The following procedures are hereby established for the appeal
of any denial or termination of disability benefits by the retirement board
following an independent medical examination by the state teachers retirement
system.
(A) At least seven days before
a recommendation is presented to the retirement board, written notification
shall be issued to the applicant or recipient. This notice shall include the
recommendation to be presented to the retirement board.
(1) No further medical evidence shall be
considered once written notification has been issued to an applicant or
recipient pursuant to paragraph (A) of this rule.
(2) Should the retirement system receive
further medical evidence after written notification has been issued to an
applicant or recipient pursuant to paragraph (A) of this rule, the medical
evidence shall be held and included as part of the appeal documentation if a
right to appeal is exercised as set forth in paragraph (B)(2) of this rule.
Should a right to an appeal not be exercised as set forth in paragraph (B)(2)
of this rule, the medical evidence will be returned to the person who submitted
the information.
(B)
Following retirement board action terminating or denying disability benefits:
(1) The applicant or recipient will be
informed in writing of the action taken by the retirement board. Notification
shall include:
(a) A statement that medical
evaluation and retirement board action was conducted in accordance with section
3307.48
or
3307.62
of the Revised Code.
(b)
Confirmation that the applicant or recipient has the right to appeal the
retirement board action.
(c) A
statement explaining that written notice of appeal must be
received
by the retirement system no later than fifteen calendar days from receipt
of notification of denial or termination.
(d) An explanation of future rights and
limitations upon the rights to again apply for disability benefits if an appeal
is not pursued.
(2)
Procedure for exercising right to appeal:
(a)
The notice of appeal must be in writing and signed by
either the applicant or recipient or the
applicant's or recipient's counsel or attending physician.
The notice of appeal must include a statement that
the appeal
will be based on additional medical evidence contrary to the findings of the
independent medical examinersand must be received by the retirement system
within fifteen calendar days of receipt of notification of retirement board
action.
(b) If an applicant or
recipient does not appeal the action of the retirement board, a person acting
on the member's behalf or the member's employer may exercise the right to
appeal in the same manner and subject to the same procedures and requirements
as specified for an applicant or recipient.
(3) Following the retirement system's timely
receipt of written notice of appeal from an applicant or recipient, the
retirement system shall provide the applicant or recipient with the following
information confirming the appeal:
(a)
Confirmation that the applicant or recipient, counsel for the applicant or the
recipient, and/or person acting on the member's behalf, member's employer, or
attending physician may present additional medical evidence orally at an appeal
hearing that will be scheduled by the retirement system or that additional
medical evidence as defined in this rule may be presented in writing. Such
additional medical evidence shall not have been previously considered by the
independent medical examiner or the medical review board. Additional medical
evidence presented in writing must be received by the retirement system on or
before the deadline date provided by the retirement system, which shall be at
least twelve business days before the date of the scheduled appeal hearing.
(i) "Additional medical evidence" means
medical evidence completed up to twelve months
preceding the written notice of appeal that has not been previously submitted
to the retirement system. Additional medical evidence outside the twelve months
preceding the written notice of appeal may be submitted only if the chair of
the medical review board has determined in his or her sole discretion that such
additional medical evidence pertains to the diagnosis of the applicant's or
recipient's claimed disabling condition. In addition:
(a) For an appeal following a denial of
disability benefits, additional medical evidence must be related to the
conditions presented and supported as part of the initial
application.
(b) For an appeal
following a termination of disability benefits, additional medical evidence
must be related to the recipient's current medical status.
(ii) The chair of the medical review board
may request additional medical evidence from the applicant or
recipient.
(iii) The chair of the
medical review board shall review all information received on appeal. If
information is determined not to be additional medical evidence as defined by
this rule, the information will not be considered.
(b) Notice that the applicant or recipient
may appear at the appeal hearing in person, be represented by counsel and/or an
attending physician, or may choose to not appear in person but have the case
reviewed by the retirement board or its designee(s).
(c) Notice that if a personal appearance at
the appeal hearing is requested by the deadline date provided by the retirement
system, the applicant or recipient shall inform the retirement board of the
name, title, and position of each person appearing on his/her behalf.
If a personal appearance is requested and scheduled, the
applicant or recipient shall appear at the appeal hearing on the date and at
the time specified by the retirement system. If the applicant or recipient
fails to appear on the specified date and time for any reason, all rights to a
personal appearance at an appeal shall terminate and the appeal shall be
decided on the basis of written evidence previously submitted.
(d) Notice that the applicant or
recipient may request one delay of the deadline date provided by the
retirement system, as set forth in paragraph (B)(4) of this rule.
(e) An explanation of the procedures and
limitations applicable to the appeal hearing, as set forth in paragraph (B) of
this rule.
(f) A statement
explaining that any costs incurred by the applicant or recipient in the appeal
process will not be reimbursed by the retirement system.
(4)
(a)
An applicant or recipient may request in writing one
delay of the deadline date provided by the retirement system as outlined in
this rule, provided that the request for a delay is received on or before the
deadline date provided by the retirement system.
(b)
One forty-five calendar day delay may be requested for any reason. A new
deadline date will be provided by the retirement system to the applicant or
recipient that is forty-five calendar days from the original deadline date
provided by the retirement system.
(5) Scope and procedure upon appeal:
(a) An appeal hearing will be scheduled and
conducted by the retirement board or its designee(s).
(b) The chairman of the retirement board or
the designee(s) shall be responsible for conducting the appeal hearing and the
executive director, deputy executive director -- member benefits, or the
designee(s) and the chair or designated member of the medical review board may
be in attendance to act as advisor.
(c) The purpose of the appeal hearing shall
be for the applicant or recipient to present information to the retirement
board or its designees(s) based on additional medical evidence not previously
considered by the independent medical examiner or the medical review board.
Additional medical evidence to be presented at the hearing must be provided to
the system by the deadline in paragraph (B)(3)(a) of this rule and should
substantiate the applicant's or recipient's claim that the eligibility
requirements of section
3307.48
or
3307.62
of the Revised Code have been met and that the applicant or recipient is
medically incapacitated from the performance of duty by a previously reported
mental or physical condition that is permanent or presumed to be
permanent.
(d) Additional medical
evidence or other written information may not be submitted at the
hearing.
(e) Upon consideration of
the record on appeal and the information, positions, contentions and arguments
of the applicant or recipient, the retirement board or its designee may request
additional medical evidence or direct further examination or testing by
independent medical examiners and may return a record for review and
recommendation by the medical review board.
(f) When the retirement board is satisfied
that the record before it is complete and has completed its deliberations, it
may affirm, disaffirm or modify its prior action by a majority vote. Written
notice of such action shall be given to the applicant or recipient.
(g) A stenographic record of the appeal
hearing will be made only upon request of the applicant or recipient and any
and all costs shall be at the applicant's or recipient's expense. Such request
must be made in
writing and received by the retirement system on or before the deadline date
provided by the retirement system as listed in paragraph (B)(3)(a) of this
rule.
(h) All communications
or notifications during the appeal process shall be sent to the applicant or
recipient by certified or priority mail, with copies by regular mail to counsel
if the applicant or recipient has notified the retirement system of
representation by counsel and signed an appropriate authorization for release
of information.
(C) Any subsequent applications for
disability benefits received by the retirement system after a denial or
termination of benefits shall be submitted with additional medical evidence not
previously submitted in connection with prior applications for disability
benefits, supporting progression of the former disabling condition or evidence
of a new disabling condition. If such evidence is evaluated by the medical
review board chair and found to be inadequate to establish the progression of
the disabling condition or the existence of a new disabling condition, the
application shall be voided and a notice will be sent to the applicant. The
decision of the medical review board chair shall be final. If two years have
elapsed since the date the member's contributing service terminated, no
subsequent application shall be accepted except if the member did not earn
service credit before July 1, 2013, the application must be made within a
one-year period from the date contributing service terminated.