< 2{3 SAIh W 500.67 then WAC=

2l3afAW1d 286.13 - -

WEEKLY W4NliM' CCI_MPENSATI®N AA3Oiih'T EQ'CTAIS: 375.54^_ ... _.- ^^

2 Ueterminia PTi7 Retet Ca}cukations pursuant to Clbio lievised Code 412358(B) E nelmbles setluired I - I -

_ __ _ _375.50 WWCA

Weewp SSD C - tvicnthlySSL' x 12! 52j751.00

2

&A.WV1' (oesximum.PTD from cate chart fur date of injpry)_ .. ..---- - - -- -- - -'286.13 f3 A1i'W;

- 500.67 2f3 SAWW

e_.... ...- _,_ --__ . _..... .__ ^ -........._. ^.__^----Na a) •,I4iA'WCA + SSi1 37550 >= SAVYW 751.00 #hea PT D race=

^CA 375_50

- _.- i. ...--- .-._...._ ._.. _-_ I __ . . ..l ss b} !If6YWCA+SSD 375.50 <SAW^V , 751.00

sad 2t3 AWW 286.13 <=213 SAIYW 500-67 thm PTD rate =;94 WCA 375_50 Y_

-- ' _ _Ido cj If514YCA+SSD 375.50 rSAWW - 751.00

and213 AWiW 286.13 > 26 SAWW 500_67 but<SAVfVJ : 751.00 then PT7] rate

IVO

13AWW

- --- -- _d} + SSD 375.50 < SAW W 751.00 ;, but

1l3AWW 286751.00 ^thcnpTBrate=

dATE EQUALS in thr; claim}

p11[ PTD Tola] P CI?e 375.50 ix'a in this ciaimcquais PTD rate fr3r t3[is c}a#m ss pazt of spli[ PTD ^5,g0

tecf TJ6l20I3-pieLUGIC CI3F-C3C:

at urore t3[att I"Ya" item in each of rES 1 snd 2

PAGE 6143 x RC1(D AT 2l261209310:24:17 AM [Eas@em Standard Time] s SVR:tWt09F7tPD04115DNpS:144584756' CS1D:19374104565 x pURATtqN (mm-ss):62-44^^ '`S

of 48

Laura Baker 08°3$2336

Future medical expenses

Age of claim (in years):

Total medical beneftts paid to date:

Average medical benefits per year,

entire i ife of ciaim:

Remaining life expectancy, per BWC

Tables

Projected future medical beuefrts,

based on average of life of claim

Add: One-tiane iuture expenses CiteYUiae)

4.24

28,598.81

6j/6(J0

31.7

220,000.00

Total, one-time items

TOTAL MEDICAL AND PRESCRIPTIOIVSETTLEMENT DEMAND 22t,000.00

PA:.E6ft3*RCWDA72J26f2D131D:24:M7AM[EasternStandardTiine$`SVR:IMD9FXPDD4/15xDNf5:144564756xC5ID:19"s741D4565'DURtFTK3N(mn,-ss):02-0.4 ^+^

OhioBWC - Common - Service: (Correspondence)

Injured worker: LAURA BAKER€Jhioi;WC - Common - Service: (Correspondence)

#Bin7NE'VSQ

#1W43083179965040#

LAURA BAIK,ER

7649 STONE RIDGE DR

SPRINGBORO OH 45066-8766

Injured worker: LATJRA BAKER

i.laim number: 08-382336

InJury date: 11/10/2008

Claim type: Accident

Dear Injured Worker and Employer:

07/17/2013

Date Mailed

Employer's na_me: ADtTANCE AMERICA CASH ADVAIqCE

Policy number: 1244253-0

Manual number: 8810

The purpose of this order is to inform, you of BWC's decision regarding your

Settlement Agreement and Application for Approval of Settlement Agreement

(C-240) previously filed in the above-referenced claim(s). After careful

review and negotiation, BWC cannot approve the agr_eement. You will find

the details of the decision outlined below. Please understand that this

order is not appealable pursuant to Oh3.o Revised Code section 4123.65. You

may, however, file another application for settlement in the future. if

you have any questions or need further clarification, please call the

claims service specialist listed below..

DISAPPF;OV.AL OF SETTLEN,ENT AGREEAZENT

The Adniinistrator finds that a Settlement Agreement and Application for

Approval of Settlement Agreement has been filed ia the above-referenced

claim(s). After a review of the application, the adtrLi.nistrator finds the

following:

The application is deried - All parties do not agree with the settlement

terms.

Settlement of this claim is not in the Ohio Bureau of Workers' Compensation'sbest interest at this time.

PLEASE I;EEP A COPY OF THIS LETTER FOR YOUR RECORDS

Ctaim #: 08-382336DOI: 11/10/2008

Page 22 of 48

https://-,A,",vw.bwe.ohio.gov/includes/przntF}̀riencll-,J.asp 5129/20I4

OhioBWC - Cozaman - Service: (Coxrespondence)

https://www.bwc.ohio.gov/includes,^Printfriendly.asp

BWC Use Only

05/43/02

Page 23 of 48

5/23/2U 1 4

'22,1

Hochman PlunkettCU.L.P.A.

ATTORNEYS AT IAW

James B. HochmanGary Q. Plunkett

Caria J. Lauer'

Todd T- [Jlilier

Brett R. Bissonnetle

Donald K. ScotiCinaman S- Ftaruston°'E

David F- Rudwa#I''•

''aGo adcnitze6 in Ce[iForrya& Nevad®•al= atlmirxed "v, indigna& ICentucky

"'Or counseE

Vlk FACSIMILE 866-281-9356

Theresa B.Jim L.Ohio Bureau of Workers' CompensationDayton Service Office

N71A RACSDM,E 877-520-6446

Sarah MorrisonChief ofLegal OfficerOhio Bureau of'Pi%orkers° Compensation30 West Spring StreetColumbus, Ohio 43215

Re: Laura Baker1-C. Claim No. 08-382336

D= SirfMadasrts:

May 22, 2012

Page 24 of 48

On or about Febrczary 19, 2013, we filed a settlement application with the Bureau of Workers'

Compensation on behalf of our client, Laura Baker. To date, we have received no offer on the claim, nor

have we received the affirmative represenintion of the BWC that the claim has no value to settle.

Notwithstanding the lack of the determination that the claim has no value, the BWC has dimnissed the

settlement application,. There appears to be no reason why the BWC is neglecting to fulfill its statutory

duty to thouahtfully consicier a settlement application filed by Ms. Baker. We respectfully request the

BWC immediately revoke its disapproval of settlement agreement order, issued on July 17, 2013, and

provide us with assurance that the BWC will immediately begin to fulfill its statutory obligation to

evaluate Ms. Baker's settlement application in good faith pursuant to its-sta.tutorry obligation under R.C.4123.65.

The Workers' Compensation Act requires the BWC to consider settlement applications filed byin.jured workers. R.C. 4123.65. This statutory duty has been recognized to entail an obligation ianpo=d onthe BWC to determine the appropriateness of settlement applications, in good faith. As stated by theSupreme Court in State ey- rel. Johru7on v. Ohio BWC, 92 Ohio St.3d 463, 475, 751 N.E.2d 974, 2001-Ohio-1284:

t2agton Cincinnati Springfield Troy3033 Kettering Bivd., Suite 207 810 Sycamore Street One South Limestone 8treet 22 North Short StreetDayton, Ohio 45439 Third Floor Suite D Troy, Ohio 45373937-228-2666 Cincinnati, Ohio 45202 Springfieid, Ohio 45502 937-333-4410

5 T 3-338-1898 937-325-2995

hochnanpiunkett.corn To3l Free: 877-266-7465 Pacsimife: 937-228-0508

PAGE 115 " RCVD AT 712312013 2.1fi:31 P[ai [Eastem Daylight T"srnel'SVR:IM09FXPD®4d5 ` DNlS:144564756 x CSED:15374104565'x DURATION (mm-ss):02-27 -1A

of 48

Ohio Bureau of Vvorkers' CompensationJuly 23, 2013Page Two

"While this provision does not require the Administrator to approve a settlement application on

demand or aecept the terms agreed to by the parties, nor does it give the Administrator the

unfettered discretion to reject settlements out of hand. There is nothing in the statute to support

the notion that the Adrniuistrator can properly reject an application that be determines to be

appropriate. Semantics aside, the Administrator has an affismative statutory duty to determine the

propriety of settlement applieations, the performance of wh ich can be enforced by proceedings inmandamus,"

It is important to note that the Supreme Court granted the Relator's application for a writ ofmandamus in Jo.hnVon, and required the BWC to consider the settlement application that was filed before

the claimant's death, providing an exception to the rule that a settlement application normally abates at thetime of a claimant's death.

In this case, Ms. Baker receives permanent and total disability compensation benefits. The 13WC

has significant exposure, as permanent and total disability compensation benefits are payable until her

death. The BWC has given no explanation why it refuses to make a settlement offer, or why, pursuant to

the order dismissing settlement, that 'settlerraent of the claim is not in the Ohio Bureau of Workers'

Compensation's best interest at this time." The BV'C`s decision not to make an offer is unusual, as the

BWC routinely settles cases on a daily basis, even whsen those claims are not yet allowed claims, or when

the claimant is not receiving ongoing compensation at the time of settlement.

Refusing to make an offer in a claim which has ongoing iiability from the BWC's perspective is

illogical, and indefensible, and demonstrates a lack of good faith. We cannot understand why the BWC

would choose to not even make a settlement offer, when the BWC routinely settles other PTD cases,

which ultimately saves the BWC money in the long run. A review of the notes within the claim file on the

BWC's Dolphin websitel reveals that even the BWC's claims representative did not understand why the

BWC would take the illogical arad unreasonable position that settlement is not appropriate in this clain).,

and there is nothing contained in the record which sets forth the BWC's decision making process. As Jirn

L. stated in his July 18, 2(} 1? note to the fiie, "Received call back from M explained that the BWC is not

settiing the claim at this point. Did not receive much explanation from Columbus, but an order will be

published once we receive the paperwork." This well-documented failure to consider settlement in good

faith is clearly redressable through a mandamus action as enforced by the Supreme Court in the Johnstoncase.

Without question, no one can accurately predict the date of death of another individual.

Nonetheless, standani risk management tools take into account the fact that life expectancies can be

1 A copy of the notes is attached hereto.

PAGE 2i5 s RCVD AT 712312013 2:76:37 PM (Eastemm DayligttTime]' SVR:INI09FXPD0415 ° DNIS:144564756 * CS1D:1a374704505 " DURATION (mm-ss):02-27 ^^^

of 48

Ohio Bureau of Workers` Compensation

July 23, 20I3

Page Three

statistically estimated. The Federal Government produces the United States Life Tables, found by courts

to be reliable evidence to determine an individual's life expectancy. The BWC, previously recognizing

that statistical evidence is required to estimate life expectancy when deterniining the value of settlement

applications, previously commissioned a study to determine the life exEsectancy of a very specific group

of individuals - those persons found by the lndustrial Commission to be entitled to permanent and total

disability compensation. Ms. Baker is a member of that group, and her life expectancy should be judged,

beginning with the assumption that Ms. Bakeris life expectancy does not significantly deviate from themembers of tbe group studied.

This analysis leads to the conclusion that the value ofNfs. l^ker`s workers` compensation benefits

may be rationally determ»ned through a mathematical proeess which takes into account a combination of

ber life expectancy based upon her known age, and a reduction of her benefits to present day value based

upon a 4% discount rate used by the BWC. This is the process that is engaged in by the BWC to

determine the value of a workers' compensation claim, and has been the process for many years, In fact,

the BWC's commission of a study to determine the life expectancy of PTD recipients is directly related to

the Bureau's settlernent fianction. Using the guidelines issued by the BWC, we have submitted an initial

settlement demand of $354,000.0(1 for the net present value of the indemnity payments the BWC is

virtually assured of paying in the future.

Additionally; based upon the substantial costs of medical treahment in this claim, we have

rationally determined a value of approximately $204,040.00 for initial negotiation purposes.

Given that we have specifically idendfied sigo.ificant benefit classes to which Ms. Baker has a

current entitlement, no rational person can state that the claim has no value. Yet, the BWC's failure to

evaluate the settlement request, as shown througb its failure to document the same, leads to the un-

refutable presumption that the BWC simply does not believe the claim has value. Otherwise, an offer

would have been made, or some rationale given which explains why settlement of this valuable claim

does not comport with the BWC's overall risk management stiategy.

We would respectfully request that you refrain from abrogating your statutory duty to considersettlement applications by dismissing this settlement application without a valid, justifiable explanation of

how this settlement application was considered in good faith. From the BWC's own notes, it is clear that

the settlement application was not considered in good faith. Therefore, we are requesting that the

setflement application be reconsidered, evaluated, and sent to the Executive Committee for consideration

within the next 30 days. If you choose to do so, we will be filing an Application for a Writ of Mandamusseeking an Order from the Supreme Court directing the BWC to consider Ms. Baker's settlementapplication on a rational basis.

PAGE 351 RCVD AT 712312Q43 2:7fi:39 PM [Eastem Daylight Timej R SVR:1M09FXPpD4F5 x DNlS:444.564756 'CSID:79374104565 " DURATION ^ntn-ssj:02-27

lp)

of 48

Ohio Bureau of Workers Coznpextsati.onIuIv 23, 20I3

Page Four

Thank you for your attention in this matter,

GDFijad

PRGc' 4!5 z RCVB a.T ?123Y1043 2:16:31 PdV! [Eastem DaybyFst Timej- SVR:IAd09FXPD0415 x D09IS:144564758 x CSfR:t 9374104565 x DUR6lT1pH {mm-ssj:02-27 ^®

I

Very truly yours,

of 48

07f2212013LflNIP SUM SETTLEMEEN1'(LSS) MCO t37f2212013 - Lump Sum Settfemenf(LSS) -the se ...

4712?12013 - Lump Sum Settlement(t-S,% -the setUement application has been disallowed on 7117113

- --- -..^ - -------- 711812013CALL FROM !W RE: LSS BWC Received cali from DW raquesong status of

LSS ...

Received call from IW requesting siatus of LSS request? Erplained that I would have to cantact Coiumlyus to find outstatus, Stated I would return herr,atL Jim L,IMS

Le1t message 420pm 7-17-13 requestina a calt bacL

7-16-'t3 Reaeived call back from tW, explained that the BtAiC is not setrGng the ctaarn at this painL fW not receivemuch exptanation irom C:afumbua, brA an order w311 be published once we receive the paperwork. Jirn L, IMS

^_._.....wA....r___.^..,....._-fl7/17/2[^13BWC ATTORNEY DOES NOT SWC { receivgd the Lurnp

_..-,.....,.-,...-:,.-^.-^,,.,^^,^y,r,a.,._-^,Sum Settfemertt

RECOMMEND LSS Workbvok ba..,

I nec®iver} the Lump Sum Setttement 4varkbnok hack frwn BWC Attornxey Peggy K. stattng that it teas not in BWC'sbest interest to settie this claim,Theresa B., tSSlCSS

06/131201 °,AULIRESS GHANGE BY INETREASSIGN

0512012443ASSfGNED C; S UhIAVAiL,4SLE 8{11tC D1ARY 73534

PAGE 515 " RCVD AT 712312013 2:16:31 PM [Eaatem F)aylight Tirnej' SVR:IM09FXPD0415 * DNIS:144564756" CSED:19374104:965 ° DuRATIBN (mm-ss);02-27

vrrl r1LVJ3LZ:iti-tl(sapprovat t3VYC

-ubf I srlu°t 3t:HLL t-KUM IVY - LU5 UPDRFL BWC I received a call from the RW inquiring about

1 received a call from the !W inquiring about ttie settlement of this daim. I explained to Ms. Baker that I am waiting onBWCs Attorney Peggy K. reviear- I explained that I sent this to fhe attomey on 5-17 2l)13. t agreed ta contact Ihe iVVonce I see mavement vaith the settiementTheresa B., LS',SJCSS

of 48

^ Bureau aff Workers' S^ t Agreement and ^pdic^,tioaa forOhl Compensation Appr+aara8 of Se nt Agreeaorent

($or rst:ate-fopad ctafrns mily)(5e3f-3ttaurod da4ma file 5I-42)

Filethrs appRcstion to sattle workecs' cnmpensatian rSaims with statsfand employem (}Evo Rovisad Code 4;23.E5 reqviresihe injured worker andtheemplayer to sign sealament app)ications unlestthe emplayar is na iongar domg busness m Ohm, )f thodaim to be settied isa state-fundcfairn, andHro employrl is naw sal^msuring, BWL charges.tho seif-uisuaing employer dollar for dollar far any poriwn of the settlement attrbuted to pasL prasentarfuwre t)isabled Wprkers' Reisef Fund if3iNRF) llabirrty.

By tfling thfsapplicatlon, the iniured workbr and the mployer agre6 all unresolved issues wi# besuspended Ag ongomg compansation and rnedl¢alpaymenta however, will corrlinuo un[il tha eftecfive setilerrrant data, The effeCtiV9 settfement date is the mailing da'w of 8WC's appravaf of semlemahtagreerrrerst.

fi)eRS6 IURt13: The perrons rnvolved wf9h Bhng thia settlement agree tfany other c[aimtsi or part of errv ciarm{9) being soIIlad has been racagnired oralfowad. thm thecost ofalt medical services, hospisal bHls, drugs and miedicrnes with date;s) of service orfdLng of ralsted preesptions tnotto extedda 90-day suppiyl prav7ded to the injured worker before the effective settlement date, shall be ihe responamiIItp of the stats Insuranee fvnd, prpvidedsuch costs reSuft frumtne aliowed canditaans of tne cieims and ara prroperdy payafrle undar currcnt medlcaf papereni guidelin:s, The casts oP ap madiealsenRcgs, hospitat bills, druy% and medicine wtth the datelsi of servlca ef gl)mp of related prescriplions lnatto exceed a 313-day suppfyl providedta Theinjured worker on or af)erthe effecovesettlemera date are tha responcibility ofthe injured worker

9y inrtipting this box, the injured worker acknowterJges he or she ha5 read an¢ understands the above atatement

SpeciaE IYotfceta Wledicare Bertefitiario>:11>edicare does not pay medical bNts for curditions covered by yourworkers' compensation dairn, If a eaftlam®ntof your workers' compensatismc{ame rsreached- a ndthe setdement 68acatesCwtarn aniountsiorfutvro medicel expenses, Medicare do9s not pay fortno&esrjriAces uatii mpdiaalexpenses re.iated to your vuprkers' compensatian claim equal the amaunt of the lump sumsealemsnt allocatad to future med'scai Bzpelrses, Foradtiflional mformatlor,, p)aasecall the Medicare coordrnation ofbcne5rs cantractnr at IOW) M. 11Z8.

rlnStnryt18r15 - -< Fnr lost-time and medicaf-onlycEamis, maitthss Wmpieted appticatmn to your nearest customrer seroloe office.• Cait 1-BDO-0HIOBUJCfarthe address ofyourlpnal ausiorner serolce office.

Tosettieacialmwitheseif+nsurin&employar-pleasecompletaandforwardfurmSl42,arscrrrtaetyourself-insuringemplayerforotherformssottingout the agreement laenrreer, The Injured wonwr and sel'r.insurir.g emp)oyer

'• Ta'iacilitate seitierrn tt o`thisciaun, please forlYard any unpaid i7iRstr your rnanaged tare organizafion.• fncludeaRatafanyonpaidbulsyouareawareofarattachcuplesofanyunpaidb7tsorsteternents-

Applicatlon for AppravaI of Sett[ernrsrrt kgreomerrtThe mjured worker and employe , as agreed lo be4ovc ma4e appiicauon to BWC for approvaf pf a flnaf settiemant tnthe uyured wor)cer'sclarm(s{.

y:rorkar name;AUru+BAicEta

76e9STONE WI76EUR

)dWr representat'rve nanse

HOCHMAN !i PLUM17K67T

3133 XETTERn1G BLYIJ ST 1M

nameuCG Ah1ERiCA CfiSti ALrVANCF CE1CEri$ IIYC

135 Fv CwUeZp-t ST

represerrtative neme

n•mafian eo other reLevard emplayars Is otFeched uyes uAb

CEairnfsM to b® inClaim Number" Rerprested nmouut for

complete set7iernent"•

otia8233e ss6p.poo t%I

•Lfst any claims specrKcypy excit,ded from settiement

••Pfease esmla+n ar+v mauest fer a RarK a! rert4ament

Security numtser poroofirirth PEam numbor

2h9.a9•131z tlslofi1969 fg77)gyC.gu_g4

State ZRr code

SPRIWG9DRL OR 4586687Eti

ID numbar Phenanurriber

02p51EAi (a37)T28-7666

State ZiP code

C1Ayil'1N OR 4SQ$#

xnher Faxnumber ono number1 2442.53-0 (864) 336-1356 (884) 362-564e

Steto iPcode

SPARTAftlBtJRG qC 299o6-5t38

set forth the edreunistances by reason of which the proposed settlemont ls deemed desirabte

Clainiant wishes to receive the bene^ts from a P p

suzn settlement to assist in recttvering from thedi-fftcufties the industrial injury has caused,

on

treah(^ reent et ttris

s qr^ tao

? If yes, who Fs ycarNo

C-230 AT1`

IAte- you recelvlrrg, ar have yorr appRed for f13e!dieara 6eoefits?-No Yes 0 N.;ur^a gPhys;osok5f2 ffifevsettimeoffnj

Si t- 6 rPploy%r7 1Mhat is your presgrr, accutgation7 'yPfratare Vour mnseot Mn

Propnsed agacation of r®yur-^ssemn

.oc^M __dllt^ P1^0. ke}tfty Prescri -a ,^^i l.

30M 'Xettering PIvd.Srute ZCll j

-BaSton,-°Qhio 4^439ID# 2051 fx-91

PAGE 11'd3 s RCVD AT 5l2f2ftT4 10:12:11 AItA [Eastem Daylight Time] " SVR:IayIn9F%PEA03CS1 * DitiBfS:144564756 ` CSlD:19379135570" DURATION (fnrri-ss):g240

of 48

Employer SignaturefEtecguired by ORC 4123.&5 unless the ersspfoyar is no laa<ger doing business in Ohio)

i^ttrsc[inas•ftase Cheok mre of fhe fa3low!ng botrsand ssgn hefuvt Your sqnamre daes aatwdiaa th¢ empleyei s sigM ta mthdraw censomf te the settkment ay praadmg

wdtaen nrdice ta Ere smpeogee an6 fha 9WC admna^oatnrwurin 3g days arterthe adffitafsn'emr rgsues the apnravat of dre setdeeaant agreemrt

® A. The empimler ts 9rpportiva af and egreeai.de to a settlement up to the amaunt rrSked an thb front nf this applicafion.

L S. The ernplover does not 8gree with the requested settlement terms but wiH participeie with the 81b'C ln the negotiatfon proce+t.

^ C. Theempf qven>sup¢ortiveotand8grggabtatnsattlementofthectainesl'utedonthefrontofthiaappiication.noweveGtheemptoyerwill not partizipate sr The sett6e*rFent ntVmtiatlon6 and recquests the SWC tonegotiate the se[tiementon baha)f of the ernp3oyer

Ld 2 The empfoyer is aat aoreeabts to settfoment of the ctaim€s) fated on the front of thi.s appricatton_

$y sigrrirrg dhhis agtt•emenG an empivper tkat is cwrent7y salf^fnsufed ac#nowredges its obfigatron ra reifnburse $WC fQr the parkion of ffiu setdtament

emount sUacaredio DWRF custs af rrie above-referenesd slairnfsi. 96trC txilt fx7t the f7tWltFporttan of ttre setEtementto the selr-brsur7rrg emptaye, evertif fLe enjored wgrFer has nntyei bec» dedarmGted to be permener7ffy' ana'Yo1'affyt3isabteti or crerier.tiy efigrhte farQAYRti benetits.

Settlement Agreement and Refease

Assetforth fn this agreement,the injured workerforand in consideration aftha receiptofthe settiement amourtt approvedbythe BWC, whrch sum wH! be paid from the approprlate fund on behaif of the emplvyar after approval by the g'{TtrCadministrator, unlessavithrn30 days sftersuch approval the adminfstratorthe employer orthe injured worker, withdrawsc(insentte, ©r unless the [ndustrial Commission of Ohip ([C) disapproves the agreement, does heraby for himftrseifand for anyone claiming by. through or under hirsf/her, furever release and discharge the above referenced employer,its otBcers, employees, agents, representatives, successors and assigns, the IC, the BWC, the appropsiate fund, and allpersons, firms or carporafrons from any or all cfaims, dema nds, actions or causes of action incurred lon or prior to thedate of the approval of this agreement arfsrng out of Ohio Ravised Code Chapter 4121 _ or 4123., which he/she navv hasorwhtch hefshe hereafter claim to have, whether known orunknawn by reason of or in any manner growing out of theclaims or parts thereof mforth above. The injuredworker further understa nds and agrees that any amotmtpaid pursuantte this agreement is subjecttro enyvalid court-ordered child support The persons involved with filing this settfementagree that if any clalmis ► or part of any claimf sf being settled has been recognited or allowed, then the cost of all fnedicaiservices, hosprtai hilis, drugs and medicines with datelsi of service or filling of related prescriptions (not io exceed a3D•day su pply) prov,d ed to the inj ured worker hefo re the ~ffective settlement date, shall he the responsibility of the stateinsuranca fund, provided such costs result from the allowed cunrf•rtions of the claims and are properly payable undercurrent medtcaf paYment guidelines. The costs of medical services hospital bflls, drugs and medicines (nrftto exceed a30-day supply) provrded to the inltfred workeran or after the effective date of the settlement date are the responsibilityuffhe inlured worker

^^^ By intbalfng this box,the injured worker acknovAedges he or she has read and understands the abovestatement

Also as setforth above, the inlured workerundetstands thatanysettfement amounts allocated for future medical servicesmust be used far rr,edical services before Medicare wiE[ consid er payment for servfces for the conditions of the workers'compensation c3atm

Settletnsnt af any ctarm[s} included fn tffis agreemeni in no way impairs S1NC's statutory rights to subrogation recovery.Also, be advtsed that upnn a find;ng of fraud,the administrator retains the rightto rescind this settlement agreemeni andre-open the claim for an administrative overpaymerrt hearing and refer<al for erimnal prosect)tiorf,

worker signature

Power of Attorney

Hy sign;xrg betow tne rnl4red vrortcer grarrts a limited pcnrrer of attorney to the a[torney of record for the purpose df recehdnp the warrert;iSSued because of tyis 5ettfernent agr'eerrterlt.

oat^ k ii`^

eagnatute

SWC-1S72 ffievC-24Q

PAGE 2143 `' RCVDAT 512f2a14 1 Q:12:1 t AM [easterrf Daylight Timej * SVR:lfl9D9F'KPDe3(31 " DNIS:944564758 " CSlD:19379135570 x DURATItJN !mm-ssi:02-4o ^ 1^

Laura Baker OS-3$2336

Calculatiep of Sett9ement Demand

1

_......__..._ . _ _. .._ .... ._. ... . . ..i

_ - . .

Page 31 of 48

PAGE 3t13 " RCVD AT 5020941 R:42219 AM [Eastern Dayfight Tinae] " SVR:6MU9FXPDQ3131 * DNIS:144554756" CSID:99379135570* D11RAT10N imm-ssj:6240 A

Laura Baker 08-3$2336T''TQ Calculations (cansidering D4iPS entitfenaent)

Regular P'TD Senel6ts

Weekly PTD Rate (from worksheet

^xsiinus LSAs)

equals Week(y P'I'D Rate (adjusted for LSAs)Factor firoui SWC Life EVectancv Tahles

Equals 100% NPV al'rebular PTD benefits

Plus: DVVRF benefitsCurrent weekly DWRF floor

minus Weekly SSD benefits

minus PTD payments allocated to other elms

minus Weekly PTD Rate)

equals Cttrrentweekly DWRF entitfementx Factor from BWC Life Expect,ancy Tables

Eqnals 100% NPV of DWRF benefits

Eqtxals Full PTf} Value

} 3 75 .5 0

375.50

884

33I,94Z.00

358.62

375,5{?

L -

I S 331,942.0{l

Page 32 of 48

PAGE 4113=RCVp AT Sf212014 90.1214 AM [`eastern BayfightTimeJ g SVR:IM09FXPD03139 x DNIS:944564758 x CSiD:49375t3557U" DURATION (m[n-ss):02-40 "'^ â̂ P/'

^^ ^3

A fi ^ G ^ D E [ F I G ( H ^

laeura Baker 0$-38Z336

CAIA'f]LATIJ+IG PTIi RATES WETY-N COPtSIDEMNG SrSD BElYEFI'f'Si i i -r-- -^

Calculat3vg the xeeldy wortcrc' compensutios amoujkt pnrsoaet to Ohio Revised Code 4}Z3.5$(A).Vscr.iabie 9

42920 43l^1 ^ k

Page 33 of 48

E - - -- J --K

37550 50% SAW W{minirrtum FfD from 1Rate Chsrt for D!)I) - Y - -^^

286 13 2f3wW

500 67 213 SAWW ('prp ofLset" amonnt from Itate Chart for DC3I)

?do a) If2t3 flfAW4V 28613 213S)500 67 then WWAC=

Z13ofSAWW

;}fAWw

AWW

Yes c} ff AWW

but 213 AWW

SU°fo SAW W

dJ. 1f2f3ofAWW

but 2f3 AW1S'

-^ ^2/3bPAWW

5D067- - -- 7 ^_

42920 <<509'o SAVJ4i`^ - '- ' 375 50 .fhen WFNAC=

42920 - + ---- - t -_ _ i----

429 20 - >- 50".6 SAWi°V 375 50 3,286 13 <50% SAWW 37550 tbeU W13'AC=375 50 --r ^_

- --z--^ - .____

28613 >5D"J ofSAWW 375 50

Z86 !3 z 213 SAWW 500 67 then iA GVA^ ^

-^ 29613- "T--^wEEKI+Ywf3R^Eli^+' CC1IeSPENSATIOI4° AMO[1NT EQUALS: I - - 375 5Ci a T

4 Determiniug PTf3ltate: Ca}w}atioss pursuaut to Ohio i2evised Code 4123.58{B) Variab}es required

-37550 wWCA ! ^- -'-^ - - 7- -

weekig SSD { ^Monthly SSD x 12152) -

75[00 -SA13'TV (mmimum PTdD from rate chart for Gxtte of injury)

29613 2/3 AFk`9E- - - ^

5d0 67 ?l3 SAO^YIV- ---^ -^ ^^

___+wo a} - If WWCA + SSD 375 50 ;>= SAWW -^- ^ 75 [ 00 rhen FID rate-

SI'WCA 3750 - - - t- -

Yes b) IfVt'WCA + SSD 375 5D < SAWW t --- 751 00

and 2I3 A4iNr 286 13 <= 213 SAW W^ 50067 t5en PTD rate =

WWCA 375 50 ^ --l _ -;------ • - - _- -

No c} TtWi's'CA+SSD 37550 <SA1YW 751 00and 2f3 AW W 29613 > 213 SA.WbV 50067 bnt<SAWW 75300 thenPT'Drate= ^"^

'!-213 AW W 286 l3^_ - - -....-^

- tto d? AfR'WCA^SSD 37550 <SAWW__ 75100 but - ^- -^*---- -- ^ _ _. _ L_713 AWW 286 I3 > SAWW 75100 Eben P'CD rate

- SA3^ W y -^ 751 001 --•-1-- . .^- _ . .- . _ . .. _

---^ - 1 ^- _ ,--`PTD RATE EQUflIS ^ 375 50 {ff PTT} pd }00'/o ia ttess eiatm) -

I<or BpFit ITD Tn[a[ PTD iLate _ fi 375 5D : x in tFus ClaEm } O% u ^-JIlequals PTT3 tate for this ctaun as part nf'spi it PTT3 3 75 50 -' -

Dafe Caurpiete^ 4130.T10I4IAIGEC C[3FCk _ ^ ^ - - - ° -

(Nttt more tSran l"Yes" item tra each of pasts{])and(Z)1

PfiGE 51131 RCVD AT 502014 10:12:11 4SV! [Eastern bayfigFd Timej ° SVR:INlO9FXPD03131' DF8S:1AG5G4756 ` CSID;19379135570 ` DURATION (mur.ss):II240

of 48

La8i2'B Ba:et 08-3$2336

Future medical expenses

Age ofclaim (in years):

Total medical benefits paid to date:

Average medical benefits per year,entire life ofc}a.im:

Remaining Iife expectancy, per BWC

Tables

Prtajected future medical benefits,

based azt average of life of claim

Add: ()ne-time future expenses (itemize)

Total, one-time items

TOTAL MEDICAL AND PRESCRIPTION

S]L:'I'TLE.ME, NT IfE'ViAt't`D

5.47

2&.,698.8I

5,248.99

30.8

174,000.00

170,000.00

PAGE 6f43 * RC1dD AT 5J212014 10:52:11 AM [aastern Dayfight Timaj " SVR:NO9FXPD03137 " DMIS:14458475E * CS3D:7937913557U"DURATIL7Ci (nnrn-ss):®2-41t ^^^

OhioBWC - Comtn.o-n - Service: (Correspcsndence)

Injured worker: LAURA BAKEROhioBWC - Common - Service: (Corresponclence)

#BWNFVSQ

#IW43083179965040#

LAURA BAhER

7649 STONE RIDGE DR


Injured worker: LAURA BAKER

Claam nii-Tnber: 08-382336

Injury date: 11/10/2008


Dear Injured Worker and Employer:

05/15/2014

Date Mailed

Employer's name: ADVANCE AMERICA CASH ADVANCEPolicy number: 1244253-0

Manual number: 8$10

The purpose of this order is to inform you of BWC's decision regarding your

Settlement Agreement and Application for Approval of Settlemznt Agreeme:it

(C-240) previously filed in the above-referenced claun(s). After careful

review and negotiation, BWC cannot approve the agreement. You will find

the details of tiie decision outlined below. Please und.erstand that this

order is not appealable pursuant to Ohio Revised Code section 4123.65. You

may, however, file another application for settlement in the future. If

you have any auest.ions or need further clarification, please call theclaims service specialist listed below.

DISAPPRO\TAL OF SETTLEEKENT AGREEMENT

The Administrator finds that a Settlement Agreement and Application for

Approval of Settlement Ayreement has been filed in the above-referenced

claim(s). After a review of the application, the administrator finds thefollowing:

The application is der,.ied - A11 parties do not agree with the settlementterms.

BWC does not wish to settle this claim at this time.

PLEASE KEEP A COPY OF THIS LETTER FOR YOLTR RECORDS

THERESA B

OHIO BWC DAYTON SERVICE OFFICE

3401 PARK CENTER DR STE 100

DAYTON O.i? 45414-2577

Team number: 43

Phone niimber: (937) 264-5075

Fax number: (866) 281-9356

Clairo #: 08-352336Dt3L; 11/10/2006

Page 35 of 48

https://",w,.bwc.ohio.gov/includes/prantfriendiy.asp 5/29/2014^,^^


Page 36 of 48

CC:

ADVANCE A[IERICA CASH ADVANCE CENTERS INC

CareWorks

HOCilMAN & PLUNKETT

TAFT STETTINIUS HOLLI S TER

CAREb9ORY,S CONSULTANTS, INC

BWC Use Only

05/43/02

pre^3€a^3 ' .i

https://ww-w.bwc.ohio.govtinciuc^es/print-friendlv.asp 5129/2014a/^

of 48

HO'Ch1.1.1an j ÎAunkettCo.,L.F A.ATTORNEYS AT I.AW

.l@mes a HoChman

GarY D Ftonfceit

Carig J L.au®r'

Brett @, Bissonnette

Aonsid ¢. Stott

Ccrwman S. Houst®n"

Amy L. htierrsite May 22,2014tTnvid F, AWwrair••`•ctsu atlmmaf c Caâ..o 8 Neveaa"aisu etlrrutyJ m 1rcdât ^ Yn.nctt• •Or rouns®t,

VIA FACSla+II1LE 866-281-9356

Theresa B.Jim L.Oluo Burean of Workers' CompensationDayton Semce Office

VIA FACSIlVf.ILE 877-520-6446

Sarah MorrisonChief of Legal OfficerOliica Burem of Workers' Com.pensation30 West Spring StreetColumbus, Ohio 43215

Re: Laura BakerI.C. Claim No, 08-3$2336

Dear SirIMadarnrns:

This letter is a follow-tzp letter to my prev}ous Ietter of July 23, 20I3. This Ietier slouldbe read in conjunction with my previous Ietter of said date, I have attached a copy of that letterfor your convenience. This Ietter rvti.ll summexize the events which ba.vc taken olace since July23, 2(113.

Since July 23, 2013, Ms. Baker has coit-inued to receive Workers' Compenssation baaefitsin ihe form of perrnancnt and total disability compensation iî the a.moi.at of $61320 bi-weckly.As permanent and total disahHity cotnpensation is a nerally a Iifetime benefit, she would beentitled to receive this amount for the rest of her life.

Durk,g this time period, Ms. Baker has coniinue><i to receive medical irea,tment and,pre'.^cription medi.catians under i,ttc clE ►im far the allowed conditions. She will continue to beeligible io receive suc.h benefits; indeed, it is likely that. she will be reoeijri.ng such benefits ftar anextendecl period of time given her t.^nditaon. We have attached print-outs from the $ureau's

dayton ,~mxinnaft Spdingficid Troy3033 Kettering 86vd-, Suite 201 81 i7 SyGamore 5tteei One South tirnestone Strest Z2 North ShorT StreetDaytan, Ohio 45439 Third Fiadr Sui[e D Tray. Ohio 45373837-22$-2668 C'mc[nnarti, Ohio 45202 Springfieict, Ohio 45502 937-339-4471)

513-338-'t898 3$7 325•2995

hochmanFsteuakett.cam Tolt Firee; $77-266r7465 Fa=imie: 937-228-0506

PACE 1113 "RCVI? AT 5122l2014 3:23:e8 PM (F_astern Daplighf Timer x SYR:EX09FXPD01f" " DNIS:13451 "` CSfD:99379133570" DtPATION fmcre-ssj:06-12

PAGE 2t1d z RCYp AT 5I2212074 3:39:39 PM jEastem Daylight Tene] z SVR:Ddu9PXPDD3348 x DN1S_944564763 x CStrr:' DURATION (nm-ss):©"p

of 48

Ohio Bureau of Worl;ers° CompensationMay 22, 2014Page 2 of 2

website showing payrnents for medical treatment and prescriptions received by Ms. Ba[cer underthe claim for the Qexiod between 3uly 23, 2013 and March 31, 2014 -- these payments total$2,920.24 for a period of only 251 ciays. Projected out over an annual basis, this amount wouldbe $4,246.55. This is the medical and prescription cost to the Bureau of not setding this claim.

We re-filed the settlement application on May 2, 2014, after the disniissai of thesettlement appiicatiQn previously filed on f"'ebrESaty 19, 2013, The re-faling was summarilydisinissed, without explanation, by the Bureau on May 19, 2014 -- just seventeen days after itwas re-filed.

We do not understand why the Bureau would disnriss this settlement application for asecond time. Clearly, leaving the claim open comes at a cost to the Bureau, as documentedabove.Ms. Bakers claim has significant value. Lie,spite the fact that the Bureau has a statutoryohliBation to consider Ms. Baker's settlement applicatian, it has faited to do so. NVe have set forththe basis in the law for the Bureau to consider the settlement app[icsE.ti.on in good faith in ourprevious letter a-ad we would direct the reader to the attached letter for fcaE-F.her elaboraticx on thisissue.

We respectfully re4uest the Bureau reverse its clecision to dpsrniss the re-tiled settlementapplication and ptoEdde us ivith asscu:ance that the Bureau wvi.ll consider the settlementapplication in good faith, pro%dding an offer that is fair, appropriate, and in line with sirnilarguidelines the Bureau has used in the past to extend offers to settle. This wovld be especially true

given the nattrrc of Ms. Baker's claim, which is allowed for conditiom which have found her tobe permanently and totally disabled and.er theWorkers' Compensation Act - a status reservert forthose individuals who have suffered the most serious injuries.

If we do not have assurance by the cIase of business on Friday, May 30, 2014 that theBureau will con.sider Ms. Baker`s seltlement application in good faith and tliat the Bureau willreinstate the settlement application, we will have no choice but w assert Ms. Baker's zight to

obtain a writ af mandamus directing the Bureau to carry out its duty, clearly articulated in thestatute and previously reinforced under Obio law.

Tfia.nk you for your attention in tllis matter.

Very truly yaurs,.C.ZOCHYAAPLIY & ^LUNJ,S.ETT CO., L.1 .('Zr

/ V • ^^^ '^^^^i ^

Brett R. B1ssCtI3Ilette ^

BRB/enh

P'AGE 7,'13 * RCfiD AT 5l2212614 3;23A8 PM EEastern Daylight iane]' SVR:EX09F-J4PD01J9 ' DNES93A5S ^ GSED:S937943557p ^ DUR^i EON parn ss):46 S2

PAGE it14 x RCVE1 AT 5P22F2R14 3.35:39 PM [Eastern Daylight T une] * SVR:IMU9FXPDOS148 ^ DNE5:9445647E3 ` CSID: " DURATION (mrr, ss);00 t10 ^^

Hodunan Plunkettm,p.A.ATTt}RNEYS A.T Lkw

a&rc*B HOChman

Gary D F'iuakettCariD J Lauer'

Brett R. H.-sonrictte

Donald K. SGptt

Cormmott S, tluustnn"

4tmy L Metzaatte

DavrC F, Ru&AratP a °

`GC advKttbd m CatN-ra d Nevada ,Ouyv '^ 201'3••a^m adm.uW m i+aA.e.+a 8 Ke+^wcx, a• •p, en....aa^

V'TA FACSLIVME 866-281-931,56

T'heresa B.Tim L.

Ohio Bureau ofGVorkers' CompensationDayton Service ®ffice

VIA F+'.AACSIMII,E 877•520-6446

-Sarah MorrisonCltief of Legal t3ff"acerOhio Bureau of Workers' Compensation30 Wesi Spring StreetColumbus, Ohio 432115

Re: Laura BakerI.C. Claim No. 0$-382336

Dear SirlMadams:

Page 39 of 48

On or about February 19, 2013, wc filed a settlernent application with f6e Bureau of Workers'Compensation on behalf of our cfient, Laura Baker. To date, we have received no offer on the claim, norhave we received the sffi..rtnative representation of the BWC that tlae ctaim has no value to settle.Notwitnstandfng the lack of ttie deteratination tbdt the claim has no value, the BWC has dismissed tttesettlement application. There appears to be no reason why the BWC is neglecting to fulfill its statutoryduty to thoughtfutly eomsider a settletnent appIication filed by Pdls. Bak-er. We respectfully request theBWC imuieciiately revoke its disapproval of settlenqent ageemenfi order, issued o-n July 17, 2013, andproaide us with assnrance that the BWC will immediately° begin to fulfill its statutory abligatton to

emaluaf.e iMs. Baker's settlement application in good faith pursuant to its stattttory obligation under R.C.4t23.65_

The Workers' Compensation Act requires the BS74'C to consider settlement applicatiorts filed by

injured workers. RC. 4123.65. This statiztory tltrty has 6een recognized to entail an obligation imposed on

the BWC to deterxuiae the appropriatereess of setttement appIications, in good faith. As sfatcd by thcSuprente Court in State ex. ret. JoFzn,ston v. Ot'tio BWC, 92 Ohio St.3d 463, 475, 751 1.1.E.2d 974, 240I-(7hio-i2&4:

€s®ycon c'isxannad Sprinpfie[d TmY3033 Kettering Mvd., Sutte 201 810 Sycamare Street Orsa South Lirnestnne Street 22 f+iorth Shart Streetf2ayton, Oba, 45439 Tflinf Fl(70r Suite Q Troy, CIh'sn 46373937-228-2856 CSna3nnati, Ohio 452CF2 Siaingfie#„ Ohio 45502 937-339-4434

513-338-18B8 937-325-2835

hvchmaplurtkeit.com TaR Free: 877-266-74e5 Facsimde: 937-`126-0508

PAGG; 3113* RGVD AT 512212014 3:21,08 PM tEastem Daylight Tanep " SVR:EX09FXPD01i1 ' DFEu 13451 * CED;10379135Fs70 * HURATIOfi (rnrn-ss):06-t2

PAGE 4114 x RGVQ AT 5122t2014 3:89r:39 PM [Eastem Daylight Ti:ne] = SVR:iMOaFXPQDU8 * QidIS:744564763 x CSI[a: x QURATFQPt (mm•ss):0a-00

of 48

Ohio Biureau of ik`orkee' CompensationJuly 23,2013

Pap Two

V6i1e this provision does not require the Administrator to approve ik settlement application ondemnd or accept the terms agreed to by The parlies, nor doas it give the ,4dminist.rrator theunfettered ciiscadion tD reject settieaents out of hand. There is nothnng in the statute to s-apl(d

the m©tion that the Adrnirtistrat2r can properly reject an arppli,:ation that hc determines to be

appropriaee. Semantics aside, the Administrator has an afftrraative s'tatutory duty to deteimine the

propriety Df settlement applications, the performance of which can be enforeed by proc.eedings inmandanrus.II

It is important to note that the 3upreme Court grxnted the Relatna's application for a^eerit ofmandamos in 3ohnston, and requD,r•d the BWC to consider the settiement application that was filed beforethe etairttants death, providing an ex.ceptioae to the nale that a settiement appticafion norma3ly abates st thetime ofa eiaiznanY`s death.

Ta this casc, Ms. Baker rcecives percnanent and total disabitity cotrtpensation bestefits. The BWC

has sigiifiicant expastrre, as pelmanent and total disabifity compensation bvne.fi#s are payable until her

death. The BWC has given no explanation why it reCisses to make a settlement offer, or why, p,rsQ,anf to

the order disFnissing scftlcnnenf, that "seft(ensent Df the claim is not in the Ohio Bureau of Workers'

Conipensation`s best interest at this time.a The BWCs decision not to make an offer is emusyat, as the

BWC rontinely setttes cases on a daily basns, even when those claims are not yet al"ed claim,s, or whenihe claimant is not reeeiving ongoing compensation at the time af'settfement.

Refusing to make an offer in a claim which has ongoing IiabiTity frm the BWC's perspective is

illogical, and indefensilale, and demon.stti*ates a lacI: of good faith. We cannot understand why the BWC

would chanse to not even make a setE[ement offer, when the BWC routisieIy settDes other i'Ti? ea,es,

which uJtumately saves the BiV`C money in the long run. A review of the notes within the claim file Dn the

BWCs I3olphin websitel reveals that even the 8WC's ciaiuas representative did not tatderstand whY the

BWC would take the illogical and unreasonahle posztaon that scttlement is not appropriate in this alahn.,

and them is nothing contained in ihe record which sets fort.h the BWC's dccision moking prooess. As Jim

L. sfate[1 in his July 18, 2013 note tn the file, "J--zeived call back from tW, explained that the BWC is not

settling the afaim at this point. Did not receive much expianatiozc from Columbus, but an order u+itt be

published o.noe we receixe the paperwflrk." Z7tis weFf-documeuted farlare ts car,sider settiement in good

faith is aleaTly re&cssabte through a man+damus action as emForccd by the Supreme Court in theJabrsstancgse.

Vfffiont quastion, no one can accurately predict the date of death Df a3totiter indi€vidua3.

Nonetheless, standaad risk mmiagement tools take into aeooant the fact that f ife expectancies can bc

' A copy of the notes is attached hereto.

PAC;E 41:3 x RC4dD AT 5122fF014 3:23eQ8 PM [Eastern Daytight Timej " SYIL•EX0BFXpD0111 t DNtS7345t " CS1D: ts3TQ13553U' CkIRAT1oN (mrn-ss)_a6-12

,PAGE 5/14'' FR£VD AT 5t2712Q9d 3:3R:39 PM [Easkem ISaytight'1'trne3 x S1lR:lMQ9FXPDQ3f48 " DNlS: M1^44564763 ` CSf43: ` DURATION (mrre-ss):OQ-4Q ^,-

of 48

Ohio Bureau of Workers` CompensatiouJuly 23, 2013

Pagt Three

statistieally estinaxed._ The Federal Covemment produces the United States Life Tatsles, found by coLitsto be reli$ble evidence to deteruaine, an indiviciual`s tife expactancy, The SV61C, previously recognizingthat st$tistical evidence is reqaired to estimate 1"tfe expectancy when determining the value of settieanent

applications, previously commissioned a study to determine the life expectancy of a vexy specific groupof iudviduals - fb.®se persons f®und by the Iridustri'a1 Com=.ission to be entitlcd to prarnanent and totaldisabiliiy cotnpensation. Ms. Baker is a member of that g^Dup, atad het life ex,aeetancy skiould be jutiged,beginuing witfi the assuinption that IvFs_ Baker's life expectAnc,•yy does not.siga fficautly deviate from themembers of the group studieai.

This aaalysis leads to the conulasion that the value of Ms. Baker's workers' compensatisan b=fitsmay be rationally (iatermined th.rough a matftematical pracess which talces into account a combiauatum ofher Iife ex_pecsency based upon iier known al;e, and a reduction of her benefits to present day value basadupon a 4°/a discount rste used by the BWC. This is the process that is =gaged in by the BWC to

determine the value of a workers' eompensation c4a.im, and has been the proeess for many yeacs,ln fact,

the t3WC`s oomtaission of a study to detertnine the Iife cxpectancy of PrI'D recipients is dirccely related tothe $ureau's settlement i'unction. Using the guidelines issued by the BWC, we have submitted an initialsetttlem.ent deman£i of $350,000.00 for the net present value of the indemnity payments the BWC isviaualTy assured of paying in the future.

Acidit'aonally, based upon the substantial cQsts of t^a ►edicai treatment in ttsis claim, we 3raverationaliy determined a value of approxiznateiy S20Q,{fC30.04 for in-it.ist negotiation purposes.

Given that we 3►ave specifica[ly identified significarrt benefit classes to which Ms. Bakor has a

curre3u entitlement, no rational person can state that tksa claim has no vsiue.'Yet, the BiivC's failure to

evalutrte thc settiement rNuest, as shovm throagh its failura to dccument the same, }eads to the un-

refitrab4e prtsumpt3on that the BWC simpty does not betieve the claim has vaiuc. Otlter9eise, tu, reffPawould have been made, or some ratiarcale given whicia eacplaiu; why settiernetu of tius valtable etsiin

does not oomport with the BWCs overall risk maaagement strategy.

We would respecEful[y request ttsat you refrain from abrogating your sta.tutory duty to consi3e*

setttemettt appSications by d'ssmiesing this setttement application witti+aut a vaiid, justitiabfc cxplanation of

how this settlement application was cousidersd in gnoci fairia. From the BWC's own notes, it is clear that

the seitfement application was not considered in good fait:h Thercfore, we a^r. requestsng that thesettiearxent applimtiou be rcconsidered, evaluated, and sent to the Executive Committee for considerationwlthin rhe next 30days, If you choQse to do so, we will be fiiing txn App âiaation for a Writ of h'fandamasseeking an Order from the Supretnc Court directing the BWC to consider Ms. Bskefs settiementagpeication on a rational basis.

PAGE 5113 " RCVD AT 5tZ212014 3:23.08 PM (Eastem DaySght Time] x SVFt:EX09FMPD0411 `DMS:13457 * QSlD:19378135570 R D61RATfON (mmss):06-12

PAGE 6114 "RCVD AT 5122f2014 3:39:39 PM tEastem Dayl'ight Timej z SVR 1fY109FXPD0314& * uNlS:144564763 * CSID: ` DUIiiATIGN (mm-ss):00-9p

of 48

Ohio B-ueeau af Worlm' Compensataaat,TWy 23,2013PAP Fcur

Thank ynu for your aftcntion in this matter;

Very trufy, yaurs,

HClCHMAN &. CCi., L.PA^

G^ary D tankett

GDFrad

PAGE 61131 RCVD AT 512Z2014 323:O8 PIt4 IE=ern De}rlight Time) x SVR:EX09F7(PD0111 F D11RS:13451 I CSID:19379135570 ` DURATIOt+i (mnrss}:0642

PAGE 7114 1 RCVD AT 5122f2014 3:35:39 PM [Eastem I]aylight Time)' SVR:IM09FXPD03148'" DI'dtS:144564763" CSID: ° DURATtQfl (r0mm-ss):p6-®0 a i g

r -L/

UhiCi}3 WC," - Common - Service: Ned2cal bFfl payment look-up) - Results Page 43 of 48

Injured worker: LAURA BAKcR Claim #i :. 08-382336LfhinBWC - Common - Service: (AM1pclical bit( payment look-up) - Results DOOI: 11/1012008

Adjusted bill =( ) = negative amount

:ifl9 67FNVIU@F fi3rnG a ^`^e^^ ^^^^^g !"a11CE amount

H ALICHAWAGA MD J 12/06/2013 $200.00 $143.96

I ssarch sgaiin ¢resCriptitsn Faifis

h3.tps:Ifunxrw.bwc-ohi.o-gov/inclvdes/printfriendly-asp S/20/?014

€.)haof3 WC - Common pService: (Medical bill payment look-up) - Results

Yrrjured worker: l.AURe4 BAKERf)hioSWC - Common - 5ervce; (Medical beU payment look-up) - ResuEts

#1252

#'1252

TARGET PHARMACY # 1252

12/06/2013

12/06/2013

12/06/2013

11/24/2013

11/13/2013

11/09/2013

11/09/2013

11/09/2013

11/09/2013

11/09/2913

search agaEn med;cat bilFs ^

https:/fwww.bvvc.ob.i.o.gc)v/incindes/printfrie.n.dly_asp

CEairsm #t: 08-392335001: 11/1E1/2Qp8

Page 44 of 48

ommoAdjusted bill =( ) = negative amount

Results 1-10 of 21

at Paid amount

$42.99 $39.30

$ 549.99 $481.23

$40.99 $25.60

$8.00 $9.40

$42.99 $39.30

$40.99 $25.60

$8.00 $9.40

$8.00 $9.40

$16.99 $6.3.5

$516.99 $481.23

^ Next Records

5/20/2014

^^

UWoB W G- Common - Service: (Medical bill payment look-up) - Results Page 45 of 48

Injured worker: LAURA BAKER Clairn #: 08-382335t?hi®BWC - Common - Service: (NfedicaE bft€ payment loak-up) - 3Zesults Di3%: 11/PO/2008

Adjusted bill =( ) = negative amount

https:llwvaw.bwc_ohiogovlincluc#.es/pzintfriendiy.asp 5/20/2(P14

search again medicar[ bilEs ^

O.tuot3 WC -(:ommon - Service: (Medicat biT payment look-up) - keswts Page 46 of 48

Injured worker; LAURA SAICER Claim #: 08-382336OhioBWC - Common - 5ervice: (Medical tril6 payment iook-uP) - Results DOI: 11110J20O8

Adjusted bill == negative amount

#1252 10/08/2013 $ZZ.44I $23.89

Previous Records

search again medical bills

httgs:Lfwww.bwc.ohio_govTincludes/prin.tfaien.fflg'.asp 5/2U/20I4

^^

Urizot3 WU - c.:flmmca>s - Service: (Medical bzll payment look-up) -Results Page 47 of 48

Injured worker: LAURA 6,4KER Claim #: 05-382336tkhiaBWC - Cmmmon -Service, (Medical biit payment look-up) - Results DaI: 11/10/2008

Adjusted bi11 == negative amount

Billed

H ALKHAW D I 02J28/2014 $20O.00

^- .._sBanch agaRn prescription bitis [

https:f.l,TArvvw_bwc-ohio-govfinelud.es/printfriendly.asp

$0.00

5/20/2Q 2 4

t,^I

uhiob wL - Lornmon -Service: (Medicai bi1l payment look-up) - Results Page 48 ot48

Irtjured worker: LAURA BAKER Cta#m #: 08-382335ObinB1NC - Common - Service: {hfedicaf bill payment look-up) - Results DOI. 11/10/200$

Adjusted bitE =

C ) = negative amount

https://www.bwc.ohi.o.govfmcludeslprinifriendly-asp 5/20/2014

ri- - - -----z' seasch agaFn meditaF 8itls


Injured worker: LAURA BAKEROhioBWC - Common - Service: (Correspondence)

#BWNFVSQ

#IW43083179965040#

LAURA BAKER7649 STONE RIDGE DR


Injured worker: LAURA BAKER

Claim number: 08-382336

Injury date: 11/10/2008


Dear injured Worker and Employer:

Claim #: 08-382336DOI: 11/10/2008

07/11/2014

Date Mailed

Employer's name: ADVANCE AMERICA CASH ADVANCEPolicy r.umber: 1244253-0

Manual number: 8810

The purpose of this order is to inform you of BWC's decision regarding yourSettlement Agreement and Application for Approval of Settlement Agreement

(C-240) previously filed in the above-referenced claim(s). After careful

review a*_id negotiation, BWC cannot approve the agreement. You will find

the details of the decision outlined below. Please understand that this

order is not appealable pursuant to Ohio Revised Code section 4123.65. You

may, however, fiie another application for settlement in the future. If

you have any questions or need further clarification, please call theclaims service specialist listed below.

DISAPPROVAL OF SETTLEMENT AGREEMENT

The Administrator finds that a Settlement Agreement and Application for

Approval of Settlement Agreement has been filed in the above-referenced

claim(s). After a review of the application, the administrator finds thefollowing:

The application is denied - All parties do not agree with the settlementterms.

PLEASE KEEP A COPY OF THIS LETTER FOR YOUR RECORDS

THERESA B Team number: 43GOVERNOR'S HILL SERVICE OFFICE Phone number: (937) 264-5075

8650 GOVERNORS HILL DR STE 400 Fax number- (666) 261-9357CINCINNATI OH 45245-1366

CC:

Page 1 of 2

https://wdwv.bwc.ohio.gov/inciudes/printfiiendly.asp 7/18/2014^^ ^^


ADVANCE AMERICA CASH ADVANCE CENTERS INCCareWorks

HOCHMAN & PLUNKETT

TAFT STETTINIUS HOLLISTER

CAREWORKS CONSULTANTS, INC

https://vv,xnv. bwc. ohio. gov/includes/printfriendly, asp

BWC Use Only

25/43/08

Page 2 of 2

7/18/2014.^ ^

Hoch . an PlunkettCO.,L.P.A.ATTOKNEYS AT LAW

James B HochmanGary D PFunkettCarla J Lauer*Brett R. BdssonnetteDonald K. Scott

Cinamon S. Houston••Amy L. Metcalfe July 18, 2014David F. Rudvsrait°"

'®ISO adnuttxd v^ Catifomea 8 Nevada

°aLw edmttted m Indla<la 5 K®ntucMY

•• °or co-sel

VIA FACSIMILE 866-281-9356


VIA FACSIINILE 877-520-6446

Sarah MorrisonChief of Legal OfficerOhio Bureau of Workers' Compensation30 West Spring StreetColumbus, Ohio 43215

Re: Laura BakerI.C. Claim No. 08-382336

Dear Sir/Madams:

This letter is a follow-up letter to my previous letters of July 23, 2013 and May 22, 2014.This letter should be read in conjunction with my previous letters of said dates, I have attachedcopies of these letters for your convenience. This letter will summarize the events which havetaken place since May 22, 2014.

Since May 22, 2014, Ms. Baker has continued to receive Workers' Compensation benefitsin the form of permanent and total disability compensation in the amount of $613.20 bi-weekly.As permanent and total disability compensation is generally a lifetime benefit, she would beentitled to receive this amount for the rest of her life.

During this time period, Ms. Baker has continued to receive medical treatment andprescription medications under the claim for the allowed conditions. She will continue to beeligible to receive such benefits; indeed, it is likely that she will be receiving such benefits for anextended period of time given her condition. We have attached print-outs from the Bureau's

Dayton Ciocinnati Springfield Troy3033 Kettering Blvd., Suite 201 810 Sycamare Street One South Limestone Street 22 North Short StreetDayton, Ohio 45439 Third Floor Suite D Troy, Ohio 45373937-228-2666 Cincinnati, Ohio 45202 Springfield, Ohio 45502 937-339-4410

513-338-1898 937-325-2995

hochmanplunkett.com Tol! Free: 877-266-7465 Facsirm7e: 937-228-0508

^^^

Ohio Bureau of Workers' CompensationJuly 18, 2014Page 2 of 3

website showing payments for medical treatment and prescriptions received by Ms. Baker underthe claim for the period between May 22, 2014 and July 17, 2014 -- these payments total $405.44for a period of only 56 days. Projected out over an annual basis, this amount would be $2,642.67.This is the medical and prescription cost to the Bureau of not settling this claim.

We re-filed the settlement application on May 2, 2014, after the dismissal of thesettlement application previously filed on February 19, 2013. The re-filing was summarilydismissed, without explanation, by the Bureau on May 19, 2014 -- just seventeen days after itwas re-filed.

After protest, the BWC re-instated the settlement application on May 27, 2014. On June30, 2014, the BWC's "Dolphin" notes indicate that the Lump Sum Settlement Workbook wasreferred to Ken B., for review. On July 8, 2014, the workbook was referred to BWC AttorneyErica B. for review. On July 11, 2014, the notes reflect that the settlement was disallowed,without making an offer. A copy of the Disapproval of Settlement Agreement, sent to Ms. Baker,is attached, and simply indicates that the application is denied, as "all parties do not agree withthe settlement terms." We also include a copy of the BWC notes showing the progression of theclaim and settlement negotiations, as well.

We do not understand why the Bureau would dismiss this settlement application for athird time. Clearly, leaving the claim open comes at a cost to the Bureau, as documented above.Ms. Baker's claim has significant value. Despite the fact that the Bureau has a statutoryobligation to consider Ms. Baker's settlement application, it has failed to do so. We have set forththe basis in the law for the Bureau to consider the settlement application in good faith in ourprevious letters and we would direct the reader to the attached letters for further elaboration onthis issue.

We respectfully request the Bureau reverse its decision to dismiss the re-filed settlementapplication and provide us with assurance that the Bureau will consider the settlementapplication in good faith, providing an offer that is fair, appropriate, and in line with similarguidelines the Bureau has used in the past to extend offers to settle. This would be especially truegiven the nature of Ms. Baker's claim, which is allowed for conditions which have found her tobe permanently and totally disabled under the Workers' Compensation Act - a status reserved forthose individuals who have suffered the most serious injuries.

If we do not have assurance by the close of business on Friday, July 25, 2014 that theBureau will consider Ms. Baker's settlement application in good faith and that the Bureau willreinstate the sett.Iement application, we will have no choice but to assert Ms. Baker's right toobtain a writ of mandamus directing the Bureau to carry out its duty, clearly articulated in thestatute and previously reinforced under Ohio law.

Thank you for your attention in this matter.

r^ ^A^

Ohio Bureau of Workers' CompensationJuly 18, 2014Page 3 of 3

BI2B/enh

Very truly yours,I-iOCFIMAN & PLUNKETT CO., L.P.A.

Brett R. Bissonnette

^u^

V,ir

Hochman PlunkettCO.,L.P.A.

ATTORNEYS AT LAW

James B Hochmen

Gary D Plunkett

Carla J Lauer•

Brett R. Bissonnette

Donald K. Scott

Cinamon S. Houston`•

Amy L. Metcalfe May 22, 2014Dayed F. RudwalN • ^'siso ®dmRmd ue CeUior^w 3 Nevsda°•wo amnnW n lnEiins & Centucty• r0F CCV-s61

VIA RACSYMYLE 866-281-9356


VIA FACSd1ddII..E 877-520-6446

Sarah MorrisonChief of Legal CfficerOhio Bureau of Workers' Compensation30 West Spring StreetColumbus, Ohio 43215


Dear Sir/Madams:

This letter is a follow-up letter to my previous letter of July 23, 2013. This letter shouldbe read in conjuriction with my previous letter of said date, I have attached a copy of that letterfor your convenience. This letter will sununarize the events which have taken place since July23,2013.

Since July 23, 2013, Ms. Baker has continued to receive Workers' Compensation benefitsin the form of permanent and total disability compensation in the amount of $613.20 bi-weekly.As permanent and total disability compensation is generally a lifetime benefit, she would beentitled to receive this amount for the rest of her life.

During this time period, Ms. Baker has continued to receive medical treatment andprescription medications under the claim for the allowed conditions. She will continue to beeligible to receive such benefits; indeed, it is likely that she will be receiving such benefits for anextended period of time given her condition. We have attached print-outs from the Bureau's

Daytott Gincinnati Sprongfiebd Troy3033 Kettering Blvd., Suite 201 810 Sycamore Street One South Limestone Sireet 22 North Short StreetDayton, Ohio 45439 Third Fioor Suite t3 Troy, Ohio 45373937-228•2666 Cincinnati, Ohio 45202 Springfield, Ohio 45502 837-339-44 10

513-338-1898 937-325-2995

h®chenanptsmkezt.corn T®R Free: 877-266-7465 Facsim'9ee 937-228-0508

^^

Ohio Bureau of Workers' CompensationMay 22, 2014Page 2 of 2

website showing payments for medical treatment and prescriptions received by Ms. Baker underthe claim for the period between July 23, 2013 and March 31, 2014 -- these payments total$2,920.24 for a period of only 251 days. Projected out over an annual basis, this amount wouldbe $4,246.55. This is the medical and prescription cost to the Bureau of not settling this claim.

We re-filed the settlement application on May 2, 2014, after the dismissal of thesettlement application previously filed on February 19, 2013. The re-filing was summarilydismissed, without explanation, by the Bureau on May 19, 2014 -- just seventeen days after itwas re-filed.

We do not understand why the Bureau would dismiss this settlement application for asecond time. Clearly, leaving the claim open comes at a cost to the Bureau, as documentedabove. Ms. Baker's claim has significant value. Despite the fact that the Bureau has a statutoryobligation to consider Ms. Baker's settlement application, it has failed to do so. We have set forththe basis in the law for the Bureau to consider the settlement application in good faith in ourprevious letter and we would direct the reader to the attached Ietter for further elaboration on thisissue.

We respectfully request the Bureau reverse its decision to dismiss the re-filed settlementapplication and provide us with assurance that the Bureau will consider the settlementapplication in good faith, providing an offer that is fair, appropriate, and in line with similarguidelines the Bureau has used in the past to extend offers to settle. This would be especially truegiven the nature of Ms. Baker's claim, which is allowed for conditions which have found her tobe permanently and totally disabled under the Workers' Compensation Act - a status reserved forthose individuals who have suffered the most serious injuries.

If we do not have assuranee by the close of business on Friday, May 30, 2014 that theBureau will consider Ms. Baker's settlement application in good faith and that the Bureau willreinstate the settlement application, we will have no choice but to assert Ms. Baker`s right toobtain a writ of mandamus directing the Bureau to carry out its duty, clearly articulated in thestatute and previously reinforced under Ohio law.


Very truly yours,HOCHMAN & PLUNKETT CO., L.P.A.

BrettR. Bissonnette ^^

BRB/enh

Hochman PlunkettC®.,L.P.A.ATTORNEYS AT LAW

James B HochmanGary D PfunkettCarla J Lauer"Brett R. BissonnetieDonald K. ScottCinamon S. Houston-,4my L. MeteatfeDavid F. Rudwall''•

••""°'°"utt°° . C"l^° a"o„tl. Ju1y 23, 2013`aL90 iC;m4t0d n t^iMS & Rw^WCIq

•^^Qf GOIIIYM

VU FACSIIVfII.E 866-281-9356


VIA EACSUVHLE 877-520-6446

Sarah MorrisonChief of Legal OfTicerOhio Bureau of Workers' Compensation30 West Spring StreetColumbus, Ohio 43215


Dear Sir/Madams:

On or about February 19, 2013, we filed a settlement application with the Bureau of Workers'

Compensation on behalf of our client, Laura Baker. To date, we have received no offer on the claim, nor

have we received the affirmative representation of the BWC that the claim has no value to settle.

Notwithstanding the lack of the determination that the claim has no value, the BWC has dismissed the

settlement application. There appears to be no reason why the BWC is neglecting to fulfill its statutory

duty to thoughtfially consider a settlement application filed by Ms. Baker. We respectfully request the

BWC immediately revoke its disapproval of settlement agreement order, issued on July 17, 2013, and

provide us with assurance that the BWC will immediately begin to fulfill its statutory obligation to

evaluate Ms. Baker's settlement application in good faith pursuant to its statutory obligation under R.C.4123.65.

The Workers' Compensation Act requires the BWC to consider settlement applications filed byinjured workers. R.C. 4123.65. This statutory duty has been recognized to entail an obligation imposed onthe BWC to determine the appropriateness of settlement applications, in good faith. As stated by theSupreme Court in State ex. rel. .Iohnston v. Ohio BWC, 92 Ohio St.3d 463, 475, 751 N.E.2d 974, 2001-Ohio-1284:

Dayton Cincinnati Springfield Troy3033 Kettering Blvd., Suite 201 810 Sycamore Street One South Limestone Street 22 North Short StreetDayton, Ohio 45439 Third Ftoor Suite D Troy, Ohio 45373937-228-2666 Cincinnati, Ohio 45202 Springfield, Ohio 45502 937-339-4410

5 i 3-338-1898 937-325-2995

hochmanplunkett.com Tou Free: 877-266-7465 Facsimiye: 937-228-0508

Ohio Bureau of Workers' CompensationJuly 23, 2013Page Two

"While this provision does not require the Administrator to approve a settlement application ondemand or accept the terms agreed to by the parties, nor does it give the Administrator theunfettered discretion to reJect settlements out of hand. There is nothing in the statute to supportthe notion that the Administrator can properly reject an application that he determines to beappropriate. Semantics aside, the Administrator has an afffirmative statutory duty to determine thepropriety of settlement applications, the performance of which can be enforced by proceedings inmandamus."

It is important to note that the Supreme Court granted the Relatot's application for a writ ofmandamus in Johnston, and required the BWC to consider the settlement application that was filed beforethe claimant"s death, providing an exception to the rule that a settlement application normally abates at thetime of a cla°unant`s death.

In this case, Ms. Baker receives permanent and total disability compensation benefits. The BWChas significant exposure, as permanent and total disability compensation benefits are payable until herdeath. The BWC has given no explanation why it refuses to make a settlement offer, or why, pursuant tothe order dismissing settlement, that "settlement of the claim is not in the Ohio Bureau of Workers'Compensation's best interest at this time." The BWC's decision not to make an offer is unusual, as theI3WC routinely settles cases on a daily basis, even when those claims are not yet allowed claims, or whenthe claimant is not receiving ongoing compensation at the time of settlement.

Refusing to make an offer in a claim which has ongoing liability from the BWCs perspective isillogical, and indefensible, and demonstrates a lack of good faith. We cannot understand why the BWCwould choose to not even make a settlement offer, when the BWC routinely settles other PTD cases,which ult'unately saves the BWC money in the long run. A review of the notes within the claim file on theBWC`s Dolphin websitet reveals that even the BWC's claims representative did not understand why theBWC would take the illogical and unreasonable position that settlement is not appropriate in this claitn,and there is nothing contained in the record which sets forth the BWC's decision making process. As JimL. stated in his July 18, 2013 note to the file, "Received call back from IW, explained that the BWC is notsettling the claim at this point. Did not receive much explanation from Columbus, but an order will bepublished once we receive the paperwork." This well-documented failure to consider settlement in goodfaith is clearly redressable through a mandamus action as enforced by the Supreme Court in the Johnstoncase:

Without question, no one can accurately predict the date of death of another individual.

Nonetheless, standard risk management tools take into account the fact that life expectancies can be

3 A copy of the notes is attached hereto.

^^ ^^

Ohio Bureau of Workers' CompensationJuly 23, 2013Page Three

statistically estimated. The Federal Government produces the United States Life Tables, found by courtsto be reliable evidence to determine an individual's life expectancy. 'Ihe BWC, previously recognizingthat statistical evidence is required to estimate life expectancy when determining the value of settlementapplications, previously commissioned a study to determine the life expectancy of a very specific groupof individuals - those persons found by the Industrial Commission to be entitled to permanent and totaldisability compensation. Ms. Baker is a member of that group, and her life expectancy should be judged,beginning with the assumption that Ms. Baket's life expectancy does not significantly deviate from themembers of the group studied.

This analysis leads to the conclusion that the value of Ms. Bakees workers' compensation benefitsmay be rationally determined through a mathematical process which takes into account a combination ofher life expectancy based upon her known age, and a reduction of her benefits to present day value basedupon a 4% discount rate used by the BWC. This is the peocess that is engaged in by the BWC todetermine the value of a workers' compensation claim, and has been the process for many years. In fact,the BWC's commission of a study to determine the life expectancy of PTL? recipients is directly related tothe Bureau's settlement function. Using the guidelines issued by the BWC, we have submitted an initialsettlement demand of $350,000.00 for the net present value of the indemnity payments the BWC isvirtually assured of paying in the future.

Additionally, based upon the substantial costs of medical treatment in this claim, we haverationally determined a value of approximately $200,000.00 for initial negotiation purposes.

Given that we have specifically identified significant benefit classes to whicb. Ms. Baker has acurrent entitlement, no rational person can state that the claim has no value. Yet, the BWC's failure toevaluate the settlement request, as shown through its failure to document the same, leads to the un-aefutable presumption that the BWC simply does not believe the claim has value. Otherwise, an offerwould have been made, or some rationale given which explains why settlement of this valuable claimdoes not comport with the BWC's overall risk management strategy.

We would respectfully request that you refrain from abrogating your statutory duty to considersettlement applications by dismissing this settlement application without a valid, justifiable explanation ofhow this settlement application was considered in good faith. From the BWC's own notes, it is clear thatthe settlement application was not considered in good faith. Tnerefore, we are requesting that thesettlement application be reconsidered, evaluated, and sent to the Executive Committee for considerationwithin the next 30 days. If you choose to do so, we will be filing an Application for a Writ of Mandamusseeking an Order from the Supreme Court directing the BWC to consider Ms. Baker's settlementapplication on a rational basis.

..^

Ohio Bureau of Workers' ComgensationJuly 23, 2013Page Four


^'aI.7P/jad

Veey truly yours,

OhioBWC - Common - Service: (Tvledicat bill payment look-up) - Results

Injured worker: LAURA BAKER Claim #: 08-382336OhioBWC - Common - Service: (Medicat bill payment look-up) - Results oaOl: 11/10/2008

Adjusted bill =( } = negative amount

TARGET PHARMACY # 1252

Pate of Billedervice amount

07/02/2014 $10.00

06/30/2014 $4.00

06/30/2014 $10.99

06/30/2014 $423.99

search again medical bills

https_//wwvv.bwc.ohio.gov/incIudes/printfriendly.asp

-4 of 4

id

$7.73

$5.40

$6.35

$385.97

Page I of I

7/18/2014

OhioBWC - Common - Service: (Claim notes)

Injured worker: LAURA BAKERUhioBVVC - Common - Service: (Ciaim notes)

NotesEnter your search criteria and click search.

Claim #: 08-382336C)OI:11/10/2008

From date: ^M/DD/YYYY To date: /DD/YYYY

Selection Category: *A!f 0-^-j MCO €-^-^r BWC

saam:11 Ciear

+Show AllClick a column heading to sort query results

Date v Title Category Note Text

- 07/11/2014C240 FILED 5-2-2014 BWC The Lump Sum SettlementDISALLOWED Application (C240) fll ...The Lump Sum Settlement Appiication (C240) filed 5-2-2014 isdisallowed. It is not in BWC's best interest to settle this claim at this time.Theresa B., LSS/CSS

07/11/2014LSS-Disapproval BWC

® 07/08/2014LSS WORKBOOK REFERRED TOBWC The Lump Sum SettlementBWC ATTORNEY Workbook was referred ...The Lump Sum Settlement Workbook was referred to BWC's AttorneyErica B. for review.Theresa B., LSS/CSS

- 06/30/2014LSS WORKBOOK REFERRED TOBWC The Lump Sum SettlementIMS Workbook was referred ...The Lump Sum Settlement Workbook was referred to BWC's IMS (InjuryManagement Supervisor), Ken B., for review.Theresa B., LSS/CSS

- 06/26/2014SB7 TIME FRAME EXPIRES BWC The time frame for theemployer to notify BWC ...

The time frame for the employer to notify BWC that they are not inagreement to settle this claim has expired; BWC received no responsefrom the employer.Theresa B., LSS/CSS

®- 06/02/2014LUMP SUM SETTLEMENT(LSS) MCO 06/02/2014 - Lump SumSettlement(LSS) - bill r...

06/02/2014 - Lump Sum Settlement(LSS) - bill res, medical requestednot received22773622600 2/28/14 200.O0past the fillingstatue26952959000 6/27/12 215.00

® 05/29/2014LUMP SUM SETTLEMENT(LSS) MCO 05/29/2014 - Lump SumSettlement(LSS) - Sett6e ...

05/29/2014 - Lump Sum Settlement(LSS) - Settlement application rec'dper BWC letter dated 5/27/14

°• 05/27/2014C240 FILED 5-2-2014 BWC The Lump Sum SettlementREINSTATED Application (C240) fiI ...The Lump Sum Settlement Application (C240) filed 5-2-2014 wasreinstated per IW"s representative's request.Theresa B., LSS/CSS

05/27/2014SB7 LETTER TO THE BWCEM PLOYE R

+ 05/19/2014LUMP SUM SETTLEMENT(LSS) MCO 05/19/2014 - Lump Sum

+^+ 05/15/2014C240 FILED 5-2-2014DISALLO W ED

05/ 15/2014LSS-Disa pprova I

Settlement(LSS) - Disapp ...BWC The Lump Sum Settlement

Apolication (C240) fii ...BWC

Page I of 21

https://www.bwc.ohio.gov/ancludes/printfriendly.asp 7/1 8/2014^^ ^


+ 05/14/2014C240 FILED 5-2-14 - INITIALASSESSMENT

05/14/2014SB7 LETTER TO THEEMPLOYER

+ 05/08/2014LUMP SUM SETTLEMENT(LSS)

05/05/2014DWRF UPDATE

+ 05/05/2014N0 DWRF LSS VALUE

BWC

BWC

MCO

BWC

BWC

+ 03/26/2014PC; INCOME VERIFICATION BWCLETTER

03/26/2014INCOME VERIFICATION BWCLETTER

+ 02/28/2014MEDICAL MCORECEIVED/REVIEWED

+ 02/26/2014FWUP CALL FOR PSY TX BWCNOTES

+ 02/26/2014OVERPAYMENT REDUCTION BWCNOTICE SENT

02/26/2014Overpayment Reduction Notice BWC+ 02/26/2014CONTACT WITH PROVIDER MCO

+ 02/26/2014CONTACT WITH BWC

+ 02/13/2014RTN PC FROM DANA OFCAREWORKS;PSY TX


+ 02/13/2014CONTACT WITH PROVIDER



+ 02/10/2014APPEAL PER EXP;OVERPAYMENT

+ 02/10/2014FWUP PC TO MCO RE:NOTES

+ 01/22/2014RTN PC TO MCO


MCO

BWC

MCO

MCO

MCO

MCO

BWC

PSY OV BWC





+ 01/21/2014LSA PAID

+ 01/21/2014OVERPAYMENT; AD.I ORDERISSUED

+ 01/21/2014PC TO REQUEST PSY OV


01/21/2014BWC Order - Adjustments+ 01/02/2014CORRECTED LSA ORDER

ISSUED01/02/2014BWC Order - Miscetlaneous

Order12/12/2013LSAOPT LUMP SUM ADVANCE

BWC

MCO

MCO

MCO

MCO

MCO

BWC

BWC

BWC

MCO

BWC

BWC

BWC

BWC

A Lump Sum SettlementAppfication (C240) was f ...

05/08/2014 - Lump SumSettiement(LSS) - bill r ...NOTES ENTRY 74617

Based on the declared PTDweekiv rate of $375. ...LATE ENTRY - the IW phonedlate vesterdav afte ...

02/28/2014 - MedicalReceived/Reviewed - Rcvd ...CSS phoned Dana F. ofCareworks aqain this mor...CSS issued the OverpaymentReduction Notice. ...

Page 2 of 21

02/26/2014 - Contact withProvider - PC to POR ...02/26/2014 - Contact with BWC- PC to BWC Kare ...Dana of Careworks returnedCSS`s call this mor ...02/13/2014 - Contact with BWC- Rcvd VM from K ...02/13/2014 - Contact withProvider - PC to POR ...02/13/2014 - Contact withProvider - Rcvd PC f ...02/13/2014 - Contact with BWC- PC to Karen B. ...No appeal was filed for the1/22/14 Overpavmen ...CSS phoned Dana F. of MCO,Careworks, in foilo ...Veronica of Careworks returnedCSS's call to D ...01/22/2014 - Contact with BWC- Received vm me ...01/22/2014 - Contact withProvider - PC to Dr. ...01/22/2014 - Contact withProvider - Pc to tx ...01/22/2014 - Contact with BWC-PCtoBWCCSS...01/22/2014 - Contact withProvider - Pc to Kim ...LSA paid as the 1/2/14"Corrected" BWC order a ...When adjusting PTD paymentDlan for the LSA re ...CSS phoned Dana F. ofCareworks to request the ...01/21/2014 - Contact with BWC-PCtoBWCCSS...

Per review of the LSA Orderissued on 12/12/13 ...

Received signed LSA Option

kattps://www.bwc.ohio.gov/inc)ndes/PrintfriendIy.asp 7/18/2014y s,, r^


+ OPTION; LIFE+ 12/12/2013LSA ORDER ISSUED

12/12/2013BWC Order - MiscellaneousOrder

+ 12/11/2013PC:C32 AMT;CAN'T ROUND;WC MED TX BILL

+ 12/11/2013LSA STAFFING W/IMS

form from IW on 12/ ...CSS is issuing a MiscellaneousOrder to allow ...

Page 3 of 21

CSS phoned the IW thismorning in regards to h...CSS staffed the IW's C32 LSAfiled 12/9/13 wit ...CSS phoned the IW andinformed her of the resu ...CSS spoke with the IW afterreceiving a copy o ...The C32 LSA filed 12/9/13 issupported as bein ...The IW phoned this morning todiscuss her LSA ...CSS phoned TCN/Dr,Alkhawaga @ (937) 376-8700 ...Dana F. of Careworks phonedand left VMM that ...11/07/2013 - Contact withProvider - Rcvd VM f ...11/07/2013 - Contact with BWC- PC to BWC CSS ...11/06/2013 - Contact withProvider - PC to Dr. ...CSS phoned Careworks as therewas no return ca ...CSS phoned the MCO,Careworks, this afternoon ...10/30/2013 - Contact withProvider - PC to Dr. ...The IW phoned this morninginquiring about an ...08/19/2013 - C-9 - 5d f/u C9A,received medica ...08/14/2013 - Contact withProvider - Received ...08/12/2013 - C-9 - C-9 dated08/05/2013 receiv ...

BWC

BWC

BWC

BWC

+ 12/11/2013PC TO IW; ADL BILL & BWCREDUCED LSA AMT

+ 12/11/2013PC: AGREE W/LESSER BWCAMOUNT FOR LSA

+ 12/11/2013LSA OPTION FORM MAILED TO BWCIW

+ 11/19/2013PC: LSA BWC

+ 11/07/2013PC TO IW TREATING PSY BWCPROVIDER

+ 11/07/2013PC: RE NEXT PSY OFC VISIT BWC




MCO

MCO

MCO

+ 11/05/2013FWUP CALL RE: NEXT PSY OV BWCDATE

+ 10/30/2013PC RE: PROVIDERS INSPRINGBORO


+ 10/29/2013PC: LSA QUESTlONS

+ 08/19/2013C-9


+ 08/12/2013C-9

08/02/2013Contact Letter for AnnualReview of PTD

+ 07/22/2013LUMP SUM SETTLEMENT(LSS) 07/22/2013 - Lump SumSettlement(LSS) - the se ...NOTES ENTRY 73534

Received call from IWrequesting status of LSS ...The IW called requesting anupdate on her sett ...I received the Lump SumSettlement Workbook ba ...The Lump Sum SettlementApplication (C240) fil ...

BWC

MCO

BWC

MCO

MCO

MCO

BWC

MCO

07/18/2013ASSIGNED CSS UNAVAILABLE BWC+ 07/18/2013CALL FROM IW RE: LSS BWC

+ 07/17/2013CALL FROM IW - LSS UPDATE BWC

+ 07/17/2013BWC ATTORNEY DOES NOTRECOMMEND LSS

+ 07/17/2013C240 FILED 2-26-2013DISALLOWED

07/17/2013LSS-Disapproval

06/14/2013ASSIGNED CSS UNAVAILABLE06/13/2013ADDRESS CHANGE BY INET

POSS REASSIGN+ 06/13/20131W GENERAL INFO UPDATED

BY I-NET

DIARY 73534

OLD HOME PHONE:9378787162 NEW HOMEPHONE: 937 ...I received a call from the IWinquiring about ...

BWC

BWC

BWC

BWC

BWC

BWC

+ 06/13/2013CALL FROM IW - LSS UPDATE BWC

https://www.bwc-ohio.gov/includes/PrintfTiendly.= 7/18/2014

^0 2


06/13/2 0 13 Notice Of Address Change/Old BWCFor Dolphin

05/20/2013ASSIGNED CSS UNAVAILABLE BWC+ 05/17/2013LSS WORKBOOK REFERRED TOBWC

BWC ATTORNEY+ 05/15/2013CALLED ATTORNEY GENERAL'S BWC

OFFICE+ 05/15/2013LSS WORKBOOK REFERRED TOBWC

IMS+ 04/11/2013ASSIGNED CSS UNAVAILABLE BWC

+ 04/11/2013LSA/AF PAID; PTD PLANEXTENSION

+ 04/09/2013SB7 TIME FRAME EXPIRES

+ 03/07/2013C240 FILED 2-26-13 - INITIALASSESSMENT

03/07/2013SB7 LETTER TO THEEMPLOYER

+ 03/05/2013LUMP SUM SETTLEMENT(LSS)

BWC

BWC

BWC

BWC

MCO

+ 03/04/2013LUMP SUM SETTLEMENT(LSS) MCO

02/27/2013DWRF UPDATE BWC

+ 02/27/2013NO DWRF LSS VALUE BWC

+ 02/21/2013ICORDR IC - 2/15/13 SHO EXPARTE; LSA/AF

+ 02/21/2013LSA/AF OPTIONS FORMISSUED

02/15/2013NOTE ENTERED

+ 02115/2013CONTACT

+ 02/15/2013COMP PAID; INCR %PP PER1/25/13 DHO

+ 02/12/2013ASSIGNED CSS UNAVAILABLE

BWC

BWC

BWC

BWC

BWC

BWC

+ 02/12/2013NEW PTD ORDER; PTD PLAN BWCPAID

+ 02/12/2013DWRF PLAN BUILT/NOT BWCENTITLED

02/12/2013DWRF Order BWC

+ 01/31/2013ICORDR IC - 1/25/13 DHO BWCORDER; INCR %PP

+ 01/31/2013WAGE REVIEW BWC

+ 01/30/2013ASSIGNED CSS UNAVAILABLE BWC

+ 01/29/2013DWRF UPDATE

01/29/2013SS VERIFICATION

BWC

BWC

+ 01/29/2013ICORDR IC - 1/25/13 PTD BWCTENT ORDER; PTD

01/25/2013DWRF UPDATE BWC

+ 01/25/2013SSA REQUESTED BWC

+ 01/17/2013CUSTOMER CARE PLAN (CCP) MCO


12/26/2012ASSIGNED CSS UNAVAILABLE BWC

+ 12/13/2012IC167-TIC - IW OBJECTION TO BWC

httPs://www.bwc.ohio-go-v,/includes/printfriendly.asp

DIARY 73534

The Lump Sum SettlementWorkbook was referred ...I calied the Attorney General'soffice to inqu ...The Lump Sum SettlementWorkbook was referred ...NOTES ENTRY 73492COMPENSATION PL ...Per request of Theresa B.,LSS/CSS (a C240 for ...The time frame for theemployer to notify BWC ...A Lump Sum SettlementApplication (C240) was f .^,

03/05/2013 - Lump SumSettlement(LSS) - bill r ...03/04/2013 - Lump SumSettlement(LSS) - a sett ....NOTES ENTRY 74617

Based on the declared PTDweekly rate of $375 ...Per SHO Ex Parte Order issued2/15/13 - BWC is ...The LSA/AF Option Form hasbeen completed and ...CALLCENT 72372

The (IW) injured workerrequesting to have her ...Increase %PP paid per 1/25/13DHO Order. POA...INCOMING APP MODIFY 81196NOTES ENTRY ...PTD paid beginning 08-12-12per SHO tentative ...DWRF plan built. The IW is overthe DWRF entry ...

Per 1/25/13 DHO Order - theorder of the Admin ...CSS reviewed wages and theyappear to be appro ...UPDATE STAFFING 73534DIARY POP-UP...NOTES ENTRY 74617DIARY ...Injured worker is receiving SSDbenefits. CS/DWRFThe Staff Hearing Officer (SHO)concludes that ...NOTES ENTRY 81766SSA verification requested forTentative Order ...01/17/2013 - Customer CarePlan (CCP) - Clinic ...01/14/2013 - Customer CarePlan (CCP) - E-mail ...DIARY 73499

The IW has filed an objection to

Page 4 of 21

7/18/2014,^;^-^

OhioBWC - Common - Service: (CPa.in notes)

C92A AWARD+ 11/27/2012TENTATIVE ORDER FOR INCR

%PP11/27/2012Tentative Order - Increase

State Fund11/16/2012ASSIGNED CSS UNAVAILABLE

+ 11/16/2012C92A COMB EFFECTS REVIEWREQUEST

+ 11/09/2012CONTACT WITH INJUREDWORKER


+ 10/29/2012C-9

+ 10/29/2012C-9


+ 10/26/2012C-9

+ 10/24/2012C-9

+ 10/23/2012C-9

+ 10/19/2012C-9

+ 10/19/2012C-9

+ 10/16/2012C-9

+ 10/12/2012C-9

10/11/2012NOTE ENTERED+ 10/11/2012C-92 EXAM SCHEDULED

10/11/2012Physician C92 Notice

10/11/2012IW C92 Notice

+ 10/09/2012C-9

Page 5 of 21

the T.O. for ...CSS is issuing a Tentative Orderfor an Increa ...

BWC

BWC

BWC DIARY 73534

BWC C253 created for C92ACombined Effects review. ...

MCO 11/09/2012 - Contact withInjured Worker (IW) ...

MCO 11/09/2012 - Contact withProvider - PC to Dr. ...

MCO 10/29/2012 - C-9 -Readdressed: C-9 dated 9/2 ...

MCO 10/29/2012 - C-9 -Readdressed C-9 dated9/21/ ...

MCO 10/26/2012 - Contact withProvider - -Assistin ...

MCO 10/26/2012 - C-9 - C-9 dated9/21/12 from non ...

MCO 10/24/2012 - C-9 - 8 businessday f/u ca!l re: ...

MCO 10/23/2012 - C-9 - C-9 dated9/21/12 from non ...

MCO 10/19/2012 - C-9 - 8 businessday f/u call re: ...



MCO 10/12/2012 - C-9 - C-9 dated9/21/12 from non- ...

BWC NOTES ENTRY 73561

C-92 Exam has been scheduledwith Dr. Deardorf ...

BWC

10/09/2012 - C-9 - C-9 dated9/21/12 from non- ...10/05/2012 - Customer CarePlan (CCP) - Receiv ...C92A PSYCH Exam Packetcreated and diary set f...CSS phoned the IW to inquir-eher availability ...The IW is NOT available onTuesdays. She is a ...INCOMING APP MODIFY 73493

BWC

BWC

MCO


+ 10/03/2012C92A PSYCH EXAM PACKET TO BWCSCHEDULER

+ 09/25/2012PC RE: C92A PSY EXAMAVAILABILITY

+ 09/25/2012C92A PSYCH EXAMAVAILABILITY

09/24/2012SUPERVISOR REVIEW ANDUPDATE

+ 07/26/2012C92A INCREASE IN % OF PPDISABILITY

+ 07/26/2012C230 5/3/11 POA HOCHMAN#20516-91; PRE

07/26/2012INCR PPD NOTIFICATION TOAPPL TO IW

+ 07/06/20121CORDR IC - 7/2/12 SHOORDER; REFUSAL

+ 06/27/2012IC12 IC - IW APPEAL 6/11/12SHO ORDER

+ 06/13/2012ASSIGNED CSS UNAVAILABLE

+ 06/13/2012ICORDR IC - SHO HEARINGREVIEW 06/11/12

BWC

BWC

BWC

BWC CSS reviewed the C92A(increase for newly all ...

BWC CSS phoned Hochman &Plunkett to inform them t...

BWC

BWC Per 7-2-12 SHO Order - theIW's appeal filed 6 ...

BWC The IW has filed an appeal tothe 06-11-12 SHO ...

BWC INJURY ADD/MODIFY 73559INJURY ADD/MODI ...

BWC It is the finding and order of theStaff Heari ...

https:/h.vwwr.bwc.ohio.gov/zncludes/printfrienclty.asp 7/18/2014^^ ^


06/1312012Notice Of Injury/Claim Status BWCChanges

06/13/2012Notice Of Injury/Claim Status BWCChanges

+ 05/23/2012ICNOTICIC - SHO ADL CND BWCHRG NOTICE - 6/1

+ 05/18/2012IC12 IC - IW APPEAL 5/3/12 BWCDHO ORDER

+ 05/04/2012ICORDR IC - 5/1/12 DHO BWCORDER/ADL COND

+ 04/13/2012ICNOTICIC - DHO ADL COND BWCHRG NOTICE - 05

04/02/2012MEDICAL/REHAB REVIEW AND BWCUPDATE

+ 03/29/2012STAFFING A/A PSY EXAM BWCW/MSS


+ 03/29/2012IC REFERRAL PER 10-26-11 BWCC86

03/29/2012IC Referral Letter BWC+ 03/28/2012SUPERVISOR REVIEW AND BWC

UPDATE+ 03/28/2012RN REVIEW-PSYCH EXAM QA BWC

+ 03/28/2012CSS REQUEST FOR EXAM BWCADDENDUM

02/21/2012NOTE ENTERED BWC

+ 02/21/2012ADDITIONAL ALLOWANCE BWCPSYCH EXAM

02/21/2012ADDITIONAL QUESTIONS. BWC

02/21/2012Physician Addtl Aliowance BWC(Psych) Notice

02/21/20121W Additional Allowance BWC(PSYCH) Notice

+ 02/17/2012PC RE: RESCHED A/A PSY BWCEXAM/AVAILABILITY

02/17/2012SUPERVISOR REVIEW AND BWCUPDATE

+ 02/17/2012A/A PSYCH EXAM CANCELED BWC

01/25/2012ASSIGNED CSS UNAVAILABLE

+ 01/24/2012MEDICAL/REHAB REVIEW ANDUPDATE

+ 01/24/2012PHYSICIAN REVIEW QA - DRDAVID.

+ 01/24/201201/24/2012-STAFFINGMINUTES

01/23/2012MEDICAL/REHAB REVIEW ANDUPDATE

+ 01/23/2012CUSTOMER CARE PLAN(CCP)

BWC

Per notice - SHO additionalcondition (major d ...The IW has filed an appeal tothe 05-03-12 DHO ...Per 05-01-12 DHO Order - It isthe order of th ...Per notice - DHO additionalcondition (10-26-1 ...INJURY ADD/MODIFY 81000

CSS had an email staffing withAmy G., MSS, in ...DIARY 73534

CSS is issuing a Notice ofReferral to the IC ...

DIARY POP-UP 72090DIARY POP-UP ...Exam referral received today.Per the exam rep ...CSS is requesting an addendumto the 03-20-12 ...NOTES ENTRY 71164

I rescheduled additionalallowance psych exam ...

The IW phoned this afternoon,approx. 12:00) ...NOTES ENTRY 80732

Per CSS, IW called to cancel herPsych exam sc...UPDATE STAFFING 73513

BWC NOTES ENTRY 81263DIARY ...

BWC Received and reviewedphysician review complet ...

BWC MSS reviewed case, codedrequested condition, ...

BWC DIARY POP-UP 71580

MCO

+ 01/23/2012CUSTOMER CARE PLAN(CCP) MCO

01/20/2012NOTE ENTERED+ 01/20/2012ADDITIONAL PSYCH EXAM

01/20/2012ADDITIONAL QUESTIONS01/20/2012IW Additional Allowance

(PSYCH) Notice01/20/2012Physician Addtl Allowance

(Psych) Notice01/19/2012MEDICAL/REHAB REVIEW

UPDATE

BWC

BWC

BWC

BWC

BWC

AND BWC

https://www.bwc.ohio.gov/incl-Lides/Printfriendly.asp

E-MAIL RECEIVED FROM CATHYB.(ACCT EXEC) FOR P ...CLAIM DOES NOT MEET MEDCO34 CRITERIA-DUR IS N ...NOTES ENTRY 71164

I scheduled additionalallowance psych exam on ...

INJURY ADD/MODIFY 81000

Pagpe 6 of 21

7/18I20I4


+ 01/18/2012ADL/ALW PSYCH EXAM BWCPACKET TO SCHEDULER

+ 01/12/2012MEDICAL/REHAB REVIEW AND BWCUPDATE

+ 01/12/2012PHYSICIAN REVIEW REFERRAL BWC

+ 01/11/201210-26-11 C86 DUE PROCESS BWCCONTACT

+ 01/11/2012ADL/ALW PSYCH EXAM BWCAVAILABILITY

+ 01/11/201210 26 11 C86 AA MSS BWCREFERRAL

+ 11/30/2011C-9 MCO

+ 11/10/2011BWC LETTER TO DISMISS 10- BWC26-11 C86

11/10/2O11LETTER TO DISMISS 10-26-11 BWCC86

+ 10/27/2011C86 ADLCND PSY/NEED BWCDECLARATION/DUE P

10/27/2011Due Process Letter BWC

10/27/2011Due Process Letter BWC

10/27/2011DECLARATION LETTER BWC

09/29/2011SUPERVISOR REVIEW AND BWCUPDATE

+ 09/29/2011WAGE VERIFICATION BWC

+ 09/28/2011COMPENSATION PAID: %oPP BWC

09/28/2011CIaim Reassigned Letter BWC09/21/2011NOTE ENTERED BWC

09/21/2011SS REQUEST PROCESSED BWC

+ 09/08/2011SUB. 148 POTENTIAL CLAIM BWCUPDATES

+ 09/08/2011SUB. 148 POTENTIAL ICD BWCUPDATES

+ 09/07/2011CONTACT WITH PROVIDER MCO


+ 08/30/2011CONTACT WITH INJURED MCOWORKER(IW

+ 08/29/2011C253 Dr. Forte / 8-24-11 / BWC34% combine

+ 08/29/2011C-9 MCO

08/29/2011Tentative Order -Grant State BWCFund

+ 08/18/2011C92EXA Dr Kennington / 7-29- BWC11/5%

07/11/2011NOTE ENTERED BWC+ 07/11/2011C-92 EXAM BWC

07/11/2011IW C92 Notice BWC

07/11/2011 Physician C92 Notice BWC+ 07/08/2011MEDICAL/REHAB REVIEW AND BWC

UPDATE+ 07/08/2011C-92 EXAM SCHEDULED BWC

lattps://www.bwc.ohio.gov/inctudes/printfriendly.asp

Page 7 of 21

Additional Allowance PSYCHexam packet has bee ...DIARY POP-UP 81263DIARY POP-UP...MSS reviewed documentationon imaging related ...CSS phoned Tracy Dunn ofAdvance America Cash ...The IW asks that she is givenadequate notice ...The IW's C86 Motion filed 10-26-11 is requesti ...C-9 DATED 11/28/11 RECEIVEDFROM JERRY FLEXMAN ...As the required DeclarationStatement has not ...

CSS is sending the "dec{aration"letter as it ...

NOTES ENTRY 73534

Based on employer informationwage input appea ...There were no appeals filed toBWC order grant ...

NOTES ENTRY 77678

Uploaded required documentsto SS website. CANDY HACCIDENT DESCRIPTION:ROBBER HIT ME IN THE HEA ...ICD : 920LCTN:SITE:PRMY FLAG: N ...RECEIVED CALL FROM DR.THOMAS' OFFICE/DONNA AS ...RECEIVED CALL FROM DR.THOMAS' OFFICE/DONNA ST...PC TO IW DISCUSSED DR.RAMIREZ, IW STATES SHE ...Dr. Stoeckel's report from the7-6-11 psycholo ...RECEIVED C9 UNDATEDRECEIVED @ CW 08-24-11FRO ...

C92 exam on 7-29-11 by Dr.Kennington finds th ,..NOTES ENTRY 73561

IW is rescheduled with Dr.Kennington on 7-29- ...

DIARY 73495DIARY ...C-92 Exam has been scheduled

7/18/2014

OhioBWC - Common - Servvice; (Claim notes)

07/08/2011Physician C92 Notice BWC07/08/2011IW C92 Notice BWC



+ 07/06/2011IW CALL TO FRONT DESK- BWCC92EXAM


+ 06/21/2011C-92 EXAM BWC

06/21/20111W C92 Notice BWC

06/21/2011Physician C92 Notice BWC


+ 06/15/2011C-92 EXAM SCHEDULED BWC

06/15/2011IW C92 Notice BWC06/15/2011Physician C92 Notice BWC


+ 06/13/2011C-92 EXAM AVAILABILITY BWC

+ 06/13/2011C92 PSY & PHYS EXAM PKTS BWCTO SCHEDULER

+ 05/31/2011C92 DETERMINATION OF % OFBWCPP DISBLTY

05/31/2011%PP NOTIFICATION OF BWCAPPLICATION TO IW

05/31/2011REQUEST FOR CURRENT BWCMEDICAL FOR C92


+ 05/04/2011C-9 MCO


+ 02/23/2011C-9 MCO

+ 01/11/2011ICORDR IC - 1/7/11 SHO BWCORDER/REFUSAL

12/30/2010ASSIGNED CSS UNAVAILABLE BWC+ 12/20/2010ICORDR IC - 12/14/10 SHO BWC

ORDER/TT MMI+ 12/10/2010CHP4-A 11/15/10 HANDICAP BWC

REIMBURSEMENT 0+ 11/24/20101CNOTICIC - SHO MMI HRG BWC

NOTICE - 12/14/1+ 11/16/2010IC12 IC - IW APPEAL 11/3/10 BWC

DHO MMI OR+ 11/11/2010CONTACT WITH EMPLOYER MCO

11/08/2010ASSIGNED CSS UNAVAILABLE BWC11/06/2010Date Enter - Fact sheet BWC

+ 11/05/2010ICORDR IC - 11/3/10 DHO BWCORDER/MMI


+ 10/19/2010ICNOTICIC - DHO TT/MMI HRGBWCNOTICE - 11/0

+ 10/19/2010CONTACT WITH EMPLOYER MCO

https://wvuw.bwc_ohro.gov/includes/Printfriendly.asp

Page 8 of Z l

with Dr. Kenningt ...

DIARY 73506DIARY ...NOTES ENTRY 76747NOTES ENTRY ...The injured worker contactedthe front counter ...NOTES ENTRY 73561

C-92 Exam has been scheduiedwith Dr. Boyer o ...

NOTES ENTRY 73561C-92 Exam has been scheduledwith Dr. Stoeckel ...

NOTES ENTRY 74978DIARY ...Injured Worker states that "anyWednesday in t ...C92 PSYCH & PHYS exampackets completed and di ...CSS is sending a copy of theC92 filed 05-27-2 ...

RECEIVED CALL FROM IWASKING IF I COULD ASSIST..RECEIVED C9 DATED 05-02-11FROM JERRY FLEXMAN ...MEDICATIONS REVIEWED INCLAIM. IW IS MMI FOR P...RECEIVED C9 DATED 02-21-11FROM PETER RAMIREZ ...Per 1/7/11 SHO Order - theIW's appeal filed 1 .,.DIARY 73513Per 12-14-10 SHO Order - theorder of the DHO ...Per order dated 11-15-10 - theemployer's appi ..Per notice - SHO MMI hearing isscheduled for ...The IW has filed an appeal tothe 11-03-10 DHO ...E-MAIL UPDATE TO EOR/TRACYD. AND LEIGH S. THE ...UPDATE STAFFING 81196

Per 11-3-10 DHO Order - it isthe finding of t ...UPDATED CASE SPECIALISTPLAN PER ADDTL TT, TX ...Per notice - DHO TT/MMIhearing is scheduled f ...E-MAIL UPDATE TO EOR/TRACYD. AND LEIGH S. INF ...

7/18/2014f.^^


+ 10/19/201OCONTACT WITH PROVIDER

+ 10/19/2010CONTACT WITH INJUREDWORKER(IW

+ 10/15/2010C-9

+ 09/30/201®INDEPENDENT MEDICALEXAMINATIO


+ 09/30/2010CONTACT WITH EMPLOYER

MCO

MCO

MCO

MCO

MCO

MCO

+ 09/28/2010C84 MR - EST RTW 12-15-10 BWCPAID


+ 09/28/201®MSS QA PSYCH EOD EXAM BWC

09/28/2010Exam Outcome MMI - Factssheet

09/28/20 10 Notice Of Entitlement To TTDisability

09/28/2010Notice Of Injury/Claim StatusChanges

09/28/201OMMI (tr to por

09/28/20101C Referral Letter

09/20/2010ASSIGNED CSS UNAVAILABLE

BWC

BWC

BWC

BWC

BWC

BWC

09/20/2010INDEPENDENT MEDICAL MCOEXAMINATIO


+ 09/20/2010VOCATIONAL REHABILITATION MCO







09/13/2010C84 Cover Letter+ 09/09/2010CONTACT WITH PROVIDER




MCO

MCO

MCO

BWC

MCO

MCO

MCO

MCO




htips://wvErvv.bwe.ohio.gov/includes/printfrienciiy.asp

Page 9 of 21

PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...PC TO IW TO DISCUSS HERCURRENT STATUS/PROGRE ...RECEIVED C9 DATED 10-10-10FROM JERRY FLEXMAN ...BWC PSYCH EXAM 09/10/10 =IW MMI ...PC TO IW TO DISCUSS ANYFURTHER RTW PLANS WITH...E-MAIL UPDATE TO EOR/TRACYD. AND LEIGH S. INF ...The IW has submitted a C84 forthe allowed con ...NOTES ENTRY 73495DIARY ...Per dr. Madrigal," It is myopinion that claim ...

DIARY 73500

IME 09/13/10 - NO REPORT YET

UPDATED CASE SPECIALISTPLAN PER ADDTL TX REQU ...PER IW SHE WANTS TO WAITFOR VOC REHAB - AND W...RECEIVED CALL FROM IW`STHERAPIST/TERESA CARME ...DIARY 73498PER PC TO EOR/TRACY D.W/NEW TPA/ELAINE F. DIS...PC TO BWC/KAREN B. ASKEDHER IF SHE HAD ANY IN ...PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...PC TO IW TO FIND OUT ABOUTHER APPT ON 09/13/1 ...

PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...PC TO IW TO FIND OUT ABOUTHER APPT TODAY. IW ...E-MAIL UPDATE TO EOR/TRACYD. AND LEIGH S. IN...PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...PC TO IW TO F/U ON VOCREHAB, IW STATES SHE IS ...NOT READY YET.IW ISINTERESTED BUT WANTS TODINOTES ENTRY 71164

7/18/2014


+ 08/16/2010EOD PSYCH EXAM

08/16/20101W Extent of Disability(PSYCH) Notice

08/16/201®Physician Ext of Dis. (Psych)Notice


08/13/201®INDEPENDENT MEDICALEXAMINATIO



+ 08/11/201®MEDICAL/REHAB REVIEW ANDUPDATE

+ 08/11/2010MSS EOD PSYCH EXAM NOTE

Page 10 of 21

I scheduled extent of disabilitypsych exam on ...

PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...BWC REP IS GOING TOSCHEDULE IMEPC TO IW TO FIND OUT IF SHEHAS SCHEDULED ANY...E-MAIL UPDATE TO EOR/TRACYD. AND LEIGH S. IN ...DIARY POP-UP 73495DIARY ...MSS completed the psych EODexam worksheet and ...PSYCH EOD exam packetcreated and diary set fo ...UPDATED CASE SPECIALISTPLAN PER ADDTL TT AND ...POTENTIAL CLAIM UPDATES -RTW DATE: 11/20/ ...ICD: 920LCTN:SITE:PRMY FLAG: N ...PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...E-MAIL UPDATE TO EOR/TRACYD. AND LEIGH S. IN ...PC TO EOR/TRACY D. TO MAKEHER AWARE OF HANDIC ...PC TO BWC/KAREN B. LEFTMESSAGE ON HER VM ASKI ...RECEIVED CALL BACK FROMBWC/KAREN STATING THAT ...TTDC has been paid through10-13-2010 based on ...RECEIVED C-84 DATED07/21/10 NOT ON WEBSITE,F ...

BWC

BWC

BWC

MCO

MCO

MCO

mco

BWC

BWC

+ 08/11/2010PSYCH EOD EXAM PACKET TO BWCSCHEDULER


+ 08/05/2010SUB. 148 POTENTIAL CLAIM BWCUPDATES

+ 08/05/2010SUB. 148 POTENTIAL ICD BWCUPDATES





+ 07126/2010CONTACT WITH BWC

+ 07/22/2010C84 MR - EST RTW 10-14-10/PAID


07/22/2010Notice Of Entitlement To TTDisability

07/22/2010C84 Cover Letter+ 07/20/2010C-9





07/14/2010C84 Cover Letter+ 07/08/2010CONTACT WITH INJURED

WORKER(IW+ 07/08/2010CONTACT WITH EMPLOYER

mco

MCO

MCO

MCO

MCO

BWC

mco

BWC

BWC

mco RECEIVED C9 DATED 07-15-10FROM PETER RAMIREZ ...

mco RECEIVED CALL FROM IW, SHESTATES SHE HAD A CE ...

mco PC TO IW, IN REGARDS TO HERVM MESSAGE RETURNI ...

mco PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...

MCO PC TO IW, LEFT MESSAGE ONHER VM THAT I REALLY ...

BWC

mco PC TO IW TO FIND OUT HOWSHE IS COMING ALONG N...

mco E-MAIL UPDATE TO EOR/TRACYD. CC'D LEIGH S. IN ...

httgs://wvvw.bwc.ohio.gov/includes/printfriendly.asp 7/18/2014









+ 05/199/2010C-9

+ 05/14/2010C84 MR - EST RTW 08-01-10/PAID

05/141201®Notice Of Entitlement To TTDisability

05/14/2010C84 Cover Letter+ 05/11/20 10IND EPEND ENT MEDICAL

EXAMINATIO+ 05/11/2010CONTACT WITH EMPLOYER

MCO

MCO

MCO

M CO

MCO

BWC

BWC

BWC

MCO

MCO


+ 04/29/2010EXAM RESULTS LETTER SENT BWC

04/29/2010C84 Cover Letter04/29/2010EXAM RESULTS LETTER

+ 04/28/2010MEDICAL/REHAB REVIEWUPDATE

+ 04/28/201OMSS QA PSYCH EOD EXAN

04/20/2010NOTE ENTERED

+ 04/20/2010EXAM REPORT

BWC

BWC

AND BWC

BWC

04/16/2010INDEPENDENT MEDICALEXAMINATIO




+ 04/06/201oC-9

BWC

BWC

MCO

MCO

MCO

MCO

Mco


+ 03/18/2010RTN CALL/CHANGE OF LAST BWCNAME/EXM AVAIL

+ 03/18/2010PSYCH EOD AVAILABILrN BWC

03/17/2010NOTE ENTERED+ 03/17/201®EOD PSYCH EXAM

+ 03/17/2010PC RE: PSYCH EODAVAIL,4BILITY

03/17/2010IW Extent of Disability

BWC

BWC

BWC

BWC

https://www.bwe.ohio.gov/includes/prizatffiendly.asp

Page 11 of 21

PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...DO NOT F/U WITH IW FORANOTHER 2 WEEKS, SHE JU ...WILL F/U WITH THERAPIST IFIW IS READY TO TRY ...E-MAIL UPDATE TO EOR/TRACYD. AND LEIGH S. INF ...UPDATED CASE SPECIALISTPLAN PER ADDTL TT AND ...PC TO EOR/TRACY D., LEIGH S,AND TERESA W. STA...RECEIVED CALL FROMKRISTY/DR. BLACK'S OFFICEA .UPDATED C-9 DATED06/03/09/DR. BLACK TOAPPROV ...TTDC has been paid through07-31-2010 based on ...

PSYCH IME WAS DONE ON04/02/10 FINDING IW NOT ...E-MAIL UPDATE TO EOR/TRACYD., CC'D LEIGH S. I...IW IS NOT VOC FEASIBLE -RECENT IME CONFIRMS - ...Sending Exam Results letter toPOR and a copy ...

DIARY 73495NOTES ENTRY ...Per Dr. Manges, IW has notreached MMI for psy ...NOTES ENTRY 71164

I called Dr. Manges and leftvoice mail messag ...PSYCH IME WAS DONE ON04/02/10 - NO REPORT YET.PER MEDICAL THE IW HAS AF/U APPT WITH DR. RAM ...PC TO IW, DISCUSSED HERCURRENT STATUS AND HER ...E-MAIL UPDATE TO EOR/TRACYD. CC'D LEIGH S. IN ...RECEIVED C9 DATED 03-31-10FROM JERRY FLEXMAN ...IW IS NOT VOC FEASIBLE,DISCUSSED WITH HER PHD ...The IW returned my call thisafternoon. She ...Other than on 04-06-2010, theIW is available ...NOTES ENTRY 71164I scheduled extent of disabilitypsych exam on ...CSS forgot to contact the IW forexam availabi ...

7/18/2014

°/I\


(PSYCH) Notice03/17/2010Physician Ext of Dis. (Psych) BWC

Notice+ 03/16/201®PSYCH EOD EXAM PACKET TO BWC

SCHEDULER+ 03/12/2010MEDICAL/REHAB REVIEW AND BWC

UPDATE+ 03/12/2010MSS EOD PSYCH EXAM NOTE BWC




MCO

MCO

MCO

03/04/2010ASSIGNED CSS UNAVAILABLE BWC+ 03/03/2010CUSTOMER CARE PLAN(CCP) MCO


+ 03/01/2010ICNOTICIC - DHO HEARING BWC03/17/10 ADR 020




+ 02/05/2010C-9



+ 01/19/2010INDEPENDENT MEDICALEXAMINATIO


+ 01/13/2010C84 MR - EST RTW 06-01-10/PAID


+ 01/0812010ADR RESOLVED

+ 01/08/2010ADR RESOLVED



01/08/2010BWC Order - DisputeResolution Order

+ 12/23/2009C-9


MCO

MCO

MCO

MCO

MCO

M CO

MCO

BWC

MCO

MCO

MCO

MCO

MCO

BWC

MCO

MCO



12/10/2009ASSIGNED CSS UNAVAILABLE BWC+ 12/10/2009C-9 MCO


https://www.bwc.ohio.gov/includes/printfrpendly.asP

Page 12 of 21

Created PSYCH, only, EODexam packet and set d...DIARY 73495DIARY POP-UP ...MSS completed psych EODexam worksheet and ima ...PC TO IW, TO F/U ON HERCURRENT STATUS/PROGRES ...E-MAIL UPDATE TO EOR/TRACYD. CCD LEIGH S. FO...DHO NEW HEARING DATE03/17/10 FOR DENIED TX RE ...DIARY 73513

UPDATED CASE SPECIALISTPLAN PER ADDTL TX REQU ...NOTES ENTRY 73513DIARY ...The IC has scheduled a hearingwith the DHO on ...IW IS NOT VOC FEASIBLE,DISCUSSED WITH HER PHD ...PC TO EOR/TRACY D. ANDLEIGH S. FOR CURRENT PR ...E-MAIL UPDATE TO EOR/TRACYD. CC'D LEIGH S. IN ...RECEIVED C9 DATED 12-21-09FROM JERRY FLEXMAN ...RECEIVED CALL FROM TERESACARMEN/THERAPIST PCC...PC TO IW, DISCUSSED HERCURRENT Ct.AIM, IW IS F...LAST PSYCH IME 09/04/09STATES IW HAD ONLY JUS ...E-MAIL UPDATE TO EOR/TRACYD. INFORMED HER THA ...TTDC has been paid through05-31-10 based on t ...UPDATED CASE SPECIALISTPLAN ADDTL TX REQUEST,...Ll 99351 BWC 207771 PERNEW BWC POLICY ORDER ...COULD NOT LOCATE ORIGINALAPPEAL PACKET SHOWED ...RECEIVED CALL FROM DR.BUCK'S OFFICE LORI-NO L ...PC TO DR. BUCK/LORI INREGARDS TO THE ADR FOR ...

RECEIVED C9 DATED 12-21-09FROM JERRY FLEXMAN ...E-MAIL UPDATE TO EOR/TRACYD. INFORMED HER THA ...IW IS NOT VOC FEASIBLE,DISCUSSED WITH HER PHD...RECEIVED ANOTHER CALL CALLFROM 937-427-2225 L ...DIARY 73513

RECEIVED C9 DATED 12-08-09FROM PETEP. RAMIREZ ...RECEIVED CALL FROM 937-

7/18/2014

OhioBVi%C - Common - Service: (Claim notes)














MCO

MCO

MCO

MCO

MCO

+ 11/02/2009C-9 MCO

+ 10/20/2009C84 MR - EST RTW 03-01- BWC2010/PAID



10/20/2 009 Notice Of Entitlement To TT BWCDisability


+ 10/05/2009PHYS MMI TO POR LTR & PSY BWCEXM RSLTS SENT



+ 10/05/2009C-9 MCO

10/05/2009Notice Of Entitlement To TT BWCDisability

10/05/2009C84 Cover Letter BWC10/05/2009MMI TO POR LETTER BWC

10/05/2009PSYCH EXAM RESULTS LETTER BWC10/01/2009ASSIGNED CSS UNAVAILABLE BWC



+ 09/17/2009MSS QA DR HARRIS EOD BWCPSYCH EXAM

+ 09/17/2009MSS QA EOD MED EXAM BWC

+ 09/17/2009MSS DX RX REV NOTE BWC

09/17/2009Exam Outcome MMI - Facts BWC

htqas://wvvw.bwc.ohio.gov/inciudes/grintfriendly. asp

Page 13 of 21

427-2225 LORI/BILLING/D ...DIARY 73513

RECEIVED CALL FROM TERESACARMEN/MS PCC, IN RE ...DIARY POP-UP 73506

DIARY POP-UP 73513

PC TO FLEXMAN CLINIS @ 937-256-3390 S/W JESSIC ...E-MAIL UPDATE TO EOR/TRACYD. INFORMED HER THA ...DIARY 73513

IW MAY BE VOC FEASIBLEATTEMPTING TO GET VERIF...RECEIVED VM MESSAGE FROMDR. WARD'S OFFICE STA ,..UPDATED CASE SPECIALISTPLAN PER ADDTL TT AND ...PC TO POR/DR. MARCIATHOMAS/MD PH # 937-458-4

vPCTO IW TO FOLLOW UP WITHHER, HAVING READ TH ..,E-MAIL UPDATED TOEOR/TRACY D. INFORMED HERIWRECEIVED C9 DATED 10-28-09FROM MARCIA THOMAS ...TTDC has been paid through02-28-2010 based on ...PC TO IW TO F/U ON HERCURRENT STATUS (IW GOT...E-MAIL TO EORITRACY D.INFORMED HER THAT IW SE ...

E-MAIL UPDATE TO EOR/TRACYD. INFORMED HER THA ...Sending the MMI to POR letterfor the IW's phy ..,PC TO IW TO F/U ON HERCURRENT STATUS (IW GOT ...UPDATED CASE SPECIAUSTPLAN PER ADDTL TT, POR ...ASSISTING CRR: C-9 DATED09/30/09 RECEIVED FRO ...

DIARY 73559

PC TO IW IN REGARDS TO HERIME'S, THE OUTCOME,...DIARY 73495NOTES ENTRY ...Per Dr Harris PhD:IW has not reached MMI f...Per Dr Boyer MDIW is at MMI for the physi ...MSS rev. Dx Rx report and ALLof the medicatio ...

7/18/2014


sheet09/14/2009NOTE ENTERED







BWC

MCO

MCO

MCO

M CO

MCO

MCO




+ 08/31/2009ClJSTOMER CARE PLAN(CCP) MCO






08/05/2009NOTE ENTERED+ 08/05/2009EOD PSYCH EXAM

08/05/2009IW Extent of Disability(PSYCH) Notice

08/05/2009Physician Ext of Dis. (Psych)Notice

08/03/2009NOTE ENTERED+ 08/03/2009EOD PHYSICAL EXAM

08/03/2009IW Extent of Disability (PHYS)Notice

08/03/2009Physician Ext of Dis. (Phys)Notice


+ 07/28/2009PSY AND PHYS 90 DAY EXAMPKTS CREATED

+ 07/27/2009PH CALL RE: 90 DAY EXAMAVAILABILITY

+ 07/27/200990 DAY EXAM AVAILABILITY



MCO

MCO

MCO

MCO

BWC

BWC

BW C

BWC

BWC

BWC

BWC

BWC

MCO

BWC

BWC

BWC

MCO

MCO


+ 07/17/2009C-9 MCO

07/16/2009MEDICAL/REHAB REVIEW AND BWC

b.ttps://wvvw.bwc.oh.io.gov/lncludes/printfiiemd.ly.asp

Page 14 of 21

DIARY POP-UP 71164

RECEIVED CALL FROM TERESACARMEN/MENTAL HEALTH ...PC TO EORITRACY D. ANDLEIGH S. IN REGARDS TO ...PSYCH IME 09/04/09 - IW ISNOT MMIPC TO DR. FELDMAN'S OFFICE,(OFFICE HOURS ON F ...PC TO BWC/KAREN B. LEFTMESSAGE ON HER VM ASKI .,.PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...PHYSICAL IME 08/25/09 IW ISMMITTDC has been paid through11-30-2009 based on ...

UPDATED CASE SPECIALISTPLAN PER PHYSICAL AND ...DIARY 73513

PHYSICAL IME 08/25/09 PSYCHIME 09/04/09E-MAIL UPDATE TO EOR/TRACYD. INFORMED HER THE...PC TO IW TO F/U ON HERCURRENT STATUS, TREATME ...E-MAIL TO EOR/TRACY D. INREGARDS TO IW'S CURR ...NOTES ENTRY 71164

I scheduled extent of disabilityPsych exam on ...

NOTES ENTRY 71164

I scheduled extent of disabilityphysical exam ...

ADR IME INVOICE RECEIVEDAND SENT FOR PROCESSI ...Both physical and psychological90 Day Exam pa ...Phoned the IW this afternoon toincEuire her av ...The IW is NOT avaiiabie forexam scheduling on ...PC TO EOR/TRACY D.INFORMED HER THAT I AMWAIT...UPDATED CASE SPECIALISTPLAN PER POR APPT AND ...IW HAS DECLINED VOC REHABFOR NOW, STILL HAVIN ...ASSISTING WITH CRR: C-9DATED 07/08/09 RECEIVE ...DIARY 73507

7/ 18/2E114 3^:

OhioBWC - Common - Service: (Claiaar notes)

+ UPDATE+ 07/16/2009NURSE REVIEW EXAM

READINESS+ 07/15/2009CONTACT WITH EMPLOYER


+ 07/1512009CUSTOMER CARE PLAN(CCP)

+ 07/13/2009REFERRAL FOR 90 DAY EXAMREVIEW







BWC

MCO

MCO

MCO

BWC

MCO

MCO

MCO

MCO

MCO

MCO






06/22/2009C84 Cover Letter BWC+ 06/19/2009VOCATIONAL REHABILITATION MCO



+ 06/17/2009ALTERNATIVE DISPUTERESOLUTION





+ 06/12/2009ALTERNATIVE DISPUTERESO LUTIO N



+ 06/08/2009C-9

MCO

MCO

MCO

MCO

MCO

M CO

MCO

MCO

MCO

MCO

MCO

Page 15 of 21

NOTES ENTRY ...MSS reviewed medical recordregarding exam rea ...E-MAIL TO EOR/TRACY D.UPDATING HER ON CURRENT ...ADR IME NO SHOW INVOICERECEIVED AND SENT FOR ...UPDATED CASE SPECIALISTPLAN PER ADDTL TT,AND ...Referring to MSS inquiring if itis now approp ...IME RESCHEDULED FOR07/20/09 WITH CLINDQUIST ...PC TO BWC/KAREN, INREGARDS TO HER VMMESSAGE...PC TO BWC/KAREN, INREGARDS TO HER VMMESSAGE ...PC TO IW ASKED HER IF SHEHAD CONTACTED BWC IN ...PC TO BWC/KAREN LEFTMESSAGE ON HER VMASKING ...PC TO JOANN W./ADR. ASKEDHER ABOUT THE EXAM, ...NO SHOW TO IME ON 07/01/09

PC TO IW, IN REGARDS TO HERVM MESSAGE ABOUT A ...TTDC has been paid through09-17-09 based on t ...IME SCHEDULED FOR 07/01/09WITH C LINDQUIST JR DC

IW CURRENTLY NOT VOCFEASIBLE, IW WILLDISCUSS ...RECEIVED VM MESSAGE FROMTERESA CARMEN/MENTAL ...PC TO TERESACARMEN/MENTAL HEALTHTHERAPIST @ ...Li 99351 FILE PREPARED FORPEER REVIEWER. D...PC TO 864-342-5441 S/WTRACY DUNN ASKED HER IF...E-MAIL TO EOR/TRACY D. INREGARDS TO CURRENT U ...Ll APPEAL REC'D IN ADR DEPTFOR C-9 DATED 06/0 ...PC TO 864-342-5441 S/WTRACY DUNN ASKED HER IF ...RECEIVED APPEAL DATED 06-09-09 FROM DEREK BLAC ...RECEIVED LEVEL 1 APPEALDATED 6-9-09,FAXED 6-1 ...PC TO TX PHYSICIAN/DR.BLACK/DC, LEFT MESSAGE ...RECEIVED FROM CRR/CSSTAFFING C9 DATED 06-03-

httgs://www.bwc.ohio.gov/includes/printfriendly.asp 7/1 8/2014

`"^^^







+ 05/22/2009MEDICAL/REHAB REVIEW ANDUPDATE

+ 05/22/2009NURSE REVIEW EXAMREADINESS



+ 05/15/2009REFERRAL FOR 90 DAY EXAMREVIEW



+ 05/11/2009C-9

05/07/2009Generic ID Card Letter+ 05/06/2009CONTACT WITH PROVIDER


+ 04/27/2009C-9

+ 04/23/2009C84 MR - EST RTW 07-01-09/PAID

04/23/2009CUSTOMER CARE PLAN(CCP)04/23/2009Notice Of Entitlement To TT

Disability04/23/2009C84 Cover Letter

+ 04/23/2009SUB. 148 POTENTIAL ICDUPDATES



04/22/2009CONTACT WITH INJUREDWORKER(IW


+ 04/20/2009C-9

+ 04/20/2009C-9




https://,%NTww. bwc. ohi o.gov/iacludes/printfrienclly.asp

Pa.ge 16 of 21

0. . .MCO PC TO DR. BLACK/DC JILL-NO

LAST NAME GIVEN- IN ...MCO RECEIVED CALL FROM IW, SHE

STATES APPARENTLY S ...MCO PC TO DR. BLACK/DC IN

REGARDS TO C-9 DATED 06/ ...MCO PC TO EOR/LIZZIE J,

DISCUSSED CURRENTPROGRESS ...

MCO UPDATED CASE SPECIALISTPLAN PER ADDTL TT AND ...

BWC DIARY 73507NOTES ENTRY...

BWC CSS/MSS staffed regardingextent of disability ...

MCO PC TO IW, LEFT MESSAGE ONVOICEMAIL TO PLEASE ...

MCO IW WILL BE REFERRED FOREXAM/BOTH PHYSICAL AND ...

BWC Referring to MSS for 90 DayExamination review...

MCO RECEIVED CALL FROM TXPHYSICIAN/DR. BLACK'S OF ...

MCO PC TO IW, LEFT MESSAGE ONVOICEMAIL TO PLEASE ...

MCO RECD C9 DATED 050609 FAXDATE SAME FROM JERRY ...

BWC

MCO RECEIVED CALL FROM DR.FLEXMAN'S OFFICE/CHERYL ...

MCO E-MAIL TO EOR/LIZZIE J.UPDATING HER ON CLAIM ...

MCO RECEIVED C9 DATED 04-22-09FROM MARCIA J. THOM ...

BWC TTDC has been paid through06-30-2009 based on ...

MCO F/U APPT DR. THOMAS 5/21/09BWC

BWC

BWC ICD:920LCTN:SITE:PRMY FLAG: N ...

MCO RECEIVED CALL FROM LISAWITH WORK HEALTH STATI ...

MCO PC TO LISA WALTERS @ 937-458-4223 LEFT A MESSA...

MCO ERROR

RECEIVED CALL BACK FROMLISA WALTERS, DISCUSSE ...REVIEWED FOR CRR/CSSTAFFING C9 DATED 04-15-09ENTERED TRACKING SCREENFOR APPROVED C-9/DTED ...PC TO IW, INFORMED HER OFTHE APPROVED CHIRO A ...IW IS CURRENTLY NOT VOCFEASIBLE, RECENT PSYCH ...

MCO

MCO

MCO

7/18/2f3 14^^^^

OhioB W C- Common - Service: (Claim notes)


+ 04/01/2009ICORDR IC - 3/30/09 DHOORDER/ADL COND P



+ 03/18/2009APPEAL PERIOD/WAGE/TT ATAWW PAID


03/18/2009C84 Cover Letter+ 03/16/2009135 DAY DM IME REVIEW

W/EXCEPTION+ 03/16/2009CONTACT WITH INJURED

WORKER(IW+ 03/13/2009CONTACT WITH BWC

+ 03/12/2009ICNOTICIC - DHO HEARINGNOTICE - 03/30/0


+ 03/05/2009C-9



Page 17 of 21

MCO E-MAIL TO EOR/LIZZIE J.INFORMING HER THAT ADD ...

BWC Per DHO order of 03-30-09 - Itis the order of ...

MCO PC TO IW IN REGARDS TOOUTCOME OF HEARING THE.„

MCO UPDATED CASE SPECIALISTPLAN PER HEARING DATE ...

BWC No appeal was filed for the BWCOrder setting ...

BWC

BWC

BWC

MCO

MCO

BWC

MCO

MCO

MCO

MCO

02/28/2009BWC Order - Additional BWCAllow/Wages/Comp

+ 02/20/2009BWC ORDER TO SET THE AWW BWC

+ 02/19/20091C REFERRAL PER 01-20-09 BWCC86


02/19/2009Request For Wage Information BWC02/19/2009IC Referral Letter BWC


+ 02/18/2009EXAM FINDINGS PSYCH BWCALLOW

+ 02/17/2009NOTE ENTERED BWC

02/17/2009REPORT RECEIVED


BWC

MCO

+ 02/03/2009C84 MR - ACTUAL RTW 05-01- BWC09/PAID



+ 02/03/2009C-9

MCO

MCO

02/03/2009Notice Of Entitlement To TT BWCDisabiiity


+ 01/30/2009PFi CALL RE: TEMP WAIVER 90 BWC

https://www.bwe.ohio.gov/includes/printfriendly.asp

As the claim is at the IC forconsideration of ...PC TO IW DISCUSSED HERUPCOMING HEARING, IW ST ...RECEIVED CALL BACK FROMBWC/KAREN STATING THE ...Per notice - Additional conditionPSY hearing ...PC TO BWC/KAREN B. INREGARDS TO ADDTL PSYCHC .RECEIVED C9 DATED 02-27-09FROM DEREK BLACK DC ...RECEIVED CALL FROM DR.BLACK'S OFFIC/DC, JILL- ...LATE ENTRY: UPDATE GIVENTO EOR PER PHONE CALL ...

Issuing a BWC Order to set theIW's AWW based ...Issuing a notice of referral tothe IC recomme ...VOC NOTE: IW IS NOTFEASIBLE AT THIS TIME D/T ...

DIARY 73507NOTES ENTRY ...Dr. Howard examined IW 02-09-09 regarding requ ...NOTES ENTRY 77677DIARY POP-UP ...report received and imaged.betsy w.UPDATED CASE SPECIALISTPLAN PER ADDTL TT, TX ...TTDC has been paid through04-30-09 based on t ...PC TO POR/DR. THOMAS INREGARDS TO THE C-9 FOR ...PC TO IW, ASKED HER IF SHEHAS BEEN TO A CHIRO ...RECEIVED C-9 FROM POR/DRTHOMAS, DATED 02/02/0 ...

E-MAIL TO EOR/LIZZIEJOHNSON FOR A QUICKUPDAT ...Phoned Leigh Santanelio this

7/18/2014

I'l


DAY EXAM+ 01/30/2009MEDC06 EMP SIGNED WAIVER BWC

OF EXAMINATION01/22/2009NOTE ENTERED BWC

+ 01/22/2009ADD ALL PSYCH EXAM SCHED BWC

01/22/20091W Additional Allowance BWC(PSYCH) Notice

01/22/2009Physician Addti Allowance BWC(Psych) Notice

+ 01/20/2009C86 ADL COND/PSYCH - BWCMEDICAL REFERRAL

+ 01/20/2009STAFFING W/MSS BWC


+ 01/20/2009EXAM REFERRAL PSYCH BWCALLOW

+ 01/20/2009ADL/ALW PSY EXAM BWCAVAILABILITY

+ 01/20/2009AVAILABILITY ADL/ALW PSYCH BWCEXAM

+ 01/20/2009CONTACT WITH BWC MCO


+ 01/20/2009CONTACT WITH BWC MCO




+ 01/16/2009RTN CALL RE: PA BWCALLOW/PSYCH

+ 01/16/2009C-9 MCO


+ 01/15/2009NURSE REVIEW BWC

+ 01/15/2009EMP PA ALLOW CONTACT BWC


+ 01/14/2009C9 MR - PA ALLOW BWCPSYCH/STFG/ACTION P


01/07/2009SUB. 148 POTENTIAL ICD BWCUPDATES

+ 01/05/2009APPEAL PERIOD EXP/PA BWCALLOWANCE


+ 12/26/2008LETTER TO DISMISS C86 FLD BWC12-15-08

12/26/2008LETTER TO DISMISS 12-15-08 BWC

lattps://www.bwe.ohio.gov/i.n.clttdes/printffiendly.asp

Page 18 of 21

morning to inform ...Received employer signed"temporary" waiver of ...NOTES ENTRY 77677

add all psych exam has beenset with Dr. Howar ...

The C86 Motion filed 01-20-09is requesting th ...Staffed C86 Motion filed 01-20-2009 w/MSS. It ...DIARY 73507DIARY POP-UP ...Medical packet prepared andsent to scheduler ...Phoned the IW this afternoon toinquire her av ...The IW is NOT available on 01-28-09 for schedu ...PC TO BWC/KAREN B.DISCUSSED THE C-86 MOTION,

PC TO IW, INFORMED HER OFTHE CURRENT STATUS A ...PC TO BWC/DR.THOMAS/SUSAN LEFTMESSAGE ON HER ...RECEIVED CALL FROM POR/DR.THOMAS/SUSAN @ 937-...IW IS NOT VOC FEASIBLE,CURRENTLY AWAITING REV ...PC TO POR/DR. THOMAS INREGARDS TO RTW RESTRIC ...Leigh of Advance Americareturned my call in r...RECEIVED C9 X 2 DATED 01-13-09 FROM MARCIA J. ...NOTES ENTRY 73507

MSS spoke today with Julie F,MSS&CATdaim...Phoned Lizzy Johnson ofAdvance America this a ...PC TO POR/DR.THOMAS/SUSAN HARDY INREGARDS TH ...The C9 filed 01-13-09 isrequesting proactive ...PC TO IW IN REGARDS TO THEADDTL DX THAT SHE W...ICD: 920LCTN:SITE:PRMY FLAG : NNo appeal was filed for the BWCOrder granting ...

Issuing an adhoc letter todismiss the IW's C8 ...

7/18/2014^


C8612/20/2008SUB. 148 POTENTIAL ICD

UPDATES

12/17/2008CUSTOMER CARE PLAN(CCP)



+ 12/16/2008C86 ADLCON D/PSYCH/M EDI CALREFERRAL

12/16/2008REQ FOR MEDICAL TOSUPPORT C86 PSY COND

+ 12/15/2008APPEAL PERIOD EXP/LT't°T'/TTPAID

+ 12/15/2008BWC ORDER TO GRANT PAALLOWANCE

+ 12/15/200845 DAY DM IME REVIEWW/EXCEPTION


12/15/2008C84 Cover Letter12/15/2008BWC Order - Additional

Allow/Wages/Comp+ 12/12/2008LETfER FOR RTW

Page 19 of 21

BWC ICD: 920LCTN:SITE:PRMY FLAG: N

MCO REQUEST FOR ADDTLDX/SPRAIN OF NECK IN A/ASTATUS

MCO E-MAIL TO EOR/LIZZIEJOHNSON IN REGARDS TOUPD ...

MCO PC TO IW IN REGARDS TO HERADDITIONAL CONDITIO ...

BWC The C86 Motion filed 12-15-08is requesting th ...

BWC

BWC No appeal was filed for the BWCLT/lTDC Order. ...

BWC Issuing a BWC Order to grantthe proactive all ...

BWC It is not appropriate toscheduled the 45 Day ...

BWC

BWC

BWC

MCO

+ 12/08/2008C9 PA ALLOW/MOTION BWCREQUIRED


+ 12/08/2008NURSE REVIEW BWC

+ 12/08/2008PA ALLOWANCE DUE PROCESS BWC

+ 12/08/2008PA ALLOWANCE DUE PROCESS BWC


+ 12/08/2008C-9

M CO

MCO

12/08/2008PROACTIVE ALLOWANCE DUE BWCPROCESS LETTER

12/08/2008DECLARATION LETTER BWC

12/08/2008MOTION REQUIRED LETTER BWC




+ 12/02/2008STAFFING WITH MCO




MCO

BWC

MCO

MCO

MCO

RTW LETTER REVIEWCONDUCTED. ,..he C9 fiied 12-08-08 isrequesting the proacti ...NOTES ENTRY 73507

CSS/MSS staffed regarding C9request for addit ...Phoned Lizzy Johnson ofAdvance America for pr ...Phoned the IW this afternoonfor PA Allowance ...PC TO POR/DR.THOMAS/TABITHA-NO LASTNAME GIVE ...RECEIVED C9 X 2 DATED 12-05-08 FROM MARCIA 3. ...

RECEIVED CALL FROM IW SHESTATES SHE IS VERY H...PC TO POR/DR. THOMAS, S/WSUSAN, INFORMED HER...RECEIVED CALL FROM IW,DISCUSSED HER CURRENT T ...Veronica of Careworks phonedthis morning to s ...PC TO IW IN REGARDS TO HERCURRENT STATUS/PROG ...PC TO POR/DR. THOMAS, S/WDEE OWEN AND INFORME ...PC TO BWC/KAREN B INREGARDS TO THE IW'S

https:/,Iwvvw.bvvc.ohio.gov/includes/printfr-i.endiy.asp 7/18/2014

t



+ 12/01/2008N0 CHANGE - CORRECT BWC

+ 11/26/2008FWUP CALL TO LIZZIE BWCJOHNSON/NO SAL CONT

+ 11/26/2008BWC ORDER GRANT LT/TTDC BWC

+ 11/26/200811/26/2008-STAFFING BWCMINUTES

+ 11/26/2008CLINICAL ASSESSMENT MCOREVIE W (CAR

11/26/2008Request For Wage Information BWC

11/26/2008BWC Order - Additional BWCAilow/Wages/Comp

11/25/2008PREVIOUS CLAIMS - NONE BWC

+ 11/25/2008MANUAL REVIEW BWC

+ 11/25/2008SUBROGATION - NO BWC


11/24/2008ISO BWC

+ 11/24/2008RETURN CALL/LOST TIME BWCCONTACT

+ 11/24/2008INITIAL LOST TIME CONTACT BWC





11/24/2008Request For Wage Information BWC11/24/2008SUB. 148 POTENTIAL ICD BWC

UPDATES

11/22/2008CIaim Reassigned Letter BWC

11/22/2008Notice Of injury/Claim Status BWCChanges

11/21/2008SYS REASSIGNED - WITHOUT BWCFOLDER

11/21/2008CLAIM BENEFIT TYPE CHANGE BWC

11/20/20DSASSIGNED CSS UNAVAILABLE BWC11/19/2008NOTE ENTERED BWC11/19/2008BWC ORDER - AA ALLOWANCE BWC

ORDER+ 11/19/2008CONTACT WITH PROVIDER MCO


+ 11/17/2008IW OCCUPATION INFO BWCUPDATED BY INET

+ 11/13/2008FROI INTAKE MCO

httgs://wvvw.bwc.oiiio.gov/includes/pr%ntfriendfly.asp

Page 20 of 21

CLAIM ...UPDATED CASE SPECIALISTPLAN PER ADDTL INFORMA ...IW occupation and manual codewere reviewed an ...Phoned Lizzie Johnson ofAdvance America Cash ...Issuing a BWC Order to grantlost time/payment ...Staffed claim with team on 11-26-08. Goal is ...REVIEW OF CLAIM BASED ON14 DAY REPORT; IW IS ...

The IW has no previous claims.karenb.

Manual #8810 appearsappropriate for IW's occu ...No subrogation issues areidentified at this t ...DIARY 73507NOTES ENTRY...No ISO report ...Sheron S.

The IW phoned this afternoonand left VMM. CS ...Phoned Lizzie Johnson ofAdvance Cash America. ...PC TO IW IN REGARDS TO HERPHYSICIAN, ASKED HE ...PC TO POR/DR. MARCIATHOMAS/EILEEN (FORWORKER ...UPDATED POR TO DR. MARCIATHOMAS @937-458-4220 ...ENTERED INITIAL CASESPECIALIST PLAN, FAXED TO ...

ICD : 920LCTN:SITE:PRMY FLAG: N

REP TO CLAIM POP-UP 76747

OCCUPATION 73734

UPDATED POR TO DR. RICHARDSMITH/DO LISTED ON ...PC TO IW, WHO LEFT AMESSAGE STATING SHE ISHA ..OLDWORK COUNTY: NEWWORK COUNTY: GREENEOVERIFIED EOR RISK# 1244253-0 IN EDA AS REINSTA ...

7/18/2014


11/13/2008FROI INTAKE



+ 11/13/2008FROI TRIAGE




11/13/2008FROI INTAKE+ 11/13/2008CONTACT WITH EMPLOYER


+ 11/13/2008CWOORKER(I^,r^H INJURED





+ 11/13/2008WORKER(ICONTACT INJURED



11/12/2008NEW APP NOTES

11/12/20081W Initial Notification11/12/2008EMP Initial Notification

Page 21 of 21

MCO INJURED WORKER NAME ISNOT LISTED IN EDA

MCO CHECKED MED REP, NODOCUMENTS FOUND

MCO PC TO PRIMED BEAVERCREEK@ 937-426-0106 TO OBT ...

MCO IW IS A 39 YO FEMALE. NOMEDICAL AVAILABLE FOR...

MCO PC TO PRIMED BEAVERCREEK@ 937-426-0106 TO OBT ...

MCO PROVIDER COULD NOTDETERMINE CAUSALITS'

MCO CHECKED MED REP, NODOCUMENTS FOUND

MCO "FROI SPECIALIST REVIEW"

MCO E-MAIL TO EOR/LIZZIEJOHNSON IN REGARDS TO IW,

mco PC TO IW IN REGARDS TO HERINJURY. VM MESSAGE ...

MCO RECEIVED CALL FROM IW, SHESTATES THAT THE PAR ...

MCO POR WILL E DR. CHRISTINEWELLER CAN NOT UPDATE...

mco PC TO DR. CHRISTINE WELLER@ 937-426-0106, S/W...

MCO PC TO IW; INFORMED HERTHAT DR. WELLER DOES NO ...

mco IW'S POR IS NOT BWCCERTIFIED, CAN NOT UPDATE.

MCO RECEIVED CALL FROM IWASKING IF SHE HAS A CLAI ...

mco E-MAIL TO EOR/LIZZIEJOHNSON INFORMING HERTHA ...

mco RECEIVED CALL FROMEOR/LIZZIE . EOR HAD SOMEQ -

BWC DIAGNOSIS RELATED: UBWC

BWC

Enter New Cfaim Number I Application Trackino I Claim Assaanment I C1aim CertificationClaim Documents I Claim Parties' Contact Info I Claim Status

Compensation Benefit Summary I Correspondence Information [ Demographic InformationExam Information I Iniury/Iliness Information I Diagnosis Info I Notes Information

Return to Work Historv

httgas://vaww.bwc_otaio.gov/includes/printfT-ieaaclly.asp 7/18/2014

Supreme Court of Ohio and the Ohio Judicial System...3033 Kettering Blvd. Suite 201 Dayton, Ohio...

Documents

Transcript of Supreme Court of Ohio and the Ohio Judicial System...3033 Kettering Blvd. Suite 201 Dayton, Ohio...