Offset disability insurance benefits (DIB) based on monthly WC/PDB amounts received by the NH, minus any excludable expenses. WC/PDB amounts paid on other than a monthly basis, including a lump sum (LS), also cause offset.

Some States pay additional amounts to the NH’s dependents.

To compute offset, exclude benefits paid directly to the dependent rather than the NH; but include payments made to the NH.

Mandatory or voluntary automatic payroll-type WC/PDB benefit deductions are offsettable. These include, but are not limited to:

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  Life insurance premiums,

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  Health benefit premiums,

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  Federal Insurance Contribution Act (FICA) taxes, or

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  Garnishment (e.g., for unpaid taxes or child or spousal support).

When imposing offset, use the WC rate(s) and period(s) determined by the payer to be correct and payable, i.e., the rate that should have been paid rather than the rate actually paid. This difference in rates can occur, for example, when the WC carrier overpaid the beneficiary and subsequently reduced the WC rate to recover the overpayment. Whether the carrier recovers the excess amount paid is irrelevant to the offset computation. We impose offset based on the established WC rate that should have been paid.

EXAMPLE 1:

For the 10-week period (05/01/2004 through 07/09/2004), NH received $400.00 per week in temporary total WC.

Effective 07/10/2004, NH began to receive $300.00 per week in temporary partial WC.

In 12/2006, a hearing is held and it is determined that NH’s disability did not meet the requirements for temporary total WC. The $300 payments should have started 05/01/2004 instead of 07/10/2004. This results in a $1,000 overpayment.

The WC proof indicates the WC carrier agreed to withhold $10 per week until the overpayment recovery is completed – resulting in 100 weekly payments of $290 until the overpayment is recovered. (The WC overpayment issue is between the carrier and the beneficiary.)

Therefore, code the ICF with a continuing WC rate of $300 per week for the period 05/01/2004 and continuing.

EXAMPLE 2:

NH received a letter from the insurer converting NH’s TT benefits to PP benefits (at a lower rate). The letter informed the NH that they were paid TT benefits from 04/28/2006 to 04/13/2008 and determined to be “Permanent & Stationary” beginning 02/05/2008. The letter stated the insurer was asserting credit for the TT overpayment for 02/05/2008 to 04/13/2008 against permanent disability.

Code the ICF WC/PDB with the TT rate for 04/28/2006 through 02/04/2008 and the PP rate for 02/05/2008 and continuing.

Use caution when interpreting legal documents. The payment may appear to be a LS, as defined in DI 52150.060, but may actually be a single payment that represents accumulated or past-due periodic payments. If a check represents past-due periodic WC/PDB payments that simply bring payments up to date, it is not a LS. For example:

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  The parties agree that the claimant’s disability began on 03/19/2002, and that, upon approval of this agreement for settlement, the Employer and Carrier will make a payment to the Claimant in the sum of $83,235.32, which the parties agree is in full satisfaction of all accrued and unpaid weekly benefits through 06/30/2007.

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  Respondent shall pay claimant compensation at the rate of $212.12 per week from 08/01/2007 and continuing until further order of this court. Fifteen and one-half (15.5) weeks have accrued and shall be paid in a lump sum of $3,287.86.

Use the following chart to compute a weekly rate and round to the nearest penny.

Use the following chart to compute a monthly rate and round to the next lower dime.