Basic Claims Examiner (CE) Training Course...•“P1” thru “P6” = parent •“D1” thru DZ” = grandchild ... certificate does not establish a relationship between the cause

Basic Claims Examiner (CE) Training Course

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PARTICIPANT GUIDE

Survivorship Session

Participant Guide Page i

Table of Contents Session Description ........................................................................................................ 1

Instructional Objectives ................................................................................................... 1

Introduction ..................................................................................................................... 2

Awards ............................................................................................................................ 4

Maximum Compensation Award under EEOICPA ..................................................... 5

Apportionment of Awards .......................................................................................... 7

Survivorship Criteria ........................................................................................................ 8

General ..................................................................................................................... 8

Under Part B ............................................................................................................. 9 Eligible Survivor Claim Types under Part B ....................................................... 11 Order of Precedence under Part B .................................................................... 12

Under Part E ........................................................................................................... 14 Eligible Survivor Claim Types under Part E ....................................................... 17 Order of Precedence under Part E .................................................................... 18 Other Remedies under Part E ........................................................................... 20

Development ................................................................................................................. 22

Development Letter ................................................................................................. 23

Survivorship Proof ................................................................................................... 24 Spouse .............................................................................................................. 24 Children ............................................................................................................. 25

Establishing Full-Time Student Status under Part E ................................................ 26

Establishing Incapability of Self-Support under Part E ............................................. 27

Recommended Decisions (RD) ..................................................................................... 28

Alternative to Filing a Survivor Claim under Part E ........................................................ 29

Development of Alternative Filing ............................................................................ 30

Conclusion .................................................................................................................... 33

Case Study 1 ................................................................................................................ 36

Case Study 1 Questions ............................................................................................... 36

Error! Objects cannot be created from editing field codes. ............................................ 36

Case Study 2 ................................................................................................................ 43

Evaluation Form ............................................................................................................ 55


Participant Guide Page 1

Session Description The session addresses the survivorship benefits and eligibility criteria under Part B and Part E as well as the procedures for reviewing and developing survivorship under the Act.

Instructional Objectives Upon completion of this session, you will be able to:

• List eligible Part B survivors and their order of precedence • List eligible Part E survivors and their order of precedence • Identify types of proof used to verify covered employee-survivor relationship • Identify survivorship development letter requirements • List relevant ECMS coding for survivorship



Introduction

Introduction

If an eligible employee is deceased, one or more of his or her eligible survivors may be entitled to benefits under the Act.

2

Your Notes



What We Will Cover

Part B vs. Part E - Similarities and differences in the benefits and eligibility criteria for survivorship

Procedures to review and develop survivor claims under the Act

3

Your Notes



Awards

Awards

A Part B award entitles the eligible survivor to $150,000 in lump sum compensation

A Part E award typically entitles the eligible survivor to $125,000 in lump sum compensation, plus wage loss, if applicable: • $25,000 for lost wages between 10 and 19 years

• $50,000 for lost wages 20 years or more

4 NOTE: An exception applies if the employee’s cause of death is NOT related to exposures during covered employment.



Maximum Compensation Award under EEOICPA

Maximum Compensation Award under EEOICPA

Maximum compensation is based on covered employee, NOT illness, and does not include medical benefits:• Part B is $150,000

• Part E is $250,000

Maximum aggregate compensation per covered employee (excluding medical) under the Act is $400,000

5 The CE does NOT develop for other claimed conditions in a survivor claim once the cap is reached UNLESS there are outstanding medical expenses.

For example, the survivor lists 8 conditions on the Part D form – one is determined to be covered immediately (asbestosis). The death was related to this illness and the employee died 20 years before normal retirement age.

The CE issues the RD to accept the asbestosis and does not develop for the other conditions because the cap has been reached.



Your Notes



Apportionment of Awards

Apportionment of Awards

In multiple survivor claims, if one eligible survivor does not file a claim, their portion of compensation may notbe distributed among the other remaining eligible survivors.

6 For example, the covered employee and spouse are deceased. Two (2) eligible children file survivor claims and a third child cannot be located. Each of the two claimants receives 1/3 of the award. The remaining portion is retained until the remaining child files a claim and their eligibility is established. If it is determined they are not eligible, the remaining funds are redistributed between the eligible claimants.

Your Notes



Survivorship Criteria

General

General Survivorship Criteria Survivor must file a claim

• Survivor has a choice to only claim for those illnesses in which a payment has not been received from a tort suit or state workers’ compensation claim

Employee’s death must be established by death certificate

Proof of relationship between the employee and the claimant, under the statutory criteria, must be provided

7

Your Notes



Under Part B

Survivorship Criteria under Part B

Part B covered employment includes • DOE federal, contractor, or subcontractor employees; or,

• Employees of an AWE; or

• Employees of a Beryllium Vendor; or

• Employees of a Section 5 RECA facility

8 The cause of death does NOT need to be related to the accepted condition.

Your Notes



Survivorship Criteria under Part B, continued

Cause of death does NOT need to be related to accepted condition

Eligible survivors - covered spouse, children, parents, grandparents, grandchildren, at time of payment

9

Eligible Survivors Defined under Part B Covered Spouse – the wife or husband of the employee who

was married to the employee at least one year immediately prior to the employee’s death (If a claimant is determined to be a common law spouse, he or she is considered a covered spouse. We will discuss this later.)

Child – natural child, stepchild, or adopted child who lived with the deceased employee in a regular parent-child relationship

Parent Grandchild Grandparent

10 The relationship must have been in existence at the time of payment.



Your Notes

Eligible Survivor Claim Types under Part B

Eligible Survivor Claim Types under Part B

Claim types in ECMS• “EM” = employee

• “WI” = spouse

• “C1” thru “C9” & “CA” thru “CZ” = child

• “P1” thru “P6” = parent

• “D1” thru DZ” = grandchild

• “G1” thru G4” = grandparent

11 There are also codes for siblings, former spouses, and other claimants.



Your Notes

Order of Precedence under Part B

If there is a covered spouse, the compensation shall be paid to the spouse.

If there is no covered spouse, the compensation shall be paid in equal shares to all surviving children of the deceased covered employee. In claims involving divorce between the natural parent and the stepparent, the dissolution of the marriage will not terminate the parent-child relationship for eligibility purposes and there will be no minimum time requirement for a stepchild to have lived in the same household as the covered employee.

Order of Precedence under Part B

If there is a covered spouse, the compensation shall be paid to the spouse

If there is no covered spouse, the compensation shall be paid in equal shares to all surviving children* of the deceased covered employee* Surviving children include natural children, stepchildren,

or adopted children of the employee

12

Your Notes



Order of Precedence under Part B, continued If there is no surviving spouse or children, the

compensation shall be paid in equal shares to the parents of the deceased covered employee.

If there is no surviving spouse, children, or parents, the compensation shall be paid in equal shares to the grandchildren of the deceased covered employee.

If there is no surviving spouse or children, parents, or grandchildren, the compensation shall be paid in equal shares to the grandparents of the deceased covered employee.

13

Order of Precedence under Part B, continuedNon-spousal child - Notwithstanding the above:

• If there is a covered spouse and at least one child of the deceased covered Part B employee

o Who is a minor at the time of payment and who is not a recognized natural child or adopted child of the covered spouse

• Half of the compensation shall be paid to the spouse, and the other half of the compensation shall be paid in equal shares to each child of the deceased covered Part B employee who is not a child of the spouse and who is a minor at the time of payment

14



Your Notes

Under Part E

Survivorship Criteria under Part E

Part E covered employment includes • Only contractor/subcontractor (NOT federal) employment

at DOE facility; or

• Section 5 RECA facility; or,

• Any AWE/BE facility during a period of DOE remediation (employee must have worked in remediation activities)

15

Your Notes



The cause of death MUST be related to the accepted condition. If the employee’s death certificate does not establish a relationship between the cause of death and the previously accepted condition, in order for benefits to be payable, it must be established that exposure to a toxic substance during covered employment was a significant factor in causing or contributing to the employee’s death.

Survivorship Criteria under Part E, continued

Cause of death MUST be related to accepted condition

Eligible survivors include covered spouse, covered children at the time of the employee’s death

16

Your Notes



Eligible survivors include the:

Eligible Survivors Defined under Part E Spouse – the wife or husband of the employee who was married to

the employee at least one year immediately prior to the employee’s death (If a claimant is determined to be a common law spouse, he or she is considered a covered spouse)

Covered Child – natural child, stepchild, or adopted child who lived with the deceased employee in a regular parent-child relationship who at the time of the employee’s death• Was under the age of 18 years; or• Under the age of 23 years and continuously enrolled as a full time

student; or• Any age and medically incapable of self support

17

Your Notes



Eligible Survivor Claim Types under Part E

Eligible Survivor Claim Types under Part E

Claim types in ECMS

• “EM” = employee

• “WI” = spouse

• “C1” thru “C9” & “CA” thru “CZ” = child

18

Your Notes



Order of Precedence under Part E

Order of Precedence under Part E If there is a covered spouse, the compensation shall

be paid to the spouse

If there is no covered spouse, the compensation shall be paid in equal shares to all covered children of the deceased covered employee

19

Your Notes



Order of Precedence under Part E, continuedNon-spousal child – Notwithstanding the above:

• If there is a covered spouse and at least one covered child of the deceased covered Part E employee

o Who is not a recognized natural child or adopted child of the covered spouse

• Half of the compensation shall be paid to the spouse, and the other half of the compensation shall be paid in equal shares to each “covered” child of the deceased covered Part E employee who is not a child of the spouse and who is living at the time of payment

20

Your Notes



Other Remedies under Part E

Other Remedies under Part E Election of benefits can apply - when an employee

has previously filed a claim, and his/her death is NOT the result of a covered illness, eligible survivor may elect to receive what employee would have received

Ineligible survivors are entitled to alternative filing

21 Emphasis is on the fact that the employee must have filed first! Benefits can include wage loss and impairment.

Your Notes



Your Notes



Development The claimant must file an EE-2 or have previously filed under Part D of the Act.

If other survivors are identified on the claim form, the CE must send a development letter to invite claims from the other potential survivors. The development letter advises that the claimant was identified as a potential survivor, invites them to submit a claim, and describes the criteria for coverage. The letter specifically indicates that the filing of a claim does not establish entitlement to benefits.

If a claim form is not submitted by a potential survivor, assume no filing.

If the survivor claim does not contain the appropriate documentation, the CE must request the requisite documentation in the form of a development letter.

Development Claimant must file an EE-2 or have previously filed

under Part D of the Act• If other survivors identified on claim form, send

development letter to invite claims from other potential survivors

• If not submitted, assume no filing

If the survivor claim does not contain the appropriate documentation, CE must request in the form of a development letter

22



Development Letter

Development Letter

The letter should be simple, clear and claimant friendly

Code ECMS:• “DO” (developing other) with no reason code• Date of letter and status effective date must be the same!

23

Your Notes



Survivorship Proof

Spouse

Survivorship Proof - Spouse Marriage certificate (marriage license is NOT

sufficient) and death certificate to establish at least one year of marriage.

Evidence of common law marriage (only recognized in certain states), requires proof of general reputation of marriage in the community, continuous cohabitation as husband and wife, and being so treated and reputed in the community as husband and wife – see unified PM Chapter 2-1200(5)(b)(2)

24 Divorce decrees may be necessary to establish name changes.

Your Notes



Children

Survivorship Proof – Children Part B – birth/adoption certificates are generally

sufficient, but other records include school records or transcripts, affidavits, obituaries, tax records, photographs, death certificate of employee & spouse

Part E – same as evidence under B, but must further establish eligibility as a “covered” child under the statutory criteria

25 Birth certificates must reflect the parents’ names.

Your Notes



Establishing Full-Time Student Status under Part E

Establishing Full-Time Student Status under Part E School records/transcripts The full time course of study or training at an accredited

institution is approx. 4 years of education beyond high school level or until the student reached 23, whichever comes first.

Should be continuous schooling since reaching age of 18, However;• 4 months (i.e. summer break) is reasonable• CE’s discretion if student was prevented by reasons beyond his/her

control from continuing in school during a longer period.

26

Your Notes



Establishing Incapability of Self-Support under Part E

Establishing Incapability of Self-Support under Part E Child must have been physically or mentally incapable -

unable to obtain and retain a job, or engage in self-employment based upon medical evidence documenting:• Physical/mental condition and its effects on his/her activities• At the time of the employee’s death

Evidence includes social security and/or state disability records, tax returns, and affidavits documenting medical incapability of self support• Weigh all evidence in totality

27

Your Notes



Recommended Decisions (RD)

Recommended Decisions

RD must address all survivors whether eligible or not

Separate cover letters for each survivor (compliance with Privacy Act)

28

Your Notes



Alternative to Filing a Survivor Claim under Part E

Alternative to Filing a Survivor Claim under Part E

An ineligible survivor (e.g. adult child) of a covered employee may submit a written request to the District Office for an informal determination of whether deceased employee contracted a covered illness

Request is not considered a survivor’s claim for Part E benefits

Code ECMS “XR” (Alternative Filing Review Requested)

29 Under this circumstance, there is no need for the claimant to file Form EE-2.

Your Notes



Development of Alternative Filing FAB inserts a paragraph into the denial cover letter, advising of this provision. An alternative filing review provides survivors with an assessment of a facility where the alleged employment and exposure took place and a determination as to potential causation.

If the claimant writes in and requests an alternative filing, the CE reviews the claimed employment, exposure and medical condition. No RD is issued. Instead, the CE issues a hypothetical determination, one that is NOT based on actual employment or medical development for this particular individual. It is based on where he claimed employment and the claimed medical condition.

Basically, the CE is saying that IF the employee worked in this facility during this time period, and IF the employee had the condition, here is the likelihood that the employment was related to the condition.

Such a determination does not change the survivor’s eligibility for benefits or establish causation under the EEOICPA, and it is not subject to further agency or judicial review.

Development of Alternative Filing FAB inserts paragraph into denial cover letter,

advising of this provision

If claimant writes in and requests this:• CE reviews claimed employment, exposure and medical

condition

• No RD is issued

• Determination letter sent to survivor

30

Your Notes



Development of Alternative Filing, continuedDetermination Letter

• Based on general knowledge of facility, condition and exposure (CE to use exposure matrices and other resources)

• Development for medical and employment not complete and Office NOT stating employee is a “covered” employee under Act

• Code ECMS “XC” (Alternative Filing Review Completed) o With drop-down reason code: P = Positive or N = Negative

31 Essentially, an alternative filing results in no entitlement to benefits under Part E, but may bring closure for the survivor(s).

Your Notes



Alternative Filing

Is an assessment of potential employment and exposures

Provides closure for the survivor(s) Does not establish causation nor does it change

survivorship eligibility (in other words it does not confer any entitlement to benefits under Part E of the Act)

Is not subject to judicial review

32

Your Notes



Conclusion

Conclusion

Survivorship entitlement and eligibility criteria differs depending on which Part of the Act is being adjudicated

33

Questions?

34



Your Notes



Your Notes



Case Study 1

2

Case Study 1: Scenario

Surviving Spouse Linda H. submits an EEOICPA claim. She provides the employee’s death certificate and a marriage certificate/license (see documents that follow).

Case Study 1 Questions

3

Case Study 1 - Questions

Review these documents and state whether this evidence is sufficient to establish survivorship. Why or why not?





Marriage License Valid only in the

COMMONWEALTH OF KENTUCKY To any Person Licensed to Celebrate Marriages: You are hereby authorized to join together in the Holy State of Matrimony, according to the rites and ceremonies of your Church, or religious denomination, and the laws of the commonwealth

k

Dat

y I sw



This is to CertifyThat on the 24th day of December

were by me united in

at Anytown according to the ordinance of

God and the Laws of the State of Kentucky




5

Case Study 1 – Questions (Continued)1. Are a marriage license and a death certificate sufficient

evidence to establish survivorship eligibility? Why or why not?

2. Are marriage and death certificates typically sufficient to establish survivorship eligibility for a spouse?

3. State whether the claimant has properly established her survivorship eligibility or identify what evidence is still necessary to establish it in this case.

Your Answers 1. Are a marriage license and a death certificate sufficient evidence to

establish survivorship eligibility? Why or why not?



Your Answers 2. Are marriage and death certificates typically sufficient to establish

survivorship eligibility for a spouse?

3. State whether the claimant has properly established her survivorship eligibility or identify what evidence is still necessary to establish it in this case.



Your Answers

Case Study 1 - Answers

6

Case Study 1 – Answers1. Are a marriage license and a death certificate sufficient

evidence to establish survivorship eligibility? Why or why not?No a marriage license does not establish that the marriage actually took place.

2. Are marriage and death certificates typically sufficient to establish survivorship eligibility for a spouse?Yes, these two documents are typically sufficient to establish the surviving spouse’s eligibility. However, it was not sufficient in this case because the names on the marriage certificate did not match the spouse’s maiden name.



7

3. State whether the claimant has properly established her survivorship eligibility or identify what evidence is still necessary to establish it in this case.Ultimately, the claimant must establish all name changes and her current identity. Had she not provided the license that showed her maiden name as reported on the death certificate, she would have needed to provide her birth certificate. Additionally, you still need evidence to establisheither her divorce from her previous husband or evidence that she was widowed from that marriage (because a death certificate is information reported but not verified).

Case Study 2

7

Case Study 2: Scenario

Two brothers file claims as the surviving children of the employee, . Review the documents that follow. Is this evidence enough to proceed with the claim?



Child 1’s Birth Certificate (Harold J. H.)



Child 2’s Birth Certificate (James C.H.)



Employee’s Death Certificate (Harold James H)



Employee’s Spouse’s Death Certificate (Linda Marie H)



Case Study - Questions

8


1. What evidence is typically needed to establish a surviving child’s eligibility under Part B?

2. What evidence can be used to help establish the universe of eligible survivors?

3. Under Part B, must these survivors be under the age of 18 at the time of payment? Under what circumstances would they have to be under the age of 18?

Your Answers 1. What evidence is typically needed to establish a surviving child’s

eligibility under Part B?



Your Answers

2. What evidence can be used to help establish the universe of eligible survivors?

3. Under Part B, must these survivors be under the age of 18 at the time of payment? Under what circumstances would they have to be under the age of 18?



Case Study 2 – More Questions

9


4. What criteria must these survivors meet in order to be eligible under Part B of the Act?

5. What significant information does the second birth certificate tell us?

6. What will the brothers need to produce in order for the claim toproceed?

7. Once we have established within a reasonable degree of certainty that we know how many potential eligible survivors are, do we need tohold up the claims of those who have submitted sufficient evidence to proceed with the claim, pending receipt of evidence from those claimants who have not?

Your Answers 4. What criteria must these survivors meet in order to be eligible under

Part B of the Act?



Your Answers 5. What significant information does the second birth certificate tell us?

6. What will the brothers need to produce in order for the claim to proceed?

7. Once we have established within a reasonable degree of certainty that we know how many potential eligible survivors are, do we need to hold up the claims of those who have submitted sufficient evidence to proceed with the claim, pending receipt of evidence from those claimants who have not?

Case Study 2 – Answers



10

Case Study 2 - Answers1. What evidence is typically needed to establish a surviving child’s

eligibility under Part B?The child must produce a birth certificate or other evidence that establishes the parent-child relationship between the child and the employee, plus the death certificate of the employee. Further, if the employee was not widowed or divorced (based on information in the death certificate), the child must produce the death certificate of the employee’s spouse.

2. What evidence can be used to help establish the universe of eligible survivors?An obituary.

Your Answers

Case Study 2 – More Answers



11

Case Study 2 - Answers

3. Under Part B, must these survivors be under the age of 18 at the time of payment? Under what circumstances would they have to be under the age of 18?No, because they are children of the employee and his deceased spouse. If there was a surviving spouse who was not their mother (either through birth of adoption), then they would have to be under the age of 18 to be eligible.

4. What criteria must these survivors meet in order to be eligible under Part B of the Act?In addition to providing a birth certificate (and in the case of female survivors, any applicable marriage certificates/divorce decrees/other documents to establish name changes and current identity), the evidence must establish that:• The child was under the age of 18; or• Under the age of 23 years and continuously enrolled as a full time student; or • Any age and medically incapable of self support

Your Answers

Case Study 2 – More Answers



12

Case Study 2 - Answers5. What significant information does the second birth certificate tell us?

There are other potential survivors!

6. What will the brothers need to produce in order for the claim toproceed?Birth and death certificates of the other siblings.

7. Once we have established within a reasonable degree of certainty that we know how many potential eligible survivors are, do we need tohold up the claims of those who have submitted sufficient evidence to proceed with the claim, pending receipt of evidence from those claimants who have not?No but we must set aside the remainder of the lump sum for the other potential survivors.



Evaluation Form

We value your opinion. Please rate the following: Poor Fair Good Excellent Organization of subject matter Explanation of key concepts Presenter’s knowledge of subject Presentation was clear and understandable

Appropriate pace for training Relevance of training material Correct level of detail Exercise content was appropriate Examples were clear and helpful Which topics were most beneficial to you? Which topics were least beneficial to you?



Other comments or suggestions for improvement: Name (optional): ________________________________Date: ____________________

Documents

Basic Claims Examiner (CE) Training Course...•“P1” thru “P6” = parent •“D1” thru DZ” = grandchild ... certificate does not establish a relationship between the cause