SERVICE-CONNECTED OR OCCUPATIONAL DISABILITY BENEFITS PLAN 1
Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority
5.11.01 – DEFINITIONS
“Attending Physician.” The term “Attending Physician” means:
(A) A medical doctor or doctor of osteopathy licensed under ORS 677.100 to 677.228 by the Board of Medical Examiners for the State of Oregon or a similarly licensed doctor in any country or in any state, territory or possession of the United States, or
(B) For a period of 30 days from the first visit on the initial claim or for 12 visits, whichever first occurs, a doctor or physician licensed by the State Board of Chiropractic Examiners for the State ofOregonor a similarly licensed doctor or physician in any country or in any state, territory, or possession of the United States.
“Claim.” The term “Claim” means a written request to FPDR for a retirement, disability or death benefit and may be filed by an active member, his/her representative or legal beneficiary, or surviving spouse or other legal representative of a deceased member. This term may be used synonymously with the term “application.”
“Compulsory Retirement Age:” The term “Compulsory Retirement Age” means any Member who has reached his or her sixty-fourth (64th) birthday anniversary shall be retired by the Board.
“Director.” The term “Director” where used in these Administrative Rules shall mean the Fund Director and/or Fund Administrator or his or her designee.
"Medically Stationary." The term "Medically Stationary" means that no further material improvement can reasonably be expected from medical treatment or the passage of time.
“Recurrence.” The term “Recurrence” means an Aggravation of a service-connected injury/illness or occupational disability that requires claim re-opening for additional disability benefits and/or medical benefits.
“Specialty Physician.” The term “Specialty Physician” means a licensed physician who qualifies as an Attending Physician who provides evaluation, diagnosis or temporary specialized treatment at the request of the Member’s “Attending Physician” on an approved claim.
5.11.02 – DISABILITY BENEFITS GENERALLY
(A) Payment of Disability Benefits - Disability benefits will be paid to a Member only during such time as the Member is incapacitated from performing his/her required duties on account of injury or sickness that is service connected. Thus the disability benefits being paid to a Member shall cease when the Member is capable of performing the duties required of him or her.
(B) Cessation of Benefits - A disabled Member who is receiving service-connected or occupational disability benefits pursuant to Article 5 of the Plan at the time he or she attains Compulsory Retirement Age shall only be eligible to receive disability benefits up to the date he or she attains Compulsory Retirement Age, at which time the disabled Member shall be entitled to receive only a retirement benefit.
(C) Post Compulsory Retirement Age Benefits – Pursuant to Section 5-115 of Chapter 5 of the City Charter, a member covered under Article 5 of the Plan, who is actively employed and suffers an injury in line of duty or sickness caused by the performance of duty, reaches Compulsory Retirement Age before the expiration of one (1) year from date of such disability, said member shall be paid benefits equal to the member’s full salary from FPDR until the member recovers or for one (1) year from the date of such disability, whichever event first occurs.
5.11.03 – APPLICATION FOR BENEFITS
(A) No disability benefits shall be paid to a Member unless the Member files with the Director a complete and timely application requesting such benefits.
(B) Applications shall be made on forms prescribed by the Director. The Director may require the Member to provide any information that is deemed necessary to carry out his/her duties.
(C) Applications for disability benefits may be made by the Member, or the Member's authorized representative. A representative shall submit to the Director written proof of the representative's authority.
(D) Applications for disability benefits must be submitted to the Director no later than 30 days after the Member is injured or experiences an illness unless the Member establishes that he or she had good cause for failing to do so. Failure to file an application within the time specified bars a Claim for disability benefits.
(E) By making application for disability benefits, each applicant thereby authorizes the Director to request and obtain from any physician, health practitioner, hospital, clinic, pharmacy, employer, employment agency, government agency, institution or any other person or organization, any information within any of their records or knowledge regarding the applicant's health, income and employment which in any way relates to the applicant's Claim of disability.
The applicant thereby also authorizes all such physicians, practitioners, hospitals, clinics, pharmacies, employers, employment agencies, governmental agencies, institutions, persons, and organizations to furnish such medical, health, employment and income information to the Director upon request. The applicant recognizes that the information disclosed may contain information that is protected by federal and state law, and by filing an application for disability benefits, specifically consents to the disclosure of such information. All applications for disability benefits shall contain a form to be signed by the applicant authorizing the release of the foregoing information to the Director or its authorized representatives.
(F) All applications for service-connected disability or occupational disability benefits shall contain a report of the Member's Attending Physician.
(G) Although information comes from many sources, claim assessment is frequently based in part on information provided by the Fire and Police Bureaus. If the bureau designates a process for requesting documents, then the Fund staff will comply with that process. With the exception of attorney-client privileged documents, all information gathered and made part of the claim file will be accessible to the Member, upon the Member’s request. If a bureau deems some records as privileged, it is that bureau’s responsibility to identify what information is privileged and withhold the information.
5.11.04 – CLAIM APPROVAL OR DENIAL
(A) Disability Claim applications fall into one of the following two categories:
(1) Service-Connected Disability Claims – the Director shall determine the existence of a disability and whether the preponderance of the evidence indicates it arises out of the in the course of the Member’s employment with the Bureau of Police or Fire and Rescue.
(2) Occupational Disability Claims – The Director shall presume a Member is eligible for an occupational disability as enumerated in 5-115 of the City Charter unless the Director determines, by a preponderance of the evidence, the occupational disability was not contracted as a result of service as a police officer or fire fighter.
(B) The Director shall provide written notification of Claim approval or Claim denial to the Member or the Member’s representative, and the Member’s attending physician within sixty (60) days of the Director’s receipt of a written application for benefits. This applies to the initial Claim for benefits and subsequent Claims for Recurrence or Aggravation benefits.
(1) Notice of Approval – A Notice of Approval shall be addressed to the Member and include the mailing date of the notice, and the statement that the injury/illness occurring on the particular date has been approved. The notice also shall include information on how the Member can request reimbursement for covered expenses personally paid for by the Member.
(2) Notice of Denial – A Notice of Denial shall be addressed to the Member and include the mailing date of the notice, and be sent via certified mail. The notice also shall include the factual and legal reasons for the denial, and a statement on the Member’s right to appeal the denial to an independent hearings officer for review.
(C) If sufficient information is not available within sixty (60) days of the Director’s receipt of a written application for benefits, FPDR will provide a written notice to the Member on the status of the review. If a Notice of Approval or Notice of Denial issues more than 90 days from the Director’s receipt of a written application for benefits, then the claim will be deemed denied and the Member may file a written request for hearing with the Director.
5.11.05 – AMOUNT OF BENEFITS
During the period the Member continues to be eligible under this section, benefits shall be paid as follows:
(A) First Year - Until such Member recovers or for a period of one (1) year, whichever period is shorter, Member shall be paid benefits equal to but not in excess of his full salary.
(B) After First Year - In the event that said member has not recovered at the end of one (1) year, the member shall receive after said first year and until the member recovers, but for a period of not to exceed three (3) additional years, service-connected disability benefits from the Fund equal to but not in excess of the member's full salary but in no event in excess of the then current salary of a First Class Fire Fighter or First Class Police Officer, as the case may be.
(C) After Fourth Year - If the service-connected disability continues after the end of four (4) years, the member shall be paid benefits from the Fund in an amount equal to sixty percent of the then current salary of a First Class Fire Fighter or First Class Police Officer, as the case may be, until the member recovers or if the member does not recover until the member reaches Compulsory Retirement Age.
(D) An additional percentage allowance for Dependent Minor Children shall be paid from the Fund to a member receiving under this section a sum equal to sixty percent of the then current salary of a First Class Fire Fighter or First Class Police Officer, as the case may be, until said member reaches age sixty-four (64). This allowance shall be based on the member's benefit amount and shall be according to the following percentages:
(1) Twenty-five percent for one Dependent Minor Child;
(2) Fifteen percent for the second Dependent Minor Child; and
(3) Ten percent in total for all other Dependent Minor Children over two (2) in number.
The additional allowance shall be reduced or shall cease when the child or children are no longer Dependent Minor Children.
5.11.06 – RECIPIENTS OF DISABILITY BENEFITS
(A) Certificate of Continued Disability
(1) Any Member receiving disability benefits under the Plan shall file with the Director a physician's certificate of continued disability for each pay period, unless otherwise waived by the Director.
(2) All Members drawing disability benefits shall be examined at least once during each twelve-month period by the Member’s identified Attending Physician or an Attending Physician appointed by the Director, unless otherwise determined by the Director.
(B) Outside Employment Conditions
While a FPDR One Member receives disability benefits under Article 5 of the Plan such Member shall not enter the employ of any person, firm, company or corporation, or be self employed, or follow any other calling or vocation, or be employed in any other business, without having on file in the office of the Director a "Request to Engage in Outside Employment," which has been approved by the Director. The "Request to Engage in Outside Employment" shall contain the following information:
(1) Name and address of Member;
(2) The proposed type of work, employment, business calling or vocation;
(3) Name and address of the place where the proposed employment will be done;
(4) The hours of work and the time that would be required of the disabled Member in such proposed work, employment, business, calling or vocation;
(5) The nature of duties contemplated or involved in such proposed work, employment, business, calling or vocation;
(6) Such other information which the Member feels is pertinent to his request.
Any such "Request to Engage in Outside Employment" must be accompanied by a statement from the Member's treating physician, obtained at the Member's sole expense, to the effect that the proposed type of work, employment, business, calling or vocation and the working conditions relative thereto will not tend to hinder, delay or prevent recovery of the Member from the disability for which he or she is receiving benefits from the Fund and his or her return to duty. The Director may request and the Member shall supply at his or her sole expense any additional information or supporting data which the Director deems appropriate.
Failure of a Member to comply with this rule will be cause for termination or suspension by the Director of the right of the Member to receive benefits from the Fund.
5.11.07 – AUTHORIZED HEALTH CARE PROVIDERS
(A) All Members drawing disability benefits, of whatever nature shall identify an Attending Physician, as defined by these Administrative Rules and who will be responsible for directing the Member’s medical care.
(B) Disability authorization is limited to the Member’s Attending or Specialty Physician as defined in and under the conditions prescribed for under “Attending Physician” and “Specialty Physician” in Section 5.11.01 of this Administrative Rule. Authorization from an inpatient or outpatient hospital physician (emergency room physician or hospitalist) will be considered on a case-by-case basis.
5.11.08 – INDEPENDENT MEDICAL EXAMINATIONS
(A) If requested by the Director, any Member eligible to receive benefits under this program is required to undergo a medical examination by one or more licensed physicians or psychologists. Should the Member fail to submit to the examination, or obstructs the same, the Member’s rights to benefits may be suspended or reduced by the Director until the exam has taken place.
(B) FPDR will mail a written notice to the Member by certified and regular mail at least 14 calendar days prior to the IME appointment date. If the Member has an attorney, the Member’s attorney shall be simultaneously notified in writing of a scheduled medical examination under these Administrative Rules.
FPDR may provide fewer than 14 days notice if the Member agrees. The Member’s notification of the medical examination shall include the following information:
(1) The name of the examiner or facility;
(2) A statement of the specific purpose for the examination and, identification of the medical specialties of the examiners;
(3) The date, time and place of the examination; and
(4) The first and last name of the Member’s attending physician and verification that the Member’s attending physician was informed of the examination.
(C) When necessary, the following expenses associated with the Member’s attending the medical examination will be considered by the Director:
(1) Reimbursement of reasonable cost of public transportation or use of a private vehicle; and
(2) Reimbursement of reasonable cost of child care, meals, lodging and other related services.
(D) Requests for reimbursement must be accompanied by a sales slip, receipt or other evidence necessary to support the request. Should an advance of these costs be necessary for attendance, a request for advancement must be made in sufficient time to ensure a timely review and consideration prior to the date of the examination. Mileage reimbursement will be based on City of Portland rates in effect at the time of incurred expense.
5.11.09 – PROOF OF RESIDENCY
Pursuant to Resolution No. 422, October 23, 2007, the Board of Trustees has waived the State of Oregon residency requirement that is defined in Section 5-126 (10) of Article 5 of the Plan.
5.11.10 – RECOVERY OF OVERPAYMENTS
The Director shall recover overpayments of disability benefits paid to the Member. Recovery may be made by offsetting an amount of any future payment until the overpayment is recovered in full.
Adopted November 12, 1991.
Effective February 1, 1992.
Revision filed in PPD December 28, 2005.
As Amended by: Resolution No. 287 on August 8, 1995, Resolution No. 288 on September 12, 1995, Resolution No. 298 on October 14, 1997, Resolution No. 320 on December 14, 1999, Resolution No. 323 on April 11, 2000, Resolution No.332 on April 17, 2001, Resolution No. 335 on August 14, 2001, Resolution No. 338 on December 11, 2001, Resolution No. 340 on January 15, 2002, Resolution No. 345 on April 9, 2002, Resolution No. 349 on August 13, 2002, Resolution No. 350 on August 13, 2002, Resolution No. 351 on September 10, 2002, Resolution No. 352 on October 8, 2002, Resolution No. 365 on August 12, 2003, Resolution No. 372 on February 10, 2004, Resolution No. 381 on August 10, 2004, Resolution Nos. 388, 389 and 390 on June 14, 2005, Resolution No. 392 on November 8, 2005, Resolution No. 393 on December 13, 2005, Resolution No. 405 on May 9, 2006, Resolution No. 419 on March 13, 2007, Resolution No. 423 on November 27, 2007, Resolution No. 440 on May 26, 2009, and Resolution No. 455 on June 28, 2011.