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Fire & Police Disability, Retirement & Death Benefit Plan Administrative Rules - Table of Contents

FIRE & POLICE DISABILITY, RETIREMENT & DEATH BENEFIT PLAN ADMINISTRATIVE RULES - TABLE OF CONTENTS - JANUARY 2015

 

 

FPD-5.01

PROCEDURAL RULES GOVERNING RULEMAKING

 

5.1.01             Authority

5.1.02             Purpose

5.1.03             Duties of Fund Director

5.1.04             Rulemaking Notices and Procedures

5.1.05             Adoption of Rules

 

FPD-5.02

BOARD PROCEDURES

 

5.2.01             Regular and Special Meetings

5.2.02             Agenda

5.2.03             Conduct of Meetings

5.2.04             Board Members

5.2.05             Powers of the Board

5.2.06             Duties of the Board

5.2.07             Travel Policy

5.2.08             Board Communications with FPDR Administration

 

FPD-5.03 

GENERAL ADMINISTRATION

 

5.3.01             Definitions

5.3.02             Member Absences

5.3.03             Member Home Address Notification

5.3.04             Outside Employment

5.3.05             Legal Opinions

5.3.06             Vital Statistic Records

5.3.07             Domestic Relations Orders

5.3.08             Forms and formats

5.3.09             Public Records Requests

5.3.10             Subpoenas

5.3.11             Subrogation Against Third Parties

5.3.12             Non-Military Leave of Absence

 

FPD-5.04 

RETIREMENT BENEFITS AND APPEALS PROCESS

                       

5.4.01             Definitions

5.4.02             Application for Pension Benefits

5.4.03             Retirement and Death Benefit Claims

5.4.04             Disability Retirement Age

5.4.05             Benefit Adjustments

5.4.06             Exemption from Execution

5.4.07             Recovery of Overpayments

5.4.08             Retirement and Death Benefit Appeals Process

5.4.09             Domestic Relations Orders

5.4.10             Final Payments

5.4.11             FPDR Two Transfer from PERS

5.4.12             Calculation Method for FPDR Two Final Pay

5.4.13             FPDR Two Vested Termination

 

FPD-5.05 

DEATH BENEFITS

 

5.5.01             Definitions

5.5.02             Applications and Claims for Death and Funeral Benefits

5.5.03             FPDR One Member Benefits in Service-Connected or

                       Occupational Disability Deaths

5.5.04             FPDR One Member Nonservice-Connected Deaths Before Retirement

5.5.05             FPDR One Member Deaths After Retirement

5.5.06             FPDR One Member Survivor Annuity Table

5.5.07             FPDR One Member Funeral Benefit

5.5.08             FPDR Two and FPDR Three Member Benefits on Service-Connected or

                       Occupational Death Before Retirement

5.5.09             FPDR Two and FPDR Three Member Benefits on Nonservice-Connected

                       Death Before Retirement

5.5.10             FPDR Two Member Benefits on Death After Retirement

5.5.11             FPDR Two and FPDR Three Member Funeral Benefit

5.5.12             More Than One Status

 

FPD-5.06 

APPEALS PROCESS

 

5.6.01             Definitions

5.6.02             Claim Processing: Request for Hearing

5.6.03             Conduct of Hearing

5.6.04             Evidentiary Rules

5.6.05             Appellate Panel Review

 

FPDR TWO AND THREE BENEFITS

 

 

FPD-5.07 

SERVICE-CONNECTED OR OCCUPATIONAL DISABILITY BENEFITS

 

5.7.01             Definitions

5.7.02             Disability Benefits Generally

5.7.03             Application for Benefits

5.7.04             Claim Approval or Denial

5.7.05             Amount of Benefits      

5.7.06             Form of Benefits

5.7.07             Transitional Duty Program

5.7.08             Authorized Healthcare Providers

5.7.09             Recipient of Disabiliy Benefits

5.7.10             Independent Medical Examinations

5.7.11             Suspension, Reduction or Termination of Benefits

5.7.12             Offsets to Service-Connected and Occupational Disability Benefits

                       Payable Under Article 3 of the Plan

5.7.13             PERS Offset

5.7.14             Recovery of Overpayments

5.7.15             Disability Retirement Age

 

FPD-5.08

NON SERVICE-CONNECTED DISABILITY BENEFITS

 

5.8.01             Definitions

5.8.02             Disability Benefits Generally

5.8.03             Application for Benefits

5.8.04             Eligibility

5.8.05             Claim Approval or Denial

5.8.06             Amount of Benefits

5.8.07             Form of Benefits

5.8.08             Transitional Duty Program

5.8.09             Authorized Health Care Providers

5.8.10             Recipient of Disability Benefits

5.8.11             Independent Medical Examinations

5.8.12             Suspension, Reduction or Termination of Benefits

5.8.13             Offset to Nonservice-Connected Disability Benefits Payable

                       Under Article 3 of the Plan

5.8.14             PERS Offset

5.8.15             Recovery of Overpayments

5.8.16             Disability Retirement Age

 

FPD-5.09

MEDICAL BENEFITS

 

5.9.01             Definitions

5.9.02             Recipient of Disability Benefits

5.9.03             Medical Services

5.9.04             Medical Services Guidelines

5.9.05             Non-Covered Services

5.9.06             Independent Medical Examinations

5.9.07             Medical Management Programs

5.9.08             Medical Fees and Payments

5.9.09             Medical Payment Limitations

5.9.10             Post-Retirement Medical Benefits

5.9.11             Disability Retirement Age

 

FPD-5.10

RETURN TO WORK AND VOCATIONAL REHABILITATION PROGRAMS

 

5.10.01             Purpose

5.10.02             Definitions

5.10.03             Transitional Duty Return to Work Program

5.10.04             Vocational Rehabilitation Program Goals

5.10.05             Vocational Rehabilitation Program Assessment

5.10.06             Vocational Rehabilitation Program Eligibility

5.10.07             Vocational Rehabilitation Plan

5.10.08             Cooperation in Vocational Rehabilitation

5.10.09             Seeking Other Employment

5.10.10             Suspension, Reduction and Termination of Benefits

5.10.11             Cessation of Eligibility for Vocational Rehabilitation Services

5.10.12             Vocational Rehabilitation Expenses

5.10.13             Right to Request a Different Vocational Rehabilitation Specialist

5.10.14             Right of Appeal

 

FPDR ONE BENEFITS

 

FPD-5.11

SERVICE-CONNECTED OR OCCUPATIONAL DISABILITY BENEFITS

 

5.11.01             Definitions

5.11.02             Disability Benefits Generally

5.11.03             Application for Benefits

5.11.04             Claim Approval or Denial

5.11.05             Amount of Benefits

5.11.06             Recipients of Disability Benefits

5.11.07             Authorized Health Care Providers

5.11.08             Independent Medical Examinations

5.11.09             Proof of Residency

5.11.10             Recovery of Overpayments

 

FPD-5.12

NON SERVICE-CONNECTED DISABILITY BENEFITS

  

5.12.01             Definitions

5.12.02             Disability Benefits Generally

5.12.03             Application for Benefits

5.12.04             Eligibility and Amount of Benefits

5.12.05             Recipients of Disability Benefits

5.12.06             Authorized Health Care Providers

5.12.07             Claim Approval or Denial

5.12.08             Independent Medical Examinations

5.12.09             Proof of Residency

5.12.10             Recovery of Overpayments

 

FPD-5.13

MEDICAL BENEFITS

 

5.13.01             Definitions

5.13.02             Medical Services

5.13.03             Medical Services Guidelines

5.13.04             Non-Covered Services

5.13.05             Independent Medical Examinations

5.13.06             Medical Management Programs

5.13.07             Medical Fees and Payments

5.13.08             Medical Payment Limitations

5.13.09             Post-Retirement Medical Benefits


FPD-5.01 - Procedural Rules Governing Rulemaking

PROCEDURAL RULES GOVERNING RULEMAKING

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.01


5.1.01 - AUTHORITY

Pursuant to Section 5-202 (a) of Chapter 5 of the City Charter, the Board of Trustees shall have the power to prescribe rules and regulations for administration of this program.

5.1.02 - PURPOSE

To carry out the rulemaking requirement of the Board of Trustees pursuant to Chapter 5 of the City Charter, and to provide for a process that is open and inclusive of all stakeholders to this system. This process will be applicable to all provisions of these Administrative Rules.

5.1.03 DUTIES OF THE FUND DIRECTOR

The Fund Director will

(A)  provide the Board of Trustees with the technical and staffing resources necessary for the rulemaking process; 

(B)  develop Administrative Rules and amendments for review and adoption by the Board of Trustees; and

(C)  produce, publish and distribute adopted Administrative Rules.

5.1.04 RULEMAKING NOTICES AND PROCEDURES

(A)  Any proposed change or addition to these Administrative Rules must be referred to the Board of Trustees. The Board will then consider the proposed change or addition. 

(B)  The Fund Director will provide notice of rulemaking to the Board of Trustees and known interested parties at least thirty (30) days prior to the upcoming rulemaking session by email. The notice will include:

1.  A statement of the section of the Administrative Rules to be reviewed.

2.  The date, time, and location of the Board’s consideration of the proposed Administrative Rule or amendment.

3.  How to submit comment.

(C)  The Fund Director will post the Notice of Rulemaking and draft copies of the proposed new or amended Administrative Rules on the FPDR website at least thirty (30) days prior to the Board’s review.

(D)  Notwithstanding subsections (A), (B) and (C) of this rule, housekeeping changes to the FPDR Administrative Rules are authorized to be made without the consent of the Board of Trustees if made solely for the purpose of:

1.  correcting spelling;

2.  correcting grammatical mistakes in a manner that does not alter the scope, application or meaning of the rule;

3.  correcting references to the Charter of the City of Portland or FPDR Administrative Rules; 

4.  changing the name of a bureau for consistent reference;

5.  correcting spacing or pagination; or

6.  capitalization of defined terms; or

7.  replacing gender-specific language with gender-neutral language in a manner that does not alter the scope, application or meaning of the rules.

The Fund Director, FPDR Liaisons and City Attorney’s Office must unanimously agree that the proposed changes are housekeeping changes that meet the above criteria.

The Fund Director will immediately notify the Board when housekeeping changes are made and produce, publish and distribute the updated rules.

The Board may rescind any housekeeping change.

5.1.05 ADOPTION OF RULES

Upon completion of the processes outlined in this procedure, the Board of Trustees shall adopt, for implementation, these rules by section or in its entirety.


HISTORY

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 423 and Resolution No. 424 on November 27, 2007, Resolution No. 474 on January 22, 2013, Resolution Nos. 491 and 492 on September 23, 2014, and Resolution No. 508 on March 15, 2016.


FPD-5.02 - Board Procedures

BOARD PROCEDURES

Administrative Rule Adopted by the FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.02


 

5.2.01 – REGULAR AND SPECIAL MEETINGS

 

Regular meetings of the Board are normally held on the fourth Tuesday of every month and commence at 1:00 pm. Unless otherwise stated, all meetings will be in the City of Portland Council Chambers. Special meetings may be called by the Chairperson, or by three or more members of the Board. All meetings are governed by the provisions of ORS 192.610 to 192.690 in effect at the time of the meeting. Except when in executive session pursuant to ORS 192.660, all meetings of the Board are open to the public. All meetings shall be recorded electronically or by a court reporter.

 

5.2.02 – AGENDA

 

(A) Notice of the date and time of meetings shall be included in the agenda prepared by the Director. The place where the meeting will be held shall also appear if the meeting is to be held somewhere other than the City of Portland Council Chambers.

 

(B) All business of the Board shall be transacted at regular or special meetings. Except in the case of an actual emergency, no matter will be considered by the Board unless it is included on a Board agenda. To be included on a Board agenda, a request for inclusion on the agenda must be received by the Fund Director not less than seven (7) calendar days before the date of the meeting.

 

5.2.03 – CONDUCT OF MEETINGS

 

(A) The Chairperson or Chairperson Pro Tempore shall preside over all meetings unless the Chairperson or Chairperson Pro Tempore directs otherwise. In the absence of the Chairperson or Chairperson Pro Tempore, the presiding officer of any Board meeting shall be a trustee chosen by a majority of the Board of Trustees. In the event that a meeting is being chaired by someone other than the Chairperson or Chairperson Pro Tempore, such presiding officer shall retain his or her right to vote and to participate in discussion of matters before the Board.

 

(B) Roberts' "Rules of Order", current edition, shall be controlling in governing Board procedure in the absence of any direction appearing in these rules.

 

5.2.04 – BOARD MEMBERS

 

(A) Elected Board Members

 

(1) One Active Member of the Bureau of Fire, Rescue and Emergency Services and one Active Member of the Bureau of Police shall be elected to the Board by the Active Members of their respective bureau. Elections will be held in the year of the respective board member’s expiring term.

 

(2) Elected members of the Board shall have a three-year term of office.

 

(3) Regular elections, to fill expired terms on the Board of Trustees, shall be conducted as follows:

 

(a) Elections shall be held during the month of December using a vote-by-mail process.

 

(b) Notice of elections shall be given in writing and posted in fire and police work places on or before the second Monday in October.

 

(c) Any Active Member may nominate himself or herself by filing such nomination in writing with the Director on or before the third Monday in October.

 

(d) Notice of nominations shall be given in writing and by posting in fire and police work places on or before the fourth Monday in October. If only one Active Member is nominated in any election, the election shall not be held. The Director shall determine and certify to the Board that the nominee was unopposed. The nominee so certified shall be declared elected in accordance with the procedures set out in this section of the Administrative Rules.

 

(e) If there are multiple nominees, the Director shall prepare printed ballots, listing the nominees in the order in which they file.

 

(f) The Director shall mail individual ballots for a Fire trustee election to Active Members of the Bureau of Fire and individual ballots for a Police trustee election to Active Members of the Bureau of Police, along with a postage paid return envelope marked “Ballot Enclosed”. These ballots will be mailed to Active Members on the first Friday of November.

 

(g) Completed ballots must be returned, sealed in the return envelope provided by the FPDR marked “Ballot Enclosed” and received in the FPDR office no later than 5:00 p.m. December 1st or the following Monday if December 1st falls on a Saturday or Sunday. Ballots may be dropped off at the FPDR office during normal business hours, 8:00 a.m. to 5:00 p.m., Monday through Friday, except for holidays.

 

(h) Upon receipt of the ballot, FPDR staff will immediately date stamp the return envelope and place it in a secure location. FPDR staff will not open the return envelope.

 

(i) Within two (2) business days after close of balloting, the City Auditor or the City Auditor’s designee will count and tally the ballots. An abstract of votes cast by the Active Members of each bureau signed by the Director and the City Auditor or the City Auditor’s designee, together with the tally sheets signed by the City Auditor or the City Auditor’s designee, shall be forwarded to the Board of Trustees for its next regular meeting.

 

(j) In the event no candidate receives a majority of the votes cast (equivalent to 50 percent plus 1 vote), a runoff election shall be held between the two candidates receiving the most votes. The Director shall, within three (3) business days of the initial vote count, announce to the Members of the respective bureau that a runoff election is needed.

 

(k) In the event of a runoff election, ballots will be distributed within five (5) business days of the determination of the need for a runoff election. The completed ballots must be returned, sealed in the return envelope provided by the FPDR marked “Ballot Enclosed” and received in the FPDR office no later than 5:00 p.m. the business day prior to the day ballots are to be counted. Ballots may be dropped off at the FPDR office during normal business hours, 8:00 a.m. to 5:00 p.m., Monday through Friday, except for holidays. The counting of the ballots will be conducted in the same manner as regular elections and will be scheduled on or before the last business day of December. If the last business day of December falls on a Saturday or Sunday, ballots will be counted on the preceding Friday.

 

(l) The new board members shall be elected for terms to begin January 1.

 

(4) At the regularly scheduled meeting of the Board in January, the names of the nominees and votes received shall be entered in the minutes. The nominee from each bureau, receiving the highest number of votes cast, shall be declared elected. Tie votes shall be decided by the drawing of lots, under the Director and City Auditor’s supervision. No contest of any election shall be had after said declaration.

 

(5) Special elections for a vacant elected trustee position shall be held within thirty (30) days after a vacancy occurs and such elections shall be conducted in the same manner as regular elections. The names of the nominees and votes received shall be announced at the first regularly scheduled meeting of the Board following the special election. The board member elected during a special election will serve the balance of the unexpired term.

 

(6) Any elected Board member who ceases to be an Active Member may complete the remainder of his or her term. Notwithstanding the previous sentence, a Board member who is discharged for cause shall cease to be a member of the Board on the effective date of his or her discharge.

 

(B) Appointed Board Members

 

(1) Two citizens of the City of Portland who have relevant experience in pension or disability matters, are not active or past Members nor beneficiaries of the Fire and Police Disability and Retirement Fund and who have not been employed by the Fire or Police Bureaus shall be appointed to the Board. The citizen shall be nominated by the Mayor and approved by the City Council. Following the City Council approval, the new board member shall be given an oath of office by the City Auditor or the City Auditor’s designee. The new board member(s) shall be appointed for terms to begin January 1.

 

(2) Appointed members of the Board shall have a three-year term of office.

 

(3) Appointments for a vacated appointed board member position shall be made within thirty (30) days after they occur. A new trustee shall be nominated by the Mayor and approved by the City Council. The new appointed board member will serve the balance of the unexpired term.

 

(4) Any appointed board member who misses four or more meetings in the fiscal year may be removed by the Board unless the Board determines there was a good cause for the absences.

 

(5) A Board member who is discharged for cause shall cease to be a member of the Board on the effective date of his or her discharge.

 

(C) Mayor

 

(1) The Mayor or the Mayor’s designee approved by the City Council shall serve as a board member and the Board’s Chairperson.

 

(2) Notwithstanding the above, the Mayor or the Mayor’s designee shall not be an active or past Member nor beneficiary of the Fire and Police Disability and Retirement Fund and have not been employed by the Fire or Police Bureaus.

 

(3) Should the Mayor not meet the above criteria, the Mayor must appoint a designee who does meet the criteria.

 

5.2.05 – POWERS OF THE BOARD

 

(A) The Board shall not decide applications for disability benefits provided by this Chapter.

 

(B) The Board of Trustees is authorized and empowered to require the production and examination of papers and documents for the purpose of rulemaking and consideration by a hearings officer or appellate panel.

 

(C) The Board is authorized and empowered to administer oaths, subpoena and examine witnesses.

 

(D) The Board shall retain one or more independent hearings officers who shall be members of the Oregon State Bar, have relevant disability training and experience, and who shall not be a Member or beneficiary of a Member. Such hearings officers shall conduct hearings and decide applications for benefits consistent with Chapter 5 of the City Charter, and in section 5.6.03 of these Administrative Rules.

 

(E) The Board shall establish rules of evidence and procedure for the conduct of hearings.

 

(F) The Board shall establish an independent panel to consider appeals from the hearings officer’s decisions. One panel member shall be appointed for an initial one year term and then every three (3) years thereafter; the second panel member shall be appointed for an initial two (2) year term and every three (3) years thereafter and the third panel member shall be appointed for an initial three (3) year term and every three (3) years thereafter. Panel members shall be members of the Oregon State Bar, shall have relevant disability training and experience, and shall not be a Member or beneficiary of a Member. Panel members may be removed by the Board for cause.

 

(G) The Board shall pay from the Fund the reasonable expenses of vocational rehabilitation of disabled Members established in a vocational rehabilitation plan approved by the Fund Administrator to reduce disability benefits. The Board may, but has no obligation to, pay other financial incentives that demonstrate a reduction in disability costs.

 

(H) The Board may pay its administrative expenses from the Fund and may borrow from the General Fund. The Board may purchase bonds or insurance covering any act or failure to act.

 

(I) The Board of Trustees may in these rules require applicants for benefits from the Fund and persons receiving benefits from the Fund to submit to and undergo mental and physical examinations by one or more licensed physicians or psychologists designated by the Fund Administrator for that purpose.

 

(J) The Board of Trustees may delegate these authorities to the Fund Administrator.

 

(K) The Board shall give the Fund Administrator the authority to settle and discharge all or part of the Fund’s future obligations to any Member or Member’s eligible beneficiaries for disability, retirement or death benefits as to any and all claims or entitlements to disability, retirement or death benefits as part of a settlement. The maximum settlement authority given to the Fund Administrator is $35,000 without the approval of the Board of Trustees. Any amount exceeding the maximum settlement authority shall require approval of the Board. The Board will only consider requests made by the Fund Administrator.

 

(L) Pursuant to Resolution No. 490, the Board has authorized the Fund Administrator to make all benefit and administrative expense payments. The Fund Administrator will provide the Board with a monthly summary of expenditures.

 

5.2.06 – DUTIES OF BOARD OF TRUSTEES

 

(A) The Board of Trustees shall provide enforcement of these Administrative Rules. Such enforcement may include actions up to and including forfeiture of any benefit payment or by denial of any claim, if the Member fails to comply with these Administrative Rules and regulations.

 

(B) The Board of Trustees may provide in these Administrative Rules for suspension or reduction of any disability benefit if the Member does not cooperate in treatment of the disability or in vocational rehabilitation or does not pursue other employment.

 

(C) The Board of Trustees may provide in these rules for the designation of one or more licensed physicians or psychologists to act at any time with the physicians appointed by the City Personnel Director in the mental and physical examinations of applicants for membership in the Bureau of Fire or Bureau of Police.

 

(D) The Board of Trustees may delegate these authorities to the Fund Administrator.

 

5.2.07 – TRAVEL POLICY

 

It is the desire and intention of the Board to ensure that all Trustees receive educational opportunities afforded by attendance at conferences and seminars relevant to their duties on the Board.

 

Trustees shall be reimbursed for expenses related to the conference or seminar attendance based on the City of Portland’s Rules for Travel, Miscellaneous Expenses and Receipt of Related Benefits. The Board shall file an Addendum to use the per diem method for meal reimbursement.

 

Trustees are authorized to attend up to two (2) conferences per fiscal year as long as the total number of conferences attended by the trustees does not exceed six (6) Trustees will coordinate with other Trustees and the Director to stay within the number of limited spots for each fiscal year. Prior to registering, Trustees shall notify the Director who will coordinate travel and assure that the budgeted total travel allocation is not exceeded. Trustees’ attendance at more than two (2) each or total of six (6) conferences in a fiscal year requires pre-approval by the Board of Trustees.

 

5.2.08 – BOARD COMMUNICATIONS WITH FPDR ADMINISTRATION

 

The Director will serve as the primary contact to the Board of Trustees on any issue concerning this program.

 


HISTORY

 

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, and Resolution No. 423 and Resolution No. 425 on November 27, 2007.

Amended by the Director of the Bureau of Fire and Police Disability and Retirement on March 18, 2010.

As Amended by: Resolution No. 472 on November 27, 2012, Resolution No. 490 on May 27, 2014, Resolution Nos. 491 and 493 on September 23, 2014, and Resolution No. 503 on September 22, 2015.


FPD-5.03 - General Administration

GENERAL ADMINISTRATION

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.03


 

5.3.01 – DEFINITIONS

 

For purposes of the various sections of the Administrative Rules, capitalized terms shall have the meanings described in the Definitions of each section. Capitalized terms not otherwise defined shall have the meanings prescribed under Chapter 5 of the City Charter.

 

“Active Member.” The term "Active Member" means a Member who is actively employed as a Member in the Bureau of Police or Bureau of Fire and Rescue and does not include a Member receiving disability or retirement benefits under Chapter 5.

 

“Alternate Payee.” The term “Alternate Payee” means a spouse, former spouse or dependent minor child of a Member.

 

"Board." The term "Board" or "Board of Trustees" shall mean the Board of Trustees of the Fire and Police Disability and Retirement Fund.

 

“Dependent Minor Child.” The term “Dependent Minor Child” means a child, natural or adopted, of a FPDR Two or FPDR Three Member who is substantially supported by the FPDR Two or FPDR Three Member, the FPDR Two or FPDR Three Member’s Surviving Spouse or the FPDR Two or FPDR Three Member’s estate and is under 18 years of age and unmarried.

 

“Director.” The term “Director” where used in these Administrative Rules shall mean the Fund Director and/or Fund Administrator or his or her designee.

 

”FPDR One.” The term “FPDR One” shall refer to Members who are sworn employees of the Bureau of Fire and Rescue, and Bureau of Police and who receive benefits under Article 5 of Chapter 5 of the Charter of the City of Portland, Oregon.

 

“FPDR Two.” The term “FPDR Two” shall refer to Members who are sworn employees of the Bureau of Fire and Rescue, and Bureau of Police who are not FPDR One Members and were sworn before January 1, 2007 and who receive benefits under Article 3 of Chapter 5 of the Charter of the City of Portland, Oregon.

 

“FPDR Three.” The term “FPDR Three” shall refer to Members who are sworn employees of the Bureau of Fire and Rescue, and Bureau of Police first sworn on or after January 1, 2007 and who receive retirement benefits under the Public Employees Retirement System of the State of Oregon and disability benefits under Article 3 of Chapter 5 of the Charter of the City of Portland, Oregon.

 

"Fund." The term "Fund" shall mean the Fire and Police Disability and Retirement Fund established under Section 5-101 of the Plan.

 

"Medically Stationary." The term "Medically Stationary" means that no further material improvement can reasonably be expected from medical treatment or the passage of time.

 

"Member." The term "Member" means

 

(A) Those sworn permanent employees of the Bureau of Fire and Rescue having the job classifications of Fire Fighter, Fire Fighter Specialist, Fire Fighter Communications, Fire Lieutenant, Fire Training Officer, Staff Fire Lieutenant, Fire Captain, Fire Training Captain, Fire Battalion Chief, Deputy Fire Chief, Division Fire Chief, City Fire Chief, Fire Inspector I, Fire Inspector II, Fire Inspector I Specialist, Staff Fire Captain, Fire Lieutenant Communications, Harbor Pilot, Assistant Fire Marshal, Assistant Public Education Officer and EMS Coordinator;

 

(B) Those permanent sworn employees of the Bureau of Police having the job classifications of Police Officer, Police Sergeant, Police Detective, Criminalist, Police Lieutenant, Police Captain, Police Commander, Deputy Police Chief, Assistant Police Chief, and Police Chief.

 

(C) Persons first sworn on or after January 1, 2013 shall be a Member of this plan, and eligible for benefits under these Administrative Rules, upon completion of six (6) consecutive months of employment as a permanently appointed sworn employee in the Bureau of Fire or Police.

 

Membership shall continue until the Member's employment with the Bureau of Fire and Rescue or Bureau of Police terminates for any reason, other than retirement pursuant to Section 5-304 of the Plan or disability under Section 5-306 or 5-307 of the Plan.

 

Exceptions

 

(A) Persons other than FPDR Three Members who are currently employed by the Bureau of Fire and Rescue or the Bureau of Police who participate in the Public Employees Retirement System of the State of Oregon, or will so participate after a waiting period, shall not be Members.

 

(B) The chief of the Bureau of Police or the Bureau of Fire and Rescue shall be a Member unless the terms of employment of such chief provide otherwise.

 

An Active Member (except those Members covered under Article 5 of the Plan) whose employment is terminated after completing five Years of Service shall be ineligible for any Plan benefits after such termination except the vested termination benefits described in Section 5-305 of the Plan. A Member (except those members covered under Article 5 of the Plan) whose employment is terminated after completing one-half Year of Service and before completing five Years of Service shall be ineligible for any Plan benefits after such termination except the unvested termination benefits described in Section 5-305 of the Plan.

 

A Member who is receiving benefits under Article 5, Prior Benefits, of the Plan or who has voluntarily elected to be covered under Article 5 of the Plan shall be ineligible to receive benefits under Article 3 of the Plan. Notwithstanding the preceding sentence, a Member who was receiving disability benefits on January 1, 1990 but subsequently returns to full duty, without limitation, and earns two more Years of Service may irrevocably elect to be covered under Article 3 rather than Article 5. A member who returns to duty, in a regularly budgeted sworn job classification, in the bureau of which he or she is a member on a full time basis (either 40 hours per week, 42 hours per week or 53 hours per week in the Bureau of Fire and Rescue or 40 hours per week in the Bureau of Police) will be deemed to have returned to full duty without limitation.

 

"Plan." The term "Plan" shall mean the Fire and Police Disability, Retirement and Death Benefit Plan which appears as Chapter 5 of the Charter of the City of Portland, Oregon.

 

“Significant Factor.” The term a “Significant Factor” means an important, proximate cause.

 

"Substantial Gainful Activity." A Member will be considered to be capable of "Substantial Gainful Activity" if he or she is qualified, physically, and by education and experience, to pursue activities or employment which will produce earnings, profits or remuneration equal to or exceeding one-third of the Member's rate of Base Pay while on disability. In determining whether a Member has sufficient education and experience to pursue other activities or employment, the following factors shall be considered:

 

(A) Previous employment experience;

(B) Formal and informal education;

(C) Formal and informal training;

(D) Knowledge and general abilities;

(E) Transferable skills;

(F) Residual functional mental and physical abilities.

 

“Surviving Spouse.” The term “Surviving Spouse” shall mean the person to whom the Member was legally married throughout the twelve-month period preceding death, and from whom the Member was not judicially separated or divorced by interlocutory or final court decree at the time of death. In accordance with Ordinance No. 176258, benefits provided to Fund Members’ surviving spouses are extended on equal terms to gay and lesbian Members same-sex domestic partners. All references in Chapter 5 of the Charter of the City of Portland, and/or in the Administrative Rules to “surviving spouse” shall be understood to apply on equal terms to the same sex domestic partner of the Member.

 

5.3.02 – MEMBER ABSENCES

 

All Member absences without pay shall be reported to the Director by the chief of the bureau affected.

 

5.3.03 – MEMBER HOME ADDRESS NOTIFICATION

 

All Active Members and all Members receiving disability benefits or a pension shall immediately notify the Director, in writing, of changes in their home address.

 

5.3.04 – OTHER EMPLOYMENT

 

FPDR One Members receiving disability benefits under Article 5 of the Plan shall notify the Director if the Member wishes to engage in Other Employment and complete the application process described in Sections 11 and 12 of these Administrative Rules.

 

5.3.05 – LEGAL OPINIONS

 

All requests for legal opinions concerning the Plan shall be requested by the Board, or the members thereof, and shall be transmitted to the selected legal advisor through the Director. All opinions issued in response to such requests shall be filed with the Director.

 

5.3.06 – VITAL STATISTIC RECORDS

 

All present Active Members and all persons, upon becoming Active Members of either bureau shall immediately file for permanent record with the Director, copies of their birth certificates or delayed birth certificates. In the event that a birth certificate does not exist, the Board may require a signed affidavit or other form of proof of identify. All Members shall also file copies of their marriage certificates and/or divorce, annulment or separation decrees and of their spouses' birth certificates.

 

Single Members shall, upon their marriage, immediately comply with provisions applying to married Members. Claims against the Fund will not be allowed until certificates necessary to said claim are filed.

 

5.3.07 – DOMESTIC RELATIONS ORDERS GUIDELINES

 

Payments to an Alternate Payee will be made from the Fund only if such payments are authorized in accordance with an approved Domestic Relations Order meeting the requirements of ORS 237.600. Such decrees, orders, judgments or agreements shall hereinafter be referred to as Orders

 

5.3.08 – FORM AND FORMATS

 

All forms necessary to carry out the provisions of the Plan shall be provided by the Board.

 

5.3.09 – PUBLIC RECORDS REQUESTS

 

Public records requests will be presented to the FPDR Director in the form and format pursuant to these Administrative Rules. All requests must be in writing, addressed to the Director, and include the specific information that is allowable under the Oregon Public Records Laws. FPDR reserves the right to charge the requesting party for costs associated with providing this service.

 

5.3.10 – SUBPOENAS

 

The Board and/or Director may compel the attendance of witnesses and the production of documents by the issuance of subpoenas. The Board's authority to issue subpoenas is delegated to the Director who may issue subpoenas upon his or her own motion or upon the application of a claimant. Applications for subpoenas must be in writing and must set forth the name of the witness and the general relevance and reasonable scope of the evidence sought. If the request is for a subpoena duces tecum, it also must specify the particular books, papers, records or documents to be produced.

 

5.3.11 – SUBROGATION AGAINST THIRD PARTIES

 

(A) By filing a claim for disability benefits the Member or the beneficiary of a Member agrees to be bound by the subrogation provisions of Chapter 5. If injury, death or medical condition of a Member is due to the negligent, intentional or wrongful action of a third party or product manufactured by a third party, the Member or beneficiary, or legal representative of the Member shall bring a cause of action or other claim against that third party or assign the cause of action or claim to the Fund.

 

(B) As used in this Chapter 5, “third party” includes any provider of medical care or vocational assistance to the Member and does not include any City employee acting in the course and scope of his or her employment.

 

(C) In the event a Member or the beneficiary of a Member collects damages from a third person for injury, death or medical condition inflicted on such Member for which benefits are paid or payable by the Fund, the Member or beneficiary shall pay to the Fund the money so collected or the total amount paid to such Member for any benefits paid or payable by the Fund that are authorized to be recovered by any law or this Chapter. The amount so collected by the injured Member shall be distributed as provided in the Oregon Workers’ Compensation statutes governing similar damage recoveries.

 

(D) The Fund shall have a lien on any recovery equal to the value of all benefits paid or payable by the Fund, including but not limited to, disability payments, vocational rehabilitation expenses paid on behalf of a Member, and medical expenses for the injury or medical condition. The Fund lien shall include the present value of the Fund’s reasonably expected future benefit payments.

 

(E) No compromise or settlement of a cause of action or claim described in Charter section 5‑202(i) by a Member or the beneficiary of a Member shall be valid without the approval of the Fund Administrator. In the event the Member, beneficiary or third party fails to obtain the approval of the Fund Administrator for the compromise or settlement, the Fund Administrator retains the right to pursue any causes of action against the third party.

 

(F) The Fund Administrator shall have the right to offset disability payments in the amount that is the lesser of the Fund’s unsatisfied lien or the amount recovered by the Member or beneficiary of the Member from the third party.

 

(G) The Fund Administrator shall have the authority to suspend, offset or reduce benefits if a Member or the beneficiary of a Member does not pursue or assign to the Fund the Member’s or beneficiary’s cause of action against a third party who causes the injury, death or medical condition of a Member for which the Fund pays or is obligated to pay benefits, or does not pay a Fund lien on recoveries from such third parties. Benefits so suspended or reduced shall not be payable to the Member or beneficiary at any time unless the Fund lien has been satisfied.

 

(H) The Board’s right to bring a cause of action against a third party in the name of the Member or Member’s beneficiaries shall be separate and independent of any other cause of action the City or Board may have.

 

5.3.12 – NON-MILITARY LEAVE OF ABSENCE

 

All Members granted a non-military leave of absence without pay by the Council of the City of Portland, Oregon, or the Commissioner in Charge of the bureau in which the Member is employed, shall have preserved under the Plan during such leave the following rights:

 

(A) In the case of FPDR One Members, a right of return of contributions to the Member in case of resignation or discharge in accordance with Section 5-113 of Article 5 of the Plan.

 

(B) In the case of FPDR Two Members, the right to retire or receive vested or unvested benefits under the applicable provisions of the Plan upon proper application to the Director.

 

(C) Right of reinstatement to whatever rights the Member had at the commencement of said leave of absence upon return to active duty in the bureau from which said leave of absence was granted.

 

(D) Right of surviving spouse or dependent minor children of the Member, if any, to the benefits and pensions granted by Section 5-309 of Article 3 of the Plan or Section 5-118 of Article 5 of the Plan, whichever is applicable, in those cases where a Member dies before retirement from a cause not in line of duty.

 

(E) Right to benefits or pensions for injury, sickness or death occurring during said leave of absence if such disability is directly attributable to a former injury in line of duty or occupational disability for which the Member has received benefits or which the Director may otherwise recognize as pre-existing, provided such injury, sickness or death has not been caused by an aggravation of the pre-existing injury or sickness during said leave of absence.

 

(F) For purposes of determining service credit, Members working less than full time shall be designated as on leave without pay for any period less than full time. The amount credited for each Year of Service credit shall be a fractional Year of Service based on the actual number of hours worked each year in which the Member worked part-time, as a percentage of full-time hours.

 


HISTORY

 

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, and Resolution No. 423 and Resolution No. 426 on November 27, 2007.

Amended by the Director of the Bureau of Fire and Police Disability and Retirement on March 18, 2010.

As Amended by: Resolution No. 472 on November 27, 2012, Resolution No. 491 on September 23, 2014, Resolution No. 498 on January 27, 2015, and Resolution No. 501 on September 22, 2015.


FPD-5.04 - Retirement Benefits and Appeals Process

RETIREMENT BENEFITS AND APPEALS PROCESS

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.04


 

5.4.01 – DEFINITIONS

 

“Accrued Benefit.” The term “Accrued Benefit” shall mean the amount of FPDR pension benefits a Member has earned under the Plan, generally based on the Member’s Years of Service and Final Pay and the 2.8 percent accrual rate. An Accrued Benefit is only calculated for a Member who has completed the service requirement for vesting under Chapter 5 of the City Charter.

 

“Actuarial Equivalent.” The term “Actuarial Equivalent” shall mean the adjustment necessary to convert a Member’s FPDR pension benefit into different payment forms or payment periods so that the total value of the Member’s benefit (and the cost to FPDR to provide the benefit) remains equal regardless of the form of benefit or commencement date the Member may elect.

 

“Alternate Payee.” The term “Alternate Payee” shall mean any spouse, former spouse, legally recognized domestic partner, former legally recognized domestic partner, child or other dependent of a Member who is recognized by a Domestic Relations Order as having a right to receive all or a portion of a Member’s retirement benefits.

 

“Annuity.” The term “Annuity” shall mean a contract or promise that provides an income for a specified period of time such as a certain number of years or a lifetime.

 

•  A Joint and Survivor Annuity is the form of a Member’s FPDR retirement benefit in which benefit payments continue after the Member’s death to the Member’s Surviving Spouse or, if none, the Member’s Dependent Minor Children. The amount of benefit that continues to the beneficiary of an FPDR Two Member is 25%, 50%, 75% or 100% of the benefit the Member was receiving before death, depending on the Member’s irrevocable election at retirement, and of an FPDR One Member as shown in the Survivor Annuity Table in Charter Section 5-118. Death benefits payable to a Surviving Spouse are paid for the Surviving Spouse’s life. Death benefits payable to a Dependent Minor Child are payable until the date the child reaches 18 or marries, whichever occurs first.

 

•  A Single Life Annuity is the form of benefit payment that provides a monthly income which is paid for the life of one person, the Alternate Payee.

 

“Beneficiary.” The term “Beneficiary” shall mean a person, other than a Member, who receives benefits under this program.

 

“Base Pay.” The term “Base Pay” shall mean the pay of the FPDR Two or FPDR Three Member’s position in the Bureau of Fire or Police, including premium pay but excluding overtime and payments for unused vacation, sick or other leave. When a Member is paid overtime for part of his or her regular work schedule as required by Fair Labor Standards Act provisions, the straight-time portion of the overtime hours in the Member’s regular work schedule shall be included in Base Pay.

 

“Claim.” The term “Claim” means, for the purposes of this section of the Administrative Rules, a dispute by a Member or Beneficiary of a decision by the FPDR staff with regard to a retirement or death benefit under Chapter 5 of the City Charter. A Claim may also be filed by an authorized representative of the Member or Beneficiary who is the claimant.

 

“Claimant.” The term “Claimant” means, for the purposes of this section of the Administrative Rules, a Member or Beneficiary with a Claim or an authorized representative of the Member or Beneficiary with a Claim.

 

“Discovery.” The term “Discovery” means Claim documents, including chart notes, medical records, medical and vocational reports, correspondence between the Member and the Fund, recorded statement of the Member and any witness, and correspondence related to the Member’s Claim(s) to and from the Office of Administrative Hearings. Discovery does not include Claim documents that are 1) materials protected under the lawyer-client privilege as defined in Oregon Rules of Evidence 40.225 Rule 503; 2) attorney work products; and 3) material reflecting the mental impressions, case values or merits, plans or thought processes of the Member, Member’s attorney or Member’s representative or the Fund, Fund’s attorney or Fund’s representative.

 

“Domestic Relations Order.” A "Domestic Relations Order," or “DRO,” is any judgment, decree or order (including approval of a property settlement agreement) which is made pursuant to a state domestic relations law (including a community property law) and which relates to the payment of marital property rights to an Alternate Payee and which has been entered by a court of competent jurisdiction and has been accepted by the Director. A DRO may divide a Member’s FPDR retirement benefits using one of two different approaches:

 

•  A “separate interest” DRO takes a portion of the financial value of the Member’s retirement benefit as of a particular division date and assigns it to the Alternate Payee as a separate legal interest, with the Alternate Payee’s portion of the benefit being paid to the Alternate Payee based on the Alternate Payee’s life expectancy. In all cases, the financial value of benefits divided under a separate interest DRO is determined using the Plan’s definition of Actuarial Equivalent. This is the most common type of DRO and generally applies where the DRO is entered prior to the date the Member’s benefits are in pay status.

 

•  A “shared interest” DRO is a division of the Member’s annuity payment in a specific amount or percentage between the Member and the Alternate Payee. The Member’s benefit is “shared” with the Alternate Payee; no legal separate interest is created for the Alternate Payee. The sum of total monthly benefits paid to both the Member and the Alternate Payee under a shared interest DRO is equal to the sum of monthly benefits that would have been paid to the Member in the absence of the DRO. If the Alternate Payee predeceases the Member, then the Alternate Payee’s share of the monthly benefit reverts prospectively to the Member. If the Member dies before the Alternate Payee, the Alternate Payee could be treated as a Surviving Spouse in the event the Member has a Surviving Spouse for purposes of death benefits and the DRO treats the Alternate Payee as the Surviving Spouse. Typically, this type of DRO is only used when a Member’s pension payments have commenced prior to issuance of the DRO.

 

“Final Pay.” The term “Final Pay” shall mean the highest Base Pay received by the FPDR Two or FPDR Three Member for any of the three consecutive 365-day or, in a leap year, 366-day periods where the most recent day is the last day for which pay was received in the calendar month preceding the calendar month in which the Member retires, dies, or otherwise terminates employment with the Bureau of Fire or Police. Final Pay for any such period does not include any retroactive payments received by the Member for days preceding such 365-day or 366-day period but does include adjustments to the Base Pay of the Member’s position in the Bureau of Fire or Police that would have been received had the Member’s applicable collective bargaining agreement been in effect during such 365-day or 366-day period.

 

Final Pay for any FPDR Two or FPDR Three Member who retires, dies or otherwise terminates employment with the Bureau of Fire or Police and has either received FPDR disability benefits or who was employed in a part-time status by the Bureau of Fire or Police during any such 365-day or 366-day period shall be based on the Base Pay for a full-time employee in the Member’s position in the Bureau of Fire or Police at the time of retirement, death or termination from employment.

 

“Office of Administrative Hearings.” The term “Office of Administrative Hearings” or “OAH” shall mean an independent body that has been authorized by the Board of Trustees to review the decision of the Director that is concerning retirement or death benefits. The review may take into account all comments, documents, records, and other information the Member or Beneficiary submits, without regard to whether that information was submitted or considered in the initial benefit determination.

 

“Surviving Spouse.” The term “Surviving Spouse” means the individual who, at the time of the Member’s death, was the Spouse of the Member, had been the Member’s Spouse throughout the 12-month period immediately preceding the Member’s death and had not been judicially separated or divorced by interlocutory or final court decree at the time of death, unless otherwise provided in a domestic relations order that is enforceable with respect to the Member’s Plan benefit The term “Spouse” shall, on and after June 26, 2013, mean an individual to whom a Member is lawfully married under state law, and shall be defined consistent with Rev. Rul. 2013-17 and Notice 2014-19, under which the terms “Spouse,” “husband and wife,” “husband,” and “wife” include an individual married to another individual of the same sex if the individuals are lawfully married under state law, and the term “marriage” includes such a marriage between individuals of the same sex, provided that the marriage was validly entered into in a state whose laws authorize the marriage of two individuals of the same sex even if the married couple is domiciled in a state that does not recognize the validity of same-sex marriages. A same-sex domestic partner of a Member who filed an affidavit of domestic partner status form in accordance with Ordinance No. 176258 or a registered domestic partnership certificate with FPDR prior to June 26, 2013, is also considered a Surviving Spouse.

 

“Years of Service.” The term “Years of Service” of a FPDR Two or FPDR Three Member shall mean the service credit for FPDR Two retirement benefits as defined in Charter Section 5-302 and these Administrative Rules.

 

5.4.02 – APPLICATION FOR PENSION BENEFITS

  

All applications for pensions by FPDR One and FPDR Two Members shall be made no later than the day before the day pensions become effective. Pensions shall become effective on the day after the Members' employment terminates or, for Members who are not eligible to retire or do not choose to retire from disability on the day their employment terminates, on the effective date of the pension application, which is the first day of pension benefits. Such pension applications shall be made prior to the last day of the month preceding the month in which Members will receive their first pension benefits payments on the second Tuesday.

 

5.4.03 – RETIREMENT AND DEATH BENEFIT CLAIMS

 

(A) Claims for retirement and death benefits under the Plan should be filed with the Director (or its delegate) using, if required by the Director, forms provided for that purpose.

 

(B) The Director shall provide written notification of Claim approval or Claim denial to the Member, Beneficiary or authorized representative within sixty (60) days of the Director’s receipt of a written Claim.

 

(C) If sufficient information is not available within sixty (60) days of the Director’s receipt of a written Claim, FPDR will provide a written notice to the Member, Beneficiary or authorized representative on the status of the review. If a written Claim approval or denial notice is not issued within ninety (90) days from the Director’s receipt of a Claim, then the Claim will be deemed denied. If a Claim is denied the Member, Beneficiary or authorized representative may file a written request with the Director for a review by a Hearings Officer.

 

(D) If a Member or Beneficiary Claim is denied in whole or in part, the Director shall provide a written explanation stating the reasons for the denial. The written notification will include:

 

(1) the specific reason for the denial;

 

(2) specific references to the pertinent Charter or Administrative Rule provisions on which the denial is based;

 

(3) a description of any additional material or information that the Member needs to submit with an explanation of why such material or information is necessary;

 

(4) an offer to provide the Member, on request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the Claim for benefits; and

 

(5) a description of the FPDR review procedures for retirement and death benefits and the time limits applicable to the Member.

 

5.4.04 – DISABILITY RETIREMENT AGE

 

(A) Service-connected, occupational and nonservice-connected disability benefits payable under Article 3 of the Plan shall cease upon attaining Disability Retirement Age except as provided in Section (B) hereof. A Member receiving service-connected or occupational disability benefits shall be eligible to receive a retirement benefit at Disability Retirement Age, which shall be the earlier of the dates the Member is (1) credited with 30 Years of Service for retirement benefit purposes or (2) the date the Member attains social security retirement age. Since a Member who receives a disability benefit which is less than 75 percent of the Member's Base Pay in any given year will not be credited with a full Year of Service for any such year (refer to § 5-302(c) of the Plan), there will be more than 30 years between the time a Member was hired and the time he or she will be deemed to have reached Disability Retirement Age based on 30 Years of Service. For example, assume that a Member who has 19 Years of Service becomes disabled. Assuming that the Member receives service-connected disability benefits equal to 75 percent of Base Pay during the first year of disability and 50 percent of Base Pay thereafter, the Member would have to be disabled for 16 years before he or she would be considered to have attained Disability Retirement Age based upon 30 Years of Service. For purposes of this Administrative Rule, “Social Security retirement age” means the retirement age provided in 42USC§ 416(l)(1).

 

(B) A disabled Member who is receiving service-connected, occupational, or nonservice-connected disability benefits pursuant to Article 3 of the Plan at the time he or she attains Disability Retirement Age shall only be eligible to receive disability benefits up to the date he or she attains Disability Retirement Age, at which time the disabled Member shall be entitled to receive only a retirement benefit, unless the service-connected or occupational disability is determined by the FPDR Director to be temporary. If said disability is determined by the FPDR Director to be temporary, the Member shall be eligible to receive disability benefits for a period of up to two (2) years from the date of such disability. If said disability is determined by the FPDR Director to not be temporary, Member shall be entitled to receive only a retirement benefit upon attaining Disability Retirement Age.

 

(C) A Member covered under Article 3 of the Plan, who is actively employed by the Bureau of Police or Bureau of Fire and Rescue and suffers a service-connected, occupational, or nonservice-connected disability before attaining Disability Retirement Age, shall be eligible to receive disability benefits.

 

A Member covered under Article 3 of the Plan, who is actively employed and suffers a service-connected, occupational or nonservice-connected disability after attaining Disability Retirement Age, shall be eligible to receive disability benefits, if said disability is determined by the FPDR Director to be temporary, for a period of up to two (2) years from the date of such disability, at which time the disabled Member shall be entitled to receive only a retirement benefit. If disability is determined by the FPDR Director not to be temporary, Member shall be entitled to receive only a retirement benefit.

 

5.4.05 – BENEFIT ADJUSTMENTS

 

(A) Benefits adjusted pursuant to Section 5-312 (Benefit Adjustments) of the Plan will be reviewed annually by the Board of Trustees for adjustment effective July 1 of each year to reflect changes in the cost of living. The percentage rate of change shall not exceed that applied to retirement benefits payable to police officers and fire fighters covered under the Public Employees Retirement System of the State of Oregon (PERS). A Member's benefits will be adjusted on July 1 of any given year only if the Member separates from service on or before June 30 of that year.

 

(B) To the extent there is any change in the Consumer Price Index (CPI) used by PERS to determine its annual benefit adjustment outside of the adjustment limits established for PERS, the difference between the CPI change and, as appropriate, the maximum PERS benefit increase or the maximum PERS benefit decrease will adjust a benefits adjustment bank (CPI Bank) for each fiscal year of retirement. The Board of Trustees may draw upon the CPI Bank to set the adjustment percentage(s) for FPDR Two Members and Beneficiaries.

 

(1) The fiscal year used to adjust a Member’s benefit shall be the fiscal year of the day prior to the Member’s first day of retirement benefits.

 

(2) The fiscal year used to adjust a Beneficiary’s benefit shall be the fiscal year of the related Member’s retirement or, in the case of a Member’s death before retirement, the fiscal year in which the Beneficiary entered into pay status.

 

(3) The fiscal year used to adjust an Alternate Payee’s benefit, when such adjustment is required by the Domestic Relations Order, will be the earlier of the fiscal year of the related Member’s retirement or the fiscal year in which the Alternate Payee entered into pay status.

 

(C) Pension benefits payable under Article 1 (FPDR One Benefits) of the Plan shall vary annually and shall be based upon the current salary of a First Class Fire Fighter or First Class Police Officer, as the case may be, computed annually at the beginning of the fiscal year. Current salary shall mean the maximum payment for the fire fighter or police officer civil service classification and shall not include wages or salaries for extra duties or extra services.

 

5.4.06 – EXEMPTION FROM EXECUTION

 

Pension benefits are generally exempt from assignment to another party, with the exception of properly executed and accepted Domestic Relations Orders. Properly written garnishments on distributions, such as state-ordered child support, that are executions on the payment of the benefit rather than the benefit itself will be followed.

 

5.4.07 - RECOVERY OF OVERPAYMENTS

 

The Director may recover overpayments of pension benefits paid to an overpaid Member or other eligible payee. In the case of a Member or payee currently receiving pension benefits, the Director may obtain such recovery through an offset of an amount not to exceed ten percent (10%) of any future monthly benefit payment until the overpayment is recovered in full. The Director may also allow, or the Board of Trustees may require, an overpaid Member or eligible payee to satisfy the overpayment through a different recovery method determined reasonable by the Director and/or the Board of Trustees. In the case of a deceased Member or other eligible payee, the Director may request full recoupment of any benefits paid for the period after the date of the Member’s or eligible payee’s death from the estate of such Member or eligible payee or from such other persons from whom the Director determines recovery to be appropriate.

 

5.4.08 – RETIREMENT AND DEATH BENEFIT APPEALS PROCESS

 

(A) A dispute occurs when a Member or Beneficiary disagrees with a determination made by the Director (or a person authorized by the Director) of the amount of any benefit or the resolution of any matter affecting a benefit under the Plan. An appeal may also be filed by an authorized representative of the Member or Beneficiary who is the Claimant. A Claimant may not submit an appeal with respect to a benefit under the Plan more than one (1) year after the date the individual has knowledge of all material facts that are the subject of the dispute.

 

(B) If the Claimant wants a review of a denied Claim, the Claimant may submit an appeal in writing to the Director in a manner acceptable to the Office of Administrative Hearings. The deadline for submitting any such appeal shall be sixty (60) days after the Claimant receives the written notification of the denial of the Claim by the Director as described above.

 

(C) Within sixty (60) days following the receipt of the notice of appeal, the hearings officer will give the Claimant either (i) a written notice of the decision, or (ii) if special circumstances require an extension of time for review, a notice of a sixty (60) day extension of the review period. In the latter case, the notice of the decision shall be delivered to the Claimant within 120 days after the application has been filed. The hearings officer’s review will take into account all comments, documents, records, and other information the Member or Beneficiary submits, without regard to whether that information was submitted or considered in the initial benefit determination.

 

(D) If the appeal is denied, the notification will:

 

(1) explain the specific reasons and specific Charter provisions on which its decision is based,

 

(2) include a statement regarding the Claimant’s rights to bring a civil action, and

 

(3) offer to provide the Claimant, on request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the Claim for benefits.

 

(E) The hearings officer has full and complete discretion to:

 

(1) make findings of fact pertaining to a Claim or appeal,

 

(2) interpret the Charter as applied to the facts, and

 

(3) decide all aspects of the Claim or appeal.

 

The decision by the hearings officer shall be the final and conclusive administrative review proceeding under the FPDR. The Member or Beneficiary is required to pursue all administrative appeals under the Plan as a precondition to challenging the denial of the Claim in a lawsuit.

 

5.4.09 – DOMESTIC RELATIONS ORDERS

 

(A) In order to release information to any party other than the Member or Member’s attorney, a prior written authorization from the Member must be on file.

 

(B) Draft Domestic Relations Orders (DRO) should be reviewed within thirty (30) days of receipt unless there are circumstances beyond the control of FPDR which prevent the review being completed within thirty (30) days.

 

(1) DRO’s must contain the following required information:

 

(a) the name and last known mailing address of the Member and of the Alternate Payee;

 

(b) identification of the plan name as the City of Portland, Oregon Fire and Police Disability, Retirement and Death Benefit Plan;

 

(c) the applicable article: Article 3 (FPDR Two) or Article 5 (FPDR One) of the Plan;

 

(d) the amount or percentage of the Member’s Accrued Benefit to be paid to the Alternate Payee, or the manner in which such amount or percentage is to be determined, as well as the benefit division date which may be a specific date in the past or some future date defined by the DRO;

 

(e) if the Member is currently in pay status, the Alternate Payee’s benefit start date specified as the first of the month following the Director’s acceptance of the DRO; and

 

(f) for a Member not yet in pay status, the Alternate Payee’s earliest benefit start date specified as the later of the first of the month following the Director’s acceptance of the DRO or the Member’s earliest retirement date, and the Alternate Payee’s latest benefit start date as the Member’s retirement date.

 

(2) DRO’s must not:

 

(a) require the Plan to provide any type or form of benefit, or any option, not otherwise provided under the Plan – which includes a reversion of the Alternate Payee’s interest to the Member, except as provided under 5.4.09(D);

 

(b) require the payment of benefits to an Alternate Payee that is required to be paid to another Alternate Payee under another order previously determined by the Director to be a DRO; or

 

(c) require the Plan to provide increased benefits (determined on the basis of Actuarial Equivalent value) to the Member and the Alternate Payee than would be paid to the Member and his or her Beneficiary absent the DRO.

 

(3) The Director will accept DROs that are in conformance with the Charter and Administrative Rules.

 

(C) FPDR staff or the Fund’s actuaries determine the Alternate Payee’s benefit amount using the discount rate, Member and Alternate Payee mortality and cost of living increase assumptions used in the most recent actuarial valuation of the FPDR pension plan that has been presented to the FPDR Board of Trustees at the time the Director accepts the DRO.

 

Assumptions specific to the division of benefits calculation include:

 

(1) For a DRO where the Member is not of retirement eligible age as of the benefit division date, the Member’s benefit is valued based on the Member’s expected retirement date. The Alternate Payee may begin payments no earlier than the earliest retirement date, and no later than the date that the Member actually commences retirement benefits.

 

(2) For a DRO where the Member is of eligible retirement age as of the benefit division date but has not yet commenced retirement benefits, the Member’s benefit is valued based on the Member’s expected retirement date. The Alternate Payee may begin payments no earlier than the first of the month after the Director’s acceptance of the DRO, and no later than the date that the Member actually commences retirement benefits.

 

(3) For a DRO where the Member has already commenced benefits, the Member’s benefit is valued based on the Actuarial Equivalent of projected future payments starting on the first of the month after the Director’s acceptance of the DRO based on the life expectancy of the Member and Alternate Payee and the form of benefit elected by the Member at retirement.

 

(D) Reversion to the Member of benefits assigned to the Alternate Payee may occur where:

 

(1) In the case of a separate interest DRO that does not contain instructions to the contrary, the Alternate Payee dies prior to commencing retirement benefits; the Member’s benefit shall then be determined and paid without regard to the DRO.

 

(2) In the case of a shared interest DRO, the Alternate Payee predeceases the Member; the amount that previously was being paid to the Alternate Payee shall then instead be paid to the Member for the rest of the Member’s life.

 

(E) In the event the Member predeceases the Alternate Payee:

 

(1) If the Member dies before reaching the earliest retirement date, the Alternate Payee does not have a vested interest and cannot receive any retirement benefits.

 

(2) In a separate interest DRO if the Member dies on or after reaching the earliest retirement date but has not yet commenced receiving retirement benefits, the Alternate Payee does have a vested interest and can elect to start receiving benefits.

 

(3) If the Member dies after having commenced receiving retirement benefits:

 

(a) In a separate interest DRO, the Alternate Payee continues to receive the benefit he or she was receiving; the Member’s death has no effect on the Alternate Payee’s benefits.

 

(b) In a shared interest DRO, the Alternate Payee may receive a portion of the death benefit determined by the Member’s election at retirement, if payable and the DRO treats the Alternate Payee as the Surviving Spouse.

 

(F) The administrative fee assessed will be the maximum amount permitted under, and be apportioned between the Member and Alternate Payee per, Oregon Revised Statute 237.600.

 

5.4.10 – FINAL PAYMENTS

 

Final payments of pension benefits are prorated as the days in the month up to and including the date of death divided by the total number of days in the month.

 

5.4.11 – FPDR TWO TRANSFER FROM PERS

 

Any FPDR Two Member who was appointed after July 1, 1990 but prior to January 1, 2007, immediately after leaving service as a police officer or fire fighter under the Public Employees Retirement System of the State of Oregon and received a payment of employee contributions from such system, including contributions picked up by the employer, could pay or authorize payment to the Fund the amount received within sixty (60) days after such appointment. A Member making such a payment received Years of Service credit for the service as a police officer or a fire fighter with such system to which the employee contributions related.

 

5.4.12 – CALCULATION METHOD FOR FPDR TWO FINAL PAY

 

(A) For retirements, deaths prior to retirement or terminations on or after January 1, 2013, Final Pay for an FPDR Two Member shall be calculated as the highest sum of Base Pay in three lookback periods including pay for 365 or 366 (in a leap year) days as described below.

 

(B) The sum of Base Pay in the most recent lookback period consists of the Base Pay paid during the most recent 26 pay dates prior to the calendar month in which the Member retires, dies or otherwise terminates employment with the Bureau of Fire or Police, plus 1/14th of the Base Pay paid on the most recent pay date preceding those 26 pay dates (2/14ths if there is a February 29 included in the dates from the most recent pay date back to the pay date preceding those 26 pay dates).

 

(C) The sum of Base Pay paid in the middle and oldest lookback periods consists of the Base Pay paid for the 365 or 366 days (if there is a February 29 in the period) preceding the oldest day used in the more recent lookback period.

 

5.4.13 – FPDR TWO VESTED TERMINATION

 

(A) Termination prior to January 1, 2013: An FPDR Two Member who has completed five Years of Service and whose employment with the Bureau of Fire or Police terminates prior to January 1, 2013 shall be eligible for an increase in his or her benefit on vested termination if the FPDR Two Member is employed after termination in service recognized by the Public Employees Retirement System of the State of Oregon for accrual of benefits or as a waiting period before such accrual begins. The benefit on vested termination shall be increased in the same proportion as any increases during the period of such service in the rate of Base Pay for the FPDR Two Member’s position in the Bureau of Fire or Police held at termination.

 

(B) Termination on or after January 1, 2013: An FPDR Two Member who has completed five Years of Service and whose employment with the Bureau of Fire or Police terminates on or after January 1, 2013 shall not be eligible for an increase in his or her benefit on vested termination based on subsequent employment.

 


HISTORY

 

Adopted November 12, 1991.

Effective February 1, 1992.

Revision filed in PPD December 28, 2008.

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. 435 on February 24, 2009, Resolution No. 444 on August 25, 2009, Resolution No. 447 on January 26, 2010, Resolution No. 452 on March 15, 2011, Resolution No. 472 on November 27, 2012, Resolution No. 479 on September 24, 2013, Resolution No. 491 on September 23, 2014, and Resolution No. 504 on September 22, 2015.


FPD-5.05 - Death Benefits

DEATH BENEFITS

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.05


 

5.5.01 DEFINITIONS

 

“Alternate Payee.” The term “Alternate Payee” shall mean any spouse, former spouse, legally recognized domestic partner, former legally recognized domestic partner, child or other dependent of a Member who is recognized by a Domestic Relations Order as having a right to receive all or a portion of the death benefits due a Member’s Surviving Spouse.

 

“Base Pay.” The term “Base Pay” means the base pay of the FPDR Two or FPDR Three Member’s position in the Bureau of Fire or Police, including premium pay but excluding overtime and payments for unused vacation, sick or other leave. When a Member is paid overtime for part of his or her regular work schedule as required by Fair Labor Standards Act provisions, the straight-time portion of the overtime hours in the Member’s regular work schedule shall be included in Base Pay.

 

“Conservatorship.” The term “Conservatorship” means the court appointment of a person or entity to manage the interests of an estate, a minor child or incompetent person pursuant to ORS 125.400.

 

“Dependent Minor Child.” The term “Dependent Minor Child” of a Member shall mean a child, natural (including posthumous) or adopted, of a Member, who is in fact substantially supported by said Member, or such member’s Surviving Spouse or estate, while said child remains under eighteen (18) years of age and unmarried.

 

“Domestic Relations Order.” A "Domestic Relations Order," or “DRO,” is any judgment, decree or order (including approval of a property settlement agreement) which is made pursuant to a state domestic relations law (including a community property law) and which relates to the payment of marital property rights to an Alternate Payee and which has been entered by a court of competent jurisdiction and has been accepted by the Director. A DRO accepted after June 19, 2015, may require that an Alternate Payee be treated as the Surviving Spouse for FPDR preretirement death benefits if the Alternate Payee is not already in pay status, except that any Dependent Minor Children of the Member who are not supported by the Alternate Payee shall share in the benefit.

 

“Final Pay.” The term “Final Pay” shall mean the highest Base Pay received by the FPDR Two or FPDR Three Member for any of the three consecutive 365-day or, in a leap year, 366-day periods where the most recent day is the last day for which pay was received in the calendar month preceding the calendar month in which the Member retires, dies, or otherwise terminates employment with the Bureau of Fire or Police. Final Pay for any such period does not include any retroactive payments received by the Member for days preceding such 365-day or 366-day period but does include adjustments to the Base Pay of the Member’s position in the Bureau of Fire or Police that would have been received had the Member’s applicable collective bargaining agreement been in effect during such 365-day or 366-day period.

 

Final Pay for any FPDR Two or FPDR Three Member who retires, dies or otherwise terminates employment with the Bureau of Fire or Police and has either received FPDR disability benefits or who was employed in a part-time status by the Bureau of Fire or Police during any such 365-day or 366-day period shall be based on the Base Pay for a full-time employee in the Member’s position in the Bureau of Fire or Police at the time of retirement, death or termination from employment.

 

“PERS.” The Public Employees Retirement System of the State of Oregon.

 

“Power of Attorney.” The term “Power of Attorney” means an instrument in writing by which the Member or beneficiary appoints another person as his/her agent with the authority to perform certain specified acts on their behalf.

 

“Surviving Spouse.” The term “Surviving Spouse” means the individual who, at the time of the Member’s death, was the Spouse of the Member and had not been judicially separated or divorced by interlocutory or final court decree at the time of death, unless otherwise provided in a domestic relations order that is enforceable with respect to the Member’s Plan benefit. In addition, the Surviving Spouse of a Member means the individual who had been the Member’s Spouse throughout the 12-month period immediately preceding the Member’s death, except as provided in Charter Section 5-117 and 5-126. The term “Spouse” shall, on and after June 26, 2013, mean an individual to whom a Member is lawfully married under state law, and shall be defined consistent with Rev. Rul. 2013-17 and Notice 2014-19, under which the terms “Spouse,” “husband and wife,” “husband,” and “wife” include an individual married to another individual of the same sex if the individuals are lawfully married under state law, and the term “marriage” includes such a marriage between individuals of the same sex, provided that the marriage was validly entered into in a state whose laws authorize the marriage of two individuals of the same sex even if the married couple is domiciled in a state that does not recognize the validity of same-sex marriages. A same-sex domestic partner of a Member who filed an affidavit of domestic partner status form or a registered domestic partnership certificate with FPDR in accordance with Ordinance No. 176258 prior to June 26, 2013, is also considered a Surviving Spouse.

 

“Years of Service.” The term “Years of Service” of a FPDR Two or FPDR Three Member shall mean the service credit for FPDR Two retirement benefits as defined in Charter Section 5-302 and these Administrative Rules.

 

5.5.02 – APPLICATIONS AND CLAIMS FOR DEATH AND FUNERAL BENEFITS

 

(A) All persons presenting claims for death and funeral benefits shall file, for permanent record with the Director, copies of the death certificates of the deceased Members.

 

(B) All Surviving Spouses or Alternate Payees treated as Surviving Spouses per Domestic Relations Orderspresenting claims against the Fund shall file for permanent record, with the Director, copies of their birth certificates and of their marriage certificates unless such are on file with the Director. Claims against the Fund will not be allowed until such certificates are filed.

 

(C) All persons presenting an application for benefits for Dependent Minor Children shall file for permanent record, with the Director, copies of the birth certificates or records of adoption of all Dependent Minor Child or Children entitled to participate in any benefits of the Fund. Claims against the Fund will not be allowed until such certificates are filed.

 

(D) All applications for death benefits by Surviving Spouses, Alternate Payees or Dependent Minor Child or Children shall be made within thirty (30) days after the death of Members, unless good cause is shown for the failure to do so. Such benefits shall become effective on the day after the Member’s death.

 

(E) In the event of a dispute concerning a decision by the FPDR staff with regard to a death benefit under Chapter 5 of the City Charter, the dispute shall be addressed per subsections 5.4.03 and 5.4.08 of these Administrative Rules.

 

5.5.03 – FPDR ONE MEMBER BENEFITS IN SERVICE-CONNECTED OR OCCUPATIONAL DISABILITY DEATHS

 

(A) Eligibility: If any Member shall die prior to retirement from an injury suffered in line of duty, or sickness caused by the performance of duty, or as a result of an occupational disability of heart disease, hernia of the abdominal cavity or diaphragm, tuberculosis, or pneumonia (except terminal pneumonia).

 

(1) Surviving Spouse: The Surviving Spouse shall be entitled to benefits or pension until such Surviving Spouse’s death. A DRO accepted after June 19, 2015, may require that an Alternate Payee be considered the Surviving Spouse if the Alternate Payee is not already in pay status from a division of the Member’s retirement benefit, regardless of whether or not there is a Surviving Spouse.

 

(2) Dependent Minor Child or Children:

 

a. If there is a Surviving Spouse, an additional percentage allowance shall be paid to a Surviving Spouse qualified to receive benefits or pension for the benefit of the Dependent Minor Child or Children.

 

b. If there is no Surviving Spouse, the Dependent Minor Child or Children shall receive the benefits or pension to which a Surviving Spouse without Dependent Minor Child or Children would have been entitled.

 

c. If there is a Surviving Spouse and Dependent Minor Child or Children who are not the children of the Surviving Spouse, the Surviving Spouse's benefits or pension, as the case may be, plus children's allowances to which the Surviving Spouse might be entitled were all the children of the Surviving Spouse, shall be divided with the Dependent Minor Child or Children, fifty percent to said qualified Surviving Spouse, and fifty percent to the Dependent Minor Child or Children to be divided equally among said children.

 

d. If an Alternate Payee was designated as the Surviving Spouse in a DRO accepted after June 19, 2015, and there are one or more Dependent Minor Children who are not supported by the Alternate Payee, one-half the benefit and one-half of any children’s allowances to which the Surviving Spouse might be entitled were all the dependent minor children also children of the Surviving Spouse, shall be paid to the Alternate Payee as Surviving Spouse. The other half shall be paid to the Dependent Minor Children who are not supported by the Alternate Payee until the last ceases to be minor and then paid to the Alternate Payee as Surviving Spouse.

 

e. Any Dependent Minor Child's interest in said benefits or pension plus allowances, if any, shall cease when the child is no longer a Dependent Minor Child as defined herein, and any qualified Surviving Spouse's right to an additional allowance for a Dependent Minor Child shall cease under the same conditions.

 

(B) Amount of Benefits:

 

(1) Surviving Spouse:

 

(a) The Surviving Spouse benefit is payable at the rate of fifty percent of the current salary of a First Class Fire Fighter or First Class Police Officer, as the case may be, until such time as the deceased Member would have had thirty (30) years of active service or would have reached compulsory retirement age, had the member lived, whichever event would have first occurred, at which time said Surviving Spouse shall receive a monthly pension from the Fund. This benefit is nontaxable if the member died from a service-connected injury or illness but is taxable if the member died from an occupational disability.

 

(b) A Surviving Spouse's pension shall be computed in accordance with the Survivor Annuity Table as set forth below and shall be based on the deceased Member's years of active service at compulsory retirement age, had the member lived, but in no event shall it exceed the maximum pension allowable to a Surviving Spouse. This benefit is generally taxable but is nontaxable if the Member was killed in the line of duty.

 

(2) The additional allowance where there are both a Surviving Spouse and Dependent Minor Child or children shall be based on the qualified Surviving Spouse's benefit or pension amount and shall be according to the following percentages:

 

(a) twenty-five percent for one Dependent Minor Child;

 

(b) fifteen percent for the second Dependent Minor Child; and

 

(c) ten percent in total for all other Dependent Minor Child or Children over two (2) in number.

 

In the event the Dependent Minor Child or Children are not in fact substantially supported by the Surviving Spouse, the additional percentage allowance for such Dependent Minor Child or Children shall be paid not to the Surviving Spouse, as provided above, but shall be paid to the Dependent Minor Child or shall be divided equally among the Dependent Minor Child or Children, as the case may be. The additional allowance shall be reduced or shall cease when the child isor thechildren are no longer Dependent Minor Child or Children.

 

(3) If more than one Dependent Minor Child are sharing the pension or benefits to which a Surviving Spouse without Dependent Minor Child or Children would have been entitled, the pension or benefit shall be divided equally among them.

 

(4) All persons deriving benefits from the death of any one member under the provisions of this Section may elect, if the Director after hearing finds it to be financially beneficial to the Fund, to receive collectively a five thousand dollar ($5,000) cash settlement from the Fund in lieu of all further claims to benefits and/or pension. Said cash settlement shall not be paid if the deceased member was at the time of his or her death or within one year (1) thereafter would have been eligible for a maximum pension or would have reached compulsory retirement age.

 

(C) Form of Benefit:

 

(1) The benefit shall be paid monthly.

 

(2) The benefit shall vary annually and shall be based on the current salary of a First Class Fire Fighter or First Class Police Officer, as the case may be, computed annually at the beginning of the fiscal year.

 

5.5.04 – FPDR ONE MEMBER NONSERVICE-CONNECTED DEATHS BEFORE RETIREMENT

 

(A) Eligibility: If a Member has at least one (1) year of active service and dies before retirement from any cause not in the line of duty:

 

(1) Surviving Spouse: A Surviving Spouse is eligible to receive a benefit until such Surviving Spouse's death. A DRO accepted after June 19, 2015, may require that an Alternate Payee be considered the Surviving Spouse if the Alternate Payee is not already in pay status from a division of the Member’s retirement benefit, regardless of whether or not there is a Surviving Spouse.

 

(2) Dependent Minor Child or Children:

 

(a) If there is no Surviving Spouse, the deceased member's surviving Dependent Minor Child or Children, if any, shall have the same rights of a qualifying Surviving Spouse.

 

(b) If there are both a Surviving Spouse and Dependent Minor Child or Children who are not the children of the Surviving Spouse, one-half of the Surviving Spouse’s pension shall be shared among all the Dependent Minor Child or Children.

 

(c) If an Alternate Payee was designated as the Surviving Spouse in a DRO accepted after June 19, 2015, and there are one or more Dependent Minor Children who are not supported by the Alternate Payee, one-half the benefit shall be paid to the Alternate Payee as Surviving Spouse. The other half shall be paid to the Dependent Minor Children who are not supported by the Alternate Payee until the last ceases to be minor and then paid to the Alternate Payee as Surviving Spouse.

 

(d) Any Dependent Minor Child's interest in said pension shall cease when the child is no longer a Dependent Minor Child as defined herein.

 

(B) Amount of Benefit:

 

(1) For a Member having at least one (1) year but less than twenty (20) years of active service, the benefit amount shall be either of the following options:

 

(a) The return of the Member's contributions made to the Fund and previously established pension funds less the amount of nonservice-connected disability benefits paid to the Member from the Fund and any previously established pension funds; or

 

(b) A cash settlement of fifteen hundred dollars ($1,500) plus an additional one hundred dollars ($100) for every year of the Member's active service up to twenty (20) years.

 

(2) For a member having twenty (20) years or more of active service, the taxable benefit amount shall be as follows:

 

(a) The Surviving Spouse shall be entitled, at his or her option, to either:

 

(i ) A taxable pension benefit to be computed from the "Survivor Annuity Table" set forth in Section 5.5.06 of these Administrative Rules, based upon the maximum earned pension of the deceased Member; or

 

(ii) An election, if made within one (1) year after the Member's death and if the Board (Director) after hearing so permits, to receive in lieu of further pension payments either a return of the Member's contributions made to the Fund and previously established pension funds, less the amount of nonservice-connected disability benefits paid to the Member from the Fund and any previously established pension funds, or a cash settlement of thirty-five hundred dollars ($3,500).

 

(b) Dependent Minor Child or Children:

 

(i) If at the time of said Member's death there is no Surviving Spouse, the deceased Member's surviving Dependent Minor Child or Children, if any, shall be entitled to the same pension to which a qualifying Surviving Spouse of the same age as the Member would have been entitled under the provisions of this section.

 

(ii) If a Surviving Spouse is receiving a pension under this section and later dies, the surviving Dependent Minor Child or Children shall receive, in lieu of the Surviving Spouse, said Surviving Spouse's pension.

 

(c) In the event a cash settlement option is available and exercised pursuant to this section, the election to accept it must be by or on behalf of all persons deriving or possibly entitled to derive benefits therefrom.

 

(C) Form of Benefit:

 

(1) The benefit in subsections (B)(2)(a)(i), (B)(2)(b)(i) and (B)(2)(b)(ii) shall be paid monthly.

 

(2) The benefit in subsections (B)(2)(a)(i), (B)(2)(b)(i) and (B)(2)(b)(ii)shall vary annually and shall be based on the current salary of a First Class Fire Fighter or First Class Police Officer, as the case may be, computed annually at the beginning of the fiscal year.

 

5.5.05 – FPDR ONE MEMBER DEATHS AFTER RETIREMENT

 

(A) Eligibility: In the case of a Member who retired under Charter Section 5-116 with a non-service disability, the provisions of this section shall apply only to a Member having ten (10) years or more active service.

 

(1) Surviving Spouse: Other than for a Member who retired prior to July 1, 1947, the Surviving Spouse of said deceased Member shall be eligible to receive benefits until such Surviving Spouse's death. A DRO may assign this benefit to an Alternate Payee if there is a Surviving Spouse who would otherwise be entitled to receive this benefit.

 

(2) Dependent Minor Child or Children:

 

(a) If at the time of said retired Member's death there be no Surviving Spouse, the Dependent Minor Child or Children shall receive the Surviving Spouse's pension as set forth below in the "Survivor Annuity Table", computed on the basis of a member and Surviving Spouse of the same age.

 

(b) If the Surviving Spouse is receiving a pension and later dies and there is a surviving Dependent Minor Child or Children of the Member, the Dependent Minor Child or children shall receive said Surviving Spouse's pension.

 

(c) Said pension shall be divided equally among the Dependent Minor Children, if there be more than one.

 

(d) Any Dependent Minor Child's interest in said pension shall cease when the child is no longer a Dependent Minor Child as defined herein.

 

(B) Amount of Benefit: The benefit is to be computed from the "Survivor Annuity Table," set forth below. In using the table the difference between the member's and Surviving Spouse's ages shall be determined to the closest year. This is a taxable benefit.

 

(C) Form of Benefit:

 

(1) The benefit shall be paid monthly.

 

(2) The benefit shall vary annually and shall be based on the current salary of a First Class Fire Fighter or First Class Police Officer, as the case may be, computed annually at the beginning of the fiscal year.

 

5.5.06 – FPDR ONE MEMBER SURVIVOR ANNUITY TABLE

 

Difference Between FPDR One Member's and Surviving Spouse's Age

Surviving Spouse's Pension Shall be determined as Percent of FPDR One Member's Maximum Earned Pension

 

 

FPDR One Member same age or Surviving Spouse Older

 

56%

"      1  year older

55%

"      2  years  "

54%

"      3    "        "          

53%

"      4    "        "          

52%

"      5    "        "          

51%

"      6    "        "          

50%

"      7    "        "          

49%

"      8    "        "

48%

"      9    "        "

47%

"     10   "        "          

46%

"     11   "        "          

45%

"     12   "        "          

44%

"     13   "        "          

43%

"     14   "        "          

42%

"     15   "        "          

41%

"     16   "        "          

40%

"     17   "        "

39%

"     18   "        "          

38%

"     19   "        "          

37%

"     20   "        "          

36%

 

5.5.07 – FPDR ONE MEMBER FUNERAL BENEFIT

 

Upon the death of any active or retired FPDR One Member, the Board (Director) shall pay to the person responsible for the funeral expenses of said deceased Member a sum not exceeding two hundred dollars ($200) to be used for funeral expenses.

 

5.5.08 - FPDR TWO AND FPDR THREE MEMBER BENEFITS ON SERVICE-CONNECTED OR OCCUPATIONAL DEATH BEFORE RETIREMENT

 

(A) Eligibility:

 

(1) Surviving Spouse: A Surviving Spouse of a Member who dies before retirement as a result of an illness or injury that qualifies as service-connected or occupational shall be eligible to receive a death benefit for his or her life. A DRO accepted after June 19, 2015, may require that an Alternate Payee be considered the Surviving Spouse if the Alternate Payee is not already in pay status from a division of the Member’s retirement benefit, regardless of whether or not there is a Surviving Spouse.

 

(2) Dependent Minor Child or Children:

 

(a) A Dependent Minor Child of such a Member shall be eligible to receive the benefit if the Member has no Surviving Spouse. If the Member has more than one Dependent Minor Child, the benefit payable to said children shall be divided equally among them.

 

(b) If the Member has a Surviving Spouse and one or more Dependent Minor Children who are not the children of the Surviving Spouse, one-half the benefit shall be paid to the Surviving Spouse. The other half shall be paid to the Dependent Minor Children until the last ceases to be minor and then paid to the Surviving Spouse. If the Member has more than one Dependent Minor Child, the benefit payable to said children shall be divided equally among them.

 

(c) If an Alternate Payee was designated as the Surviving Spouse in a DRO accepted after June 19, 2015, and there are one or more Dependent Minor Children who are not supported by the Alternate Payee, one-half the benefit shall be paid to the Alternate Payee as Surviving Spouse. The other half shall be paid to the Dependent Minor Children who are not supported by the Alternate Payee until the last ceases to be minor and then paid to the Alternate Payee as Surviving Spouse. If the Member has more than one Dependent Minor Child who is not supported by the Alternate Payee, the benefit payable to said children shall be divided equally among them.

 

(d) Any Dependent Minor Child's interest in said benefit shall cease when the child is no longer a Dependent Minor Child as defined herein.

 

(B) Amount of Benefit:

 

(1) The benefit shall be 75 percent of the Member’s rate of Base Pay at death until the earliest date on which the Member would have been eligible for retirement benefits under the Member’s pension plan if the Member had survived and continued in service as an Active Member. This is a nontaxable benefit.

 

(2) After such date, the benefit shall be 50 percent of the Member’s Final Pay, as adjusted as provided in Section 5-312 of Chapter 5 of the City Charter but including FPDR Three Members. This is a nontaxable benefit except that any additional tax offset benefit payable is taxable unless the Member’s death was in the line of duty.

 

(C) Form of Benefit:

 

(1) The benefit shall be paid monthly starting with the month following the Member’s death.

 

(2) The benefit shall be adjusted after payment commences. The Board shall determine the amount and timing of such adjustments in its discretion, except the percentage rate of change shall not exceed the percentage rate applied to retirement benefits payable to police and fire employees by the Public Employees Retirement System of the State of Oregon (PERS).

 

(D) Offset: The monthly amount of service-connected or occupational death benefits under Chapter 5 of the City Charter shall be reduced by any monthly death benefit payable made by PERS up to the amount provided in this section. The Director shall reduce any service-connected or occupational death benefit payable under Chapter 5 in the amount determined to be necessary by the Director to meet the limitation imposed by this subsection.

 

5.5.09 – FPDR TWO AND THREE MEMBER BENEFITS ON NONSERVICE-CONNECTED DEATH BEFORE RETIREMENT

 

(A) Eligibility:

 

(1) Surviving Spouse: A Surviving Spouse of a Member who has one or more Years of Service and dies before retirement not as a result of an illness or injury that qualifies as service-connected or occupational death, shall be eligible to receive a death benefit. A DRO accepted after June 19, 2015, may require that an Alternate Payee be considered the Surviving Spouse if the Alternate Payee is not already in pay status from a division of the Member’s retirement benefit, regardless of whether or not there is a Surviving Spouse.

 

(2) Dependent Minor Child or Children:

 

(a) A Dependent Minor Child of such a Member shall be eligible to receive the benefit if the Member has no Surviving Spouse or if the spouse is under age 55 years. If the Member has more than one Dependent Minor Child, the benefit payable to the Children shall be divided equally among them.

 

(b) If the Member has a Surviving Spouse and one or more Dependent Minor Children who are not the children of the Surviving Spouse, one-half the benefit shall be paid to the Surviving Spouse. The other half shall be paid to the Dependent Minor Children until the last ceases to be minor and then paid to the Surviving Spouse. If the Member has more than one Dependent Minor Child, the benefit payable to said children shall be divided equally among them.

 

(c) If the Member has an Alternate Payee designated as the Surviving Spouse in a DRO accepted after June 19, 2015, and one or more Dependent Minor Children who are not supported by the Alternate Payee, one-half the benefit shall be paid to the Alternate Payee as Surviving Spouse. The other half shall be paid to the Dependent Minor Children who are not supported by the Alternate Payee until the last ceases to be minor and then paid to the Alternate Payee as Surviving Spouse. If the Member has more than one Dependent Minor Child who is not supported by the Alternate Payee, the benefit payable to said children shall be divided equally among them.

 

(d) Any Dependent Minor Child's interest in said benefit shall cease when the child is no longer a Dependent Minor Child as defined herein.

 

(B) Exception for Death while on Qualified Military Service: If an FPDR Two or Three Member dies while on qualified military service on or after January 1, 2007, the Member’s Years of Service includes the time the Member spent on qualified military service for the purpose of determining eligibility for the amount and form of the benefit addressed in (C) and (D) below. Years of Service retains its standard definition for the computation of the amount of the benefit in (C).

 

(C) Amount of Benefit:

 

(1) Amount of benefit for death before five Years of Service:

 

(a) The benefit shall be a lump sum equal to the amount of the Member’s contributions as provided in 5-305 (d)(1) of Chapter 5, less any benefit paid to the Member under this Chapter. This is a taxable benefit.

 

(b) No benefit is payable to the survivors of a FPDR Two Member who had not made contributions to the Fund prior to July 1, 1990.

 

(c) Survivors of a FPDR Three Member would not be eligible for a lump sum benefit as there would be no situations where said Member would have made contributions to the Fund prior to July 1, 1990.

 

(2) Amount of benefit for death after five Years of Service:

 

(a) If the FPDR Two Member had five or more Years of Service, the benefit shall be an annuity equal to 50 percent of the Member’s accrued retirement benefit under Section 5-304 of Chapter 5, based on 2.6 percent of the Member’s Final Pay instead of 2.2 percent. This is a taxable benefit.

 

(b) If the FPDR Three Member had five or more Years of Service, the benefit shall be an annuity equal to 50 percent of what the Member’s accrued retirement benefit under Section 5-304 of Chapter 5 would have been if the Member had been an FPDR Two Member, based on 2.6 percent of the Member’s Final Pay instead of 2.2 percent. This is a taxable benefit.

 

(D) Form of Benefit:

 

(1) Less than five Years of Service: A benefit payable shall be in a lump sum.

 

(2) More than five Years of Service:

 

(a) A Surviving Spouse shall be paid the benefit monthly commencing with the month after the Member’s death if the spouse is age 55 or over and otherwise with the month after the spouse attains age 55 and shall continue for the spouse’s life.

 

(b) A Dependent Minor Child shall be paid commencing with the month after the Member’s death and shall continue until the child ceases to be a minor.

 

(c) The benefit will be suspended in cases where there is a gap between when the last Dependent Minor Child ceases to be a minor and when the Surviving Spouse attains age 55.

 

(d) The benefit will resume to the Surviving Spouse beginning the month after the spouse attains age 55, at the level that was payable when the benefit was suspended and with no adjustment in the interim.

 

(e) The benefit shall be adjusted after payment commences. The Board shall determine the amount and timing of such adjustments in its discretion, except the percentage rate of change shall not exceed the percentage rate applied to retirement benefits payable to police and fire employees by PERS.

 

(E) Offset: The monthly amount of nonservice-connected death benefits under Chapter 5 of the City Charter shall be reduced by any monthly death benefit payable made by PERS up to the amount provided in this section. The Director shall reduce any nonservice-connected death benefit payable under Chapter 5 in the amount determined to be necessary by the Director to meet the limitation imposed by this subsection.

 

5.5.10 – FPDR TWO MEMBER BENEFITS ON DEATH AFTER RETIREMENT

 

(A) Eligibility: Eligibility for death benefits after retirement shall be based on status as a Surviving Spouse or Dependent Minor Child at the date of the FPDR Two Member’s death and without regard to a person’s status at the time of the FPDR Two Member’s retirement.

 

(1) Surviving Spouse: The Surviving Spouse of a FPDR Two Member who dies after retirement shall be eligible to receive a death benefit. A DRO may assign this benefit to an Alternate Payee if there is a Surviving Spouse who would otherwise be entitled to receive this benefit.

 

(2) Dependent Minor Child or Children:

 

(a) The Dependent Minor Child of the FPDR Two Member shall be eligible to receive the benefit if the Member has no Surviving Spouse.

 

(b) If the Member has a Surviving Spouse and one or more Dependent Minor Children of a former marriage, one-half the benefit shall be paid to the Surviving Spouse. The other half shall be paid to the Dependent Minor Children until the last ceases to be minor and then paid to the Surviving Spouse.

 

(c) If the Member has more than one Dependent Minor Child, the benefit payable to the Children shall be divided equally among them.

 

(d) Any Dependent Minor Child's interest in said benefit shall cease when the child is no longer a Dependent Minor Child as defined herein.

 

(B) Certain Disabled Members: If the FPDR Two Member retired after a nonservice-connected disability and had less than ten (10) Years of Service, including service recognized by PERS for accrual of benefits or as a waiting period before such accrual begins, no death benefit shall be paid.

 

(C) Amount of Benefits: The FPDR Two Member makes an irrevocable election at the time of retirement to determine the retirement accrual rate and the corresponding level of taxable death benefits as follows:

 

(1) With a death benefit equal to 100 percent of the FPDR Two Member’s retirement benefit, the FPDR Two Member’s retirement benefit shall be based on 2.2 percent of Final Pay.

 

(2) With a death benefit equal to 75 percent of the FPDR Two Member’s retirement benefit, the FPDR Two Member’s retirement benefit shall be based on 2.4 percent of Final Pay.

 

(3) With a death benefit equal to 50 percent of the FPDR Two Member’s retirement benefit, the FPDR Two Member’s retirement benefit shall be based on 2.6 percent of Final Pay.

 

(4) With a death benefit equal to 25 percent of the FPDR Two Member’s retirement benefit, the FPDR Two Member’s retirement benefit shall be based on 2.8 percent of Final Pay.

 

(D) No Spouse or Children: If a FPDR Two Member has no Surviving Spouse or Dependent Minor Child at death, no death benefit shall be paid except for the benefit based on return of the FPDR Two Member contributions provided in Section 5-311 of Chapter 5, if any. In no event shall a FPDR Two Member receive a retirement benefit based on more than 2.8 percent of Final Pay regardless of not having a Surviving Spouse or Dependent Child.

 

(E) Form of Benefit:

 

(1) The benefit shall be paid monthly commencing with the month after death and shall continue until the later of the death of the Surviving Spouse or the date the last Dependent Minor Child ceases to be a minor.

 

(2) The benefit shall be adjusted after payment commences. The Board shall determine the amount and timing of such adjustments in its discretion, except the percentage rate of change shall not exceed the percentage rate applied to retirement benefits payable to police and fire employees by PERS.

 

5.5.11 – FPDR TWO AND THREE MEMBER FUNERAL BENEFIT

 

(A) A funeral benefit shall be paid on death of any Active Member or Member actively receiving disability or FPDR retirement benefits or FPDR Three Member who retired from City of Portland service. The funeral benefit shall be paid to the Member’s Surviving Spouse or, if there is no Surviving Spouse, to the Member’s estate.

 

(B) The funeral benefit shall be one-half of the monthly salary including maximum longevity pay at the date of death payable to the civil service classification of fire fighter if the Member was employed in the Bureau of Fire, or of police officer if the Member was employed in the Bureau of Police. If such classifications cease to exist, the benefit shall be based on the salary of comparable successor positions. If the Member was employed by both bureaus, the most recent bureau of employment will determine the funeral benefit.

 

5.5.12 – MORE THAN ONE STATUS

 

No person shall receive more than one survivor benefit under Chapter 5 at the same time, despite qualifying under more than one category, or qualifying with respect to more than one Member. A person so qualifying shall receive in any month the greatest of the benefits payable for that month.

 


HISTORY

 

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 448 on February 23, 2010, Resolution No. 472 on November 27, 2012, Resolution No. 479 on September 24, 2013, Resolution No. 491 on September 23, 2014, and Resolution No. 504 on September 22, 2015.


FPD-5.06 - Appeals Process

APPEALS PROCESS

Administrative Rule Adopted by the FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.06 


 

5.6.01 – DEFINITIONS

 

“Board of Trustees.” As used in these rules relating to hearings procedures, the term “the Board of Trustees” or “the Board” shall mean the Board of Trustees of the Fire and Police Disability and Retirement Fund or a hearings officer appointed by the Board of Trustees pursuant to Charter Section 5-202(b).

 

“Discovery.” The term “Discovery” means claim documents, including chart notes, medical records, medical and vocational reports, correspondence between the Member and the Fund, recorded statement of the Member and any witness, and correspondence related to the Member’s claim(s) to and from the Office of Administrative Hearings. Discovery does not include claim documents that are 1) materials protected under the lawyer-client privilege as defined in Oregon Rules of Evidence 40.225 Rule 503; 2) attorney work products; and 3) material reflecting the mental impressions, case values or merits, plans or thought processes of the Member, Member’s attorney or Member’s representative or the Fund, Fund’s attorney or Fund’s representative.

 

“Good Cause.” The term “Good Cause” means any reason why a hearing officer’s impartiality might reasonably be questioned. It includes, but is not limited to, personal bias or prejudice, personal knowledge of disputed facts, conflict of interest, or any other interest that could be substantially affected by the outcome of the proceeding.

 

"Member." The term "Member" means

 

(A) Those sworn permanent employees of the Bureau of Fire and Rescue having the job classifications of Fire Fighter, Fire Fighter Specialist, Fire Fighter Communications, Fire Lieutenant, Fire Training Officer, Staff Fire Lieutenant, Fire Captain, Fire Training Captain, Fire Battalion Chief, Deputy Fire Chief, Division Fire Chief, City Fire Chief, Fire Inspector I, Fire Inspector II, Fire Inspector I Specialist, Staff Fire Captain, Fire Lieutenant Communications, Harbor Pilot, Assistant Fire Marshal, Assistant Public Education Officer and EMS Coordinator;

 

(B) Those permanent sworn employees of the Bureau of Police having the job classifications of Police Officer, Police Sergeant, Police Detective, Criminalist, Police Lieutenant, Police Captain, Police Commander, Deputy Police Chief, Assistant Police Chief, and Police Chief.

 

(C) Persons first sworn on or after January 1, 2013 shall be a Member of this plan, and eligible for benefits under these Administrative Rules, upon completion of six (6) consecutive months of employment as a permanently appointed sworn employee in the Bureau of Fire or Police.

 

Membership shall commence at the time a sworn employee effectively receives his or her initial appointment to either the Bureau of Fire and Rescue or the Bureau of Police and shall continue until the Member's employment with the Bureau of Fire and Rescue or Bureau of Police terminates for any reason, other than retirement pursuant to Section 5-304 of the Plan or disability under Section 5-306 or 5-307 of the Plan.

 

Exceptions

 

(A) Persons other than FPDR Three Members who are currently employed by the Bureau of Fire and Rescue or the Bureau of Police who participate in the Public Employee Retirement System of the State of Oregon, or will so participate after a waiting period, shall not be Members.

 

(B) The chief of the Bureau of Police or the Bureau of Fire and Rescue shall be a Member unless the terms of employment of such chief provide otherwise.

 

An Active Member (except those Members covered under Article 5 of the Plan) whose employment is terminated after completing five Years of Service shall be ineligible for any Plan benefits after such termination except the vested termination benefits described in Section 5-305 of the Plan. A Member (except those members covered under Article 5 of the Plan) whose employment is terminated after completing one-half Year of Service and before completing five Years of Service shall be ineligible for any Plan benefits after such termination except the unvested termination benefits described in Section 5-305 of the Plan.

 

A Member who is receiving benefits under Article 5, FPDR One Benefits, of the Plan or who has voluntarily elected to be covered under Article 5 of the Plan shall be ineligible to receive benefits under Article 3 of the Plan. Notwithstanding the preceding sentence, a Member who was receiving disability benefits on January 1, 1990 but subsequently returns to full duty, without limitation, and earns two more Years of Service may irrevocably elect to be covered under Article 3 rather than Article 5. A Member who returns to duty, in a regularly budgeted sworn job classification, in the bureau of which he or she is a member on a full time basis (either 40 hours per week, 42 hours per week or 53 hours per week in the Bureau of Fire and Rescue or 40 hours per week in the Bureau of Police) will be deemed to have returned to full duty without limitation.

 

“Office of Administrative Hearings.” The term “Office of Administrative Hearings” or “OAH” shall mean an independent body that has been authorized by the Board of Trustees to conduct an evidentiary hearing under these rules on disputed issues concerning a Member’s benefits under the Plan.

 

“Surviving Spouse.” The term “Surviving Spouse” shall mean the person to whom the Member was legally married throughout the twelve-month period preceding death, and from whom the Member was not judicially separated or divorced by interlocutory or final court decree at the time of death. In accordance with Ordinance No. 176258, benefits provided to Fund Members’ surviving spouses are extended on equal terms to gay and lesbian Members same-sex domestic partners. All references in Chapter 5 of the Charter of the City of Portland, and/or in the Administrative Rules to “Surviving Spouse” shall be understood to apply on equal terms to the same sex domestic partner of the Member.

 

5.6.02 – CLAIM PROCESSING; REQUEST FOR HEARING

 

(A) If the Director denies a claim, the Member shall be notified in writing of the decision along with the notice of the right to request a fact finding hearing. If a Member wishes to proceed with a hearing, a request for hearing signed by or on behalf of the Member must be made, in writing, and received by the Director within sixty (60) days of the mailing date of the denial. An untimely request for hearing may be accepted by the designated hearings officer upon a finding of good cause for the untimely request. Good cause for an untimely request shall be determined by the designated hearings officer and may be established as provided for in Oregon Rule of Civil Procedure 71B.

 

(B) Within fourteen (14) days of receiving the Member’s request for hearing, the Fund shall:

 

(1) send a letter to the Member acknowledging the Fund’s receipt of the request for hearing and simultaneously copy the Member’s attorney or representative, if any;

 

(2) provide the Member, Member’s representative, or Member’s attorney with copies of all discovery in the Fund’s possession;

 

(3) complete and send a Hearings Referral Form to OAH, along with a copy of the denial; and

 

(4) assign the case to the Fund’s attorney.

 

(C) OAH shall designate a hearings officer to adjudicate the hearing and shall schedule a pre-hearing conference with the Member, Member’s representative, or Member’s attorney, and the Fund’s attorney within thirty (30) days of OAH’s receipt of the referral. OAH shall provide formal written notification of the date and time of the pre-hearing conference to the Member, Member’s representative or Member’s attorney and to the Fund and the Fund’s attorney. The purpose of the pre-hearing conference is to identify the issues for the hearing, to schedule the hearing, and to set deadlines for disclosure of expert witnesses.

 

(D) Either party may request a change of hearings officer for Good Cause. The request must be made in writing and submitted to the Chief Administrative Law Judge at OAH prior to the date of the prehearing conference. The requesting party shall mail copies of the request simultaneously to all parties. The designated hearings officer shall provide any relevant information regarding the request to the Chief Administrative Law Judge prior to the Good Cause determination. If the Chief Administrative Law Judge determines there is Good Cause, OAH shall designate a new hearings officer to adjudicate the hearing and shall schedule a prehearing conference with the parties within thirty (30) days of the new hearings officer’s designation.

 

(E) Within a reasonable time after the pre-hearing conference has been held, OAH shall provide formal written notification of the date, time and location of the hearing to the Member, Member’s representative or Member’s attorney and to the Fund and the Fund’s attorney.

 

(F) After the Fund’s initial provision of discovery to the Member, Member’s representative or Member’s attorney, the Member and the Fund shall produce to the other party, on an ongoing basis, any previously undisclosed discovery within fourteen (14) days of coming into possession of such documents.

 

(G) At least forty-five (45) days prior to hearing, the Fund’s attorney will submit a complete set of exhibits to OAH and provide a copy of it to the Member, Member’s attorney or Member’s representative. Each proposed hearing exhibit shall be marked, arranged in chronological order, and numbered in the lower-right corner of each page, beginning with the document of the earliest date, with the abbreviation “Ex” preceding the number of each exhibit. The page number of documents with multiple pages shall be designated by hyphenating the exhibit number and including the page number after the hyphen e.g., the second page of Exhibit 1 would be marked “Ex. 1-2.” The Fund’s attorney will prepare the exhibits and submit the exhibits and an index of the exhibits to the hearings officer and simultaneously to the Member, Member’s representative or Member’s attorney.

 

(H) The hearings officer may receive evidence submitted within forty-five (45) days of the hearing if such evidence was not in the possession of the party offering such evidence at the time of the initial submission of exhibits. The hearings officer may hold the record open for rebuttal evidence when there is a submission within forty-five (45) days of the hearing, or if the rebuttal report is not available at the time of the hearing despite the due diligence of the party soliciting the report. Subject to the limitations in subsection (I) of this rule, the hearings officer may hold the record open for cross examination of a medical expert by deposition.

 

(I) The Member may take the deposition of the author of any expert medical report solicited by the Fund if:

 

(1) the Fund intends to rely on that report at the hearing;

 

(2) the Fund does not call that medical expert to testify at the hearing; and

 

(3) within fourteen (14) days of disclosure of an expert medical report to the Member, Member’s representative or Member’s attorney, the Fund’s attorney is provided with a written request for cross examination of that medical expert report’s author by the Member or on behalf of the Member by his or her representative or attorney.

 

(J) For any deposition satisfying all the criteria in subsection (I) of this rule, the Fund shall pay the fee of the medical expert to be deposed for the time spent in the deposition, and the Fund shall pay the court reporter’s fee. The Fund shall also pay these same fees for any such deposition of a medical expert it requests. The Fund’s right to depose a medical expert shall be subject to the limitations imposed on a Member by subsection (I) of this rule.

 

(K) The Member or Director may request a reset of a scheduled hearing for “extraordinary circumstances” as provided for in subsection (L) of this section. The request must be made in writing as soon as practicable and include an explanation of the reason for the request to reset the hearing. If the request to reset the scheduled hearing is granted, a rescheduled hearing will then be set as soon as the hearings officer’s and parties’ calendars will permit. In any event, a hearing shall not be postponed for more than one (1) year from the date the Member requested a hearing except in extraordinary circumstances beyond the control of the Member or the Fund.

 

(L) Extraordinary circumstances for resetting a scheduled hearing may include, but are not limited to investigation by outside agencies, illness and any other basis deemed an extraordinary circumstance by the designated hearings officer.

 

(M) The decision concerning a request to reset a scheduled hearing shall be made by the hearings officer designated to adjudicate the issue(s) in dispute.

 

5.6.03 – CONDUCT OF THE HEARING

 

(A) Hearings before a hearings officer are non-adversarial fact-finding proceedings which are intended to develop an accurate and complete record which will allow the hearings officer to arrive at a fair and equitable determination.

 

(B) Claimants may elect to represent themselves, or they may be represented by an attorney.

 

(C) All hearings shall be conducted by and under the control of the hearings officer.

 

(D) Testimony in all hearings shall be taken upon oath or affirmation of the witness from whom received. The hearings officer at the hearing or the court reporter (in the event the hearing is being recorded by a court reporter) shall administer the oath or affirmation. For the sake of convenience, oaths or affirmations may be administered at the commencement of the hearing to all witnesses who are to testify. The hearings officer, the Fund’s attorney, the claimant or the claimant's attorney or representative shall have the right to question or examine any witness.

 

(E) Any part of the evidence may be received in written form as well as orally.

 

(F) Hearings on claims shall be conducted and shall proceed, subject to the discretion of the hearings officer, in the following manner:

 

(1) The parties may each present an opening statement. The Member or Member’s attorney shall have the first opportunity to present any opening statement.

 

(2) Following the Fund’s opening statement, if any, the Member or Member’s attorney shall present evidence relevant to the claim.

 

(3) After the Member’s presentation of evidence is complete, the Fund’s attorney may present evidence on behalf of the Fund.

 

(4) The parties may present rebuttal evidence. The party bearing the burden of proof on an issue shall have the right to the last presentation of evidence on the issue.

 

(5) After the parties have completed presenting evidence, they may present closing arguments.

 

(G) In disability cases before a hearings officer, if it appears to the hearings officer that further testimony or argument should be received, said officer may, in his or her discretion, continue the hearing.

 

(H) In disability cases, the hearings officer shall not excuse from the hearing room staff, the Member, Member’s representative or Member’s attorney, the Fund’s attorney or the Fund’s representative. The hearings officer may exclude all other persons and shall conduct the hearing.

 

(I) After the hearings officer has closed the hearing record, the determination or decision on any claim shall issue within thirty (30) days, shall be in writing and shall contain findings of fact, conclusions of law, rulings on admissibility of evidence (if not otherwise appearing in the record) and, if the determination is adverse to the Member, a citation of the statutes under which the determination or decision may be appealed.

 

(J) Informal disposition may be made of any claim by stipulation, agreed settlement or consent order.

 

5.6.04 – EVIDENTIARY RULES

 

(A) The Member shall bear the burden of presenting evidence to support each criterion for entitlement to service-connected disability benefits, nonservice-connected disability benefits or pension benefits, and this burden shall not shift to the Fund. A Member shall not receive disability benefits unless his or her claim is supported by medical evidence, and arises out of and in the course of the Member’s employment with the Bureau of Fire and Rescue or Police.

 

(B) The hearings officer shall exclude evidence if it is immaterial, irrelevant or unduly repetitious. Hearsay is admissible if it is of a type commonly relied upon by reasonably prudent persons in the conduct of their serious affairs. However, the probative weight given hearsay will depend upon the circumstances, such as whether the party offering the hearsay could have offered better evidence and whether the hearsay could have been but was not rebutted.

 

(C) Objections to evidentiary offers may be made and shall be noted in the record.

 

(D) All offered evidence, not objected to, will be received by the hearings officer subject to the hearings officer’s power to exclude irrelevant, immaterial or unduly repetitious matters.

 

(E) Evidence objected to may be received by the hearings officer. Rulings on its admissibility or exclusion, if not made at the hearing, shall be made on the record at or before the time a final order is issued.

 

(F) The hearings officer may take notice of facts of which a court may take judicial notice.

 

(G) Each applicant for service-connected disability benefits under Article 3 of the Plan must establish that his or her claimed condition arose out of and in the course of the Member’s employment with the Bureau of Fire, Rescue and Emergency Services or the Bureau of Police. Except for Members claiming stress or mental disorders, this means it must be proven by medical evidence, supported by objective findings, that the Member’s employment is a Significant Factor of the claimed condition, disability or need for medical treatment. Members claiming stress or mental disorders must prove that their employment is the primary cause of the disorder.

 

(H) In the case of a FPDR Two or FPDR Three Member who is disabled as a result of hernia of the abdominal cavity or diaphragm, AIDS, AIDS-related complex, tuberculosis, hepatitis B, or pneumonia (except terminal pneumonia) it will be rebuttably presumed that such condition arises out of and in the course of the Member's employment with the Bureau of Fire, Rescue and Emergency Services or Bureau of Police. The same rebuttable presumption exists with respect to a Member suffering from heart disease if the Member has five (5) or more Years of Service with his or her respective bureau when his or her condition becomes disabling. The presumptions referred to in this rule may be rebutted only if the Fund determines by a preponderance of the evidence that the Member’s condition did not result from service as a police officer or fire fighter.

 

5.6.05 – APPELLATE PANEL REVIEW

 

(A) The Member or the Fund may request review of an order by the hearings officer by filing a written request for review with the Office of Administrative Hearings. The request for review shall be received by the Office of Administrative Hearings or postmarked within 30 days of the date of the hearings officer’s order. The party requesting review shall mail copies of the request for review simultaneously to all other parties. The party not requesting review shall have ten (10) days from the expiration of the time allowed for appeal to file a cross-request for review. The Office of Administrative Hearings shall not grant an untimely request for review or cross-review. A request for review timely received by the Director within thirty (30) days of the date of the hearings officer’s Order shall be considered timely by the Office of Administrative Hearings.

 

(B) Review of a hearings officer’s order shall be performed by an appellate panel of three hearings officers assigned by the Office of Administrative Hearings.

 

(C) Review by the appellate panel shall be de novo upon the entire record developed at the hearing.

 

(D) The appellate panel will not entertain oral argument. The parties’ arguments should be reduced to writing and filed within the time frames provided in these rules.

 

(E) The party requesting review by the appellate panel shall file its appellant's brief to the appellate panel within thirty (30) days after the date of mailing of the transcript of record or the OAH’s acknowledgement of the request for review to the parties, whichever is later. The respondent shall file its brief within thirty (30) days after the date of mailing of the appellant's brief. Any party who has filed a cross-request for review shall include its cross-appellant's opening brief as a part of its respondent's brief. An appellant may file a reply and/or cross-respondent's brief within fifteen (15) days after the date of mailing of the respondent's/cross-appellant's brief. A cross-appellant may file a cross-reply brief within fifteen (15) days of the mailing date of a cross-respondent's brief. Unless otherwise authorized by the appellate panel, no other briefs will be considered.

 

(F) A party requesting an extension of time for filing a brief shall file a written request no later than the date on which the brief is due. A request for extension in all cases shall include a statement whether opposing attorney (or an unrepresented party) objects to, concurs in or has no comment regarding the extension of time requested.

 

(G) The appellate panel shall issue a written order, which shall set forth:

 

(1) the parties;

 

(2) the issues;

 

(3) the appellate panel’s decision, including findings of fact and conclusions of law;

 

(4) the date on which the order was entered: and

 

(5) the appeal rights of the parties.

 


HISTORY

 

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. 427 on February 12, 2008, Resolution No. 429 on November 25, 2008, Resolution No. 472 on November 27, 2012, Resolution No. 480 on September 24, 2013, and Resolution No. 491 on September 23, 2014.


FPD-5.07 - Service-Connected or Occupational Disability Benefits Plan 2 & 3

SERVICE-CONNECTED OR OCCUPATIONAL DISABILITY BENEFITS PLAN 2 & 3

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.07


 

5.7.01 – DEFINITIONS

 

“Aggravation.” The term “Aggravation” means a Worsening of an approved service-connected injury/illness or occupational disability that occurs after the Member’s condition has been deemed Medically Stationary.

 

“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 Oregon Medical Board, or a podiatric physician or surgeon licensed under ORS 677.805 to 677.840 by the Oregon Medical Board, an oral and maxillofacial surgeon licensed by the Oregon Board of Dentistry 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 thirty (30) days from the first visit on the initial Claim or for twelve (12) visits, whichever first occurs, a doctor or physician licensed by the State Board of Chiropractic Examiners for the State of Oregon or a similarly licensed doctor or physician in any country or in any state, territory, or possession of the United States. All Members drawing disability benefits shall be examined at least once during each twelve-month period by the Member’s identified physician or a physician appointed by the Director, unless otherwise determined by the Director.

 

“Base Pay.” The term “Base Pay” means the Base Pay of the FPDR Two or FPDR Three Member’s position in the Bureau of Fire or Police, including premium pay but excluding overtime and payments for unused vacation, sick or other leave. When a Member is paid overtime for part of his or her regular work schedule as required by Fair Labor Standards Act provisions, the straight-time portion of the overtime hours in the Member’s regular work schedule shall be included in Base Pay.

 

“Base Pay in Effect at Disability.” The term “Base Pay in Effect at Disability” means the Member’s Base Pay amount at the time the disability payment is due.

 

“Bi-weekly Disability Benefits.” The term “Bi-weekly Disability Benefits” means disability benefits payable on the same schedule as the Member’s regular payroll on approved service-connected and occupational disability Claims during a member’s first year of receiving disability benefits.

 

“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.”

 

“Date of Disability.” The term “Date of Disability” means the date that the Member’s Attending Physician establishes that the Member is first unable to perform the Member’s required duties as a result of a service-connected injury/illness or occupational disability that has been determined to arise out of and in the course of the Member’s employment in the Bureau of Police or Fire.

 

“Director.” The term “Director” where used in these Administrative Rules shall mean the Fund Director and/or Fund Administrator or his or her designee.

 

“Documented Absence.” The term “Documented Absence” means documentation of the time missed from a scheduled work shift submitted to the Director demonstrating that the Member was not paid by the Bureau of Fire or Police for that time.

 

“Full-Time Work.” For the purpose of Other Employment, the term “Full-Time Work” means working an average of at least 36 hours per week or the maximum work hours documented in the permanent restriction(s) placed by the Attending Physician.

 

“Independent Medical Examination (IME).” The term “Independent Medical Examination” means an examination by one or more licensed medical providers in order to provide an opinion of findings in connection with a service-connected injury/illness or an occupational disability Claim. A Physical Capacity Evaluation (PCE) or a Work Capacities Evaluation (WCE) is considered an “IME” under these rules.

 

“Interim Disability Benefits.” The term “Interim Disability Benefits” means an amount that may be payable to a Member for lost time from work prior to the compensability determination or withdrawal of his/her application for service-connected injury/illness or occupational disability benefits.

 

"Medically Stationary." The term "Medically Stationary" means that no further material improvement can reasonably be expected from medical treatment or the passage of time.

 

“Monthly Disability Benefits.” The term “Monthly Disability Benefits” means benefits payable once per month on approved service-connected and occupational disability claims after a Member’s first year of receiving disability benefits.

 

“Original Injury.” The term “Original Injury” means the period from the first occasion of medical treatment or disability resulting from a service-connected injury/illness or occupational disability through the date the member first reaches a medically stationary status.

 

“Other Employment.” The term “Other Employment” means employment with any person, firm, company, corporation, government agency, municipality or Self-Employment, and does not include employment as an Active Member of the Bureau of Fire or Bureau of Police, or work performed as part of an approved Transitional Duty Return to Work Program in accordance with Administrative Rule 5.10.03.

 

“Pended.” The term “Pended” means the 60-90 day period following FPDR’s receipt of a complete application for benefits on an original Claim or for a Recurrence Claim during which FPDR is evaluating the Claim to determine if the injury or illness arose out of and in the course of the Member’s employment with the Bureau of Fire or Police.

 

“Preponderance of the Evidence.” The term “Preponderance of the Evidence” means the greater weight of the evidence.

 

“Primary Physician.” See “Attending Physician.”

 

“Proximate Cause.” The term “Proximate Cause” means a cause that directly produces an event and without which the event would not have occurred.

 

“Recurrence.” An Aggravation of a service-connected injury/illness or occupational disability that requires Claim re-opening for additional disability benefits and/or medical benefits.

 

“Self-Employment.” The term “Self-Employment” means the Member is working as:

 

•  a sole proprietor who conducts a trade or business;

 

•  an independent contractor;

 

•  a member of a partnership that conducts a trade or business; or

 

•  otherwise is in business for himself or herself

 

Self-Employment is considered Full-Time Work only when the Member is working an average of at least 36 hours per week or the maximum work hours documented in the permanent restriction(s) placed by the Attending Physician.

 

“Significant Factor.” The term “Significant Factor” means an important Proximate Cause.

 

“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.

 

“Substantial Gainful Activity.” The term “Substantial Gainful Activity” means the Member is qualified, physically and by education and experience, to pursue employment with earnings

equal to or exceeding one-third of the Member’s rate of Base Pay in Effect at Disability.

 

“Suspension of Benefits.” The term “Suspension of Benefits” means the payment of disability benefits are stopped by the Director for the period of suspension when the Member has failed to comply with the provisions of Chapter 5 of the City Charter or Administrative Rules.

 

“Wages Earned in Other Employment.” The term “Wages Earned in Other Employment” includes:

 

(A) the gross salary, overtime pay, fees, commissions, and other remuneration received by a Member for services rendered as an employee to an employer in Other Employment other than the Bureau of Fire or Bureau of Police;

 

(B) any salary, fees, commissions, profits and other remuneration that the Member receives from his or her Self-Employment in a profession, trade or business; and

 

(C) any rental income that the IRS requires to be reported as Self-Employment income.

 

The term “Wages Earned in Other Employment” does not include income from investments such as interest, dividends and capital gains.

 

“Worsening.” The term “Worsening” means objective findings indicating a deterioration of the approved service-connected injury/illness or occupational disability based on expert medical opinion or an expert medical opinion explaining why the Member’s symptoms indicate a worsening of the approved service-connected injury/illness or occupational disability.

 

“Years of Service.” The term “Years of Service” of a FPDR Two or FPDR Three Member shall mean the service credit for FPDR Two retirement benefits as defined in Charter Section 5-302 and these Administrative Rules.

 

5.7.02 – DISABILITY BENEFITS GENERALLY

 

(A) Eligible Members with pended service-connected or occupational disability Claims received by the Fund Administrator after January 1, 2013 may be eligible to receive Interim Disability Benefits beginning with the payroll period the Fund Administrator receives the complete application for benefits including the Attending Physician Report form and a written statement from the physician that the Member is unable to perform his or her required duties because of an injury or illness arising out of and in the course of his or her employment in the Bureau of Fire or Police. If the Member’s claim is withdrawn by the Member or denied by the Director and the denial becomes final, the amount of Interim Disability Benefits paid to the Member is considered an overpayment.

 

(B) Payment of Disability Benefits: Disability benefits will be paid to a Member only during such time as the Member is unable to perform his or her required duties in the Bureau of Fire and Rescue or Bureau of Police. 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.

 

A Member who is unable to perform his or her usual job, but is able to do other work to which the Member may be assigned in his or her respective bureau, is ineligible for disability benefits if such a job is available to the Member. For example, a police officer whose injury prevents him or her from performing police duties in the field will be ineligible for disability benefits if the officer is capable of performing more sedentary duties and such sedentary position is available to the officer.

 

(C) Changes in Employment Status While on Disability

 

(1) If Member is demoted during the time that he/she is receiving disability benefits, his/her disability benefit will be based on the Base Pay of the position held at the time the Member first became disabled on the Claim.

 

(2) If Member is demoted and is not receiving disability benefits at the time of demotion, and later begins receiving disability benefits, said benefits will be based on the reduced base wage of the new classification.

 

(D) Extent of Disability – FPDR Extent of Disability categories include the following:

 

(1) Bi-weekly Disability

 

Term used during the first year of disability when benefits are payable on the same schedule as the Member’s regular payroll. Disability benefits are only payable for time that is authorized by the Member’s Attending Physician and as defined in these Administrative Rules. Any transitional duty performed within one year (1) of the date of disability will be included in this Bi-weekly Disability Benefits period.

 

(2) Monthly Disability

 

Term used following the first year of Bi-weekly Disability. Disability benefits are only payable for time that is authorized by the Member’s Attending Physician and as defined in these Administrative Rules.

 

(3) Permanent and Partial

 

Term used for members who have been deemed medically stationary, permanently incapable of performing their required duties in the Fire or Police Bureaus, and capable of Substantial Gainful Activity. Members may be required to submit for an examination by their physician or a physician appointed by the FPDR Director at least once during each twelve-month period. The purpose of the examination will be to determine if the Member’s approved service-connected or occupational disability condition(s) continue to prevent the member from performing his/her required duties in the Fire or Police Bureaus.

 

(4) Permanent and Total

 

Term used for members who have been deemed medically stationary, permanently incapable of performing their required duties in the Fire or Police Bureaus, and permanently incapable of any Substantial Gainful Activity. Members may be required to submit for an examination by their physician or a physician appointed by the FPDR Director at least once during each twelve-month period. The purpose of the examination will be to determine if the Member’s approved service-connected or occupational disability condition(s) continue to prevent the Member from performing his/her required duties in the Fire or Police Bureau or any other Substantial Gainful Activity.

 

(E) Cessation of Benefits - A disabled Member who is receiving service-connected, or occupational disability benefits pursuant to Article 3 of the Plan at the time he or she attains Disability Retirement Age shall only be eligible to receive disability benefits up to the date he or she attains Disability Retirement Age, at which time the disabled Member shall be entitled to receive only a retirement benefit.

 

(F) Post Disability Retirement Age Benefits – Pursuant to Section 5-306 (f) of Chapter 5 of the City Charter, a member covered under Article 3 of the Plan, who is actively employed and suffers a service-connected, or occupational disability after attaining Disability Retirement Age, shall be eligible to receive disability benefits for a period of up to two (2) years from the date of such disability, at which time the disabled Member shall be entitled to receive only a retirement benefit.

 

5.7.03 – 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 the Director deems necessary to carry out FPDR’s 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 thirty (30) days after the Member is injured or experiences an illness, unless the Member establishes 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 recover overpaid Interim Disability Benefits paid to the Member, should the application/Claim for benefits be withdrawn by the Member or be denied by the Director and the denial become final.

 

(F) 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 and/or capacity to engage in Substantial Gainful Activity.

 

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 the Director’s authorized representatives.

 

(G) All applications for service-connected injury/illness or occupational disability benefits shall contain a report of a superior officer and a report of the Member's Attending Physician.

 

(H) Although information comes from many sources, Claim evaluation 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 FPDR 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, or the Member’s authorized representative, 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 to withhold the information.

 

(I) A Member is required to cooperate with FPDR staff in the investigation of an application for benefits. This includes submitting for and cooperating with personal or telephone interviews and gathering of information. Failure to cooperate with this rule in an initial Claim for benefits may delay a compensability determination or result in a Claim denial.

 

5.7.04 – CLAIM APPROVAL OR DENIAL

 

(A) Disability Claim applications fall into one of the following three categories:

 

(1) Service-Connected Disability Claims: Except for stress or mental disorder claims, the Director shall determine the existence of a disability and whether the preponderance of the evidence indicates it arises out of and in the course of the Member’s employment.

 

A Member shall not be eligible for the service-connected disability benefit based on an injury suffered in assaults or combats which are not connected to the job assignment and which amount to a deviation from customary duties or incurred while engaging in, or as the result of engaging in, any recreational or social activities solely for the Member’s personal pleasure.

 

Stress or Mental Disorder Claims: The Director shall determine if each of the following elements exists:

 

(a) the employment conditions producing the stress or mental disorder exist in a real and objective sense;

 

(b) the employment conditions producing the stress or mental disorder are conditions other than conditions generally inherent in police and fire employment or reasonable disciplinary, corrective or job performance evaluation actions by the employer, or cessation of employment;

 

(c) there is a diagnosis of a mental or emotional disorder which is generally recognized in the medical or psychological community;

 

(d) there is clear and convincing evidence that the stress or mental disorder arose out of and in the course of employment as an Active Member; and

 

(e) the Member’s employment conditions are the primary cause the stress or mental disorder.

 

(2) Occupational Disability Claims: The Director shall presume a Member is eligible for an occupational disability enumerated in 5-306(d) 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.

 

(3) Firefighter Cancer Presumption Claims: The Director shall evaluate firefighter cancer presumption claims in accordance with ORS Section 656.802 (5)

 

(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 service-connected injury/illness or occupational disability 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 ninety (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.

 

5.7.05 – AMOUNT OF BENEFITS

 

During the period the Member continues to be eligible under this section, benefits shall be paid as follows:

 

(A) First year from date of disability:

 

(1) During the first year from the date of disability, the Member shall be paid 75 percent of the Member's rate of Base Pay in Effect at Disability.

 

(2) The Member’s disability benefit rate shall be reduced by 50 percent of any Wages Earned in Other Employment during the period the benefit is payable.

 

(B) Second year from date of disability and after:

 

(1) The Member shall continue to be paid the benefit described in “Paragraph A” after one (1) year from the date of disability until the earliest date on which the Member is both Medically Stationary and capable of Substantial Gainful Activity.

 

(C) Fourth anniversary of the date of disability:

 

(1) If not medically stationary sooner, the Member shall be deemed Medically Stationary for purposes of this Section on the fourth anniversary of the date of disability, regardless of the status of the Member's medical condition.

 

(2) If the Member is incapable of Substantial Gainful Activity, the benefit will remain at 75 percent of the Member's rate of Base Pay in Effect at Disability.

 

(3) If the Member is capable of Substantial Gainful Activity, the benefit shall be 50 percent of the Member’s rate of Base Pay in Effect at Disability, reduced by 25 percent of any Wages Earned in Other Employment during the same period.

 

(D) The minimum benefit shall be 25 percent of the Member's rate of Base Pay in Effect at Disability, regardless of the amount of wages earned in Other Employment.

 

(E) Notwithstanding any other provision of Chapter 5 of the City Charter, a disabled Member receiving or eligible to receive service-connected or occupational disability benefits under Section 5-306 shall not receive any such benefit for periods of time during which the Member is incarcerated subsequent to and for the conviction of a crime. One-half of such benefit, however, shall be payable to the Member's spouse, if not incarcerated, or Member's minor children, during such periods of incarceration. FPDR reserves the right to recover overpaid amounts in situations where a Member has been incarcerated for a period of time prior to conviction of a crime and the sentence is for time served.

 

5.7.06 – FORM OF BENEFITS

 

(A) The service-connected and occupational disability benefits shall be payable on the same schedule as Member’s regular payroll during the first year from the Date of Disability and monthly thereafter. After the first year of disability benefits, the Director may pay the disability benefit on the same schedule as Member’s regular payroll if the Member has returned to work and the period of disability is due to part-time employment restrictions or an intermittent absence on an approved service-connected or occupational disability claim. The Director may pay the benefit monthly during the first year of disability if the Member has been medically separated prior to the end of the first year of disability benefits. The benefits shall be adjusted to reflect changes in the rate of Base Pay of the position held by the Member at disability.

 

(B) After Claim approval, a Member may be paid a disability benefit by FPDR for each authorized absence from work for periods of up to four (4) hours to attend any one medical appointment for the Member’s approved service-connected or occupational disability benefits Claim. The Member must provide to FPDR written verification of any appointment from the Member’s authorized health care provider.

 

5.7.07 – TRANSITIONAL DUTY PROGRAM

 

Whenever the Director has medical evidence that a Member who is receiving disability benefits is capable of performing limited transitional duty the Director shall notify the Member's bureau chief or designee of that fact. Included in the notification will be a report of the Member's limitations and a request that the bureau chief provide the Member with a job that is compatible with the Member's limitations. Refer to Section 5.10 of these Administrative Rules for additional information on this program.

 

5.7.08 – 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 5.7.01 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.

 

5.7.09 – RECIPIENT OF DISABILITY BENEFITS

 

(A) 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. The purpose of the examination will be to determine if the Member’s approved service-connected injury/illness or occupational disability condition(s) continue to prevent the Member from performing the Member’s required duties in the Fire or Police Bureaus.

 

(B) Any Member receiving disability benefits under the Plan shall file with the Director a certificate from the Member’s Attending or Specialty Physician of the Member’s continued disability for each disability pay period, unless otherwise waived by the Director.

 

(C) A Member receiving service-connected injury/illness or occupational disability benefits, under Article 3 of the Plan, who is released to modified duty and capable of Substantial Gainful Activity, but who is unable to return to the bureau, shall pursue Other Employment within the Member’s restrictions. “Pursue Other Employment” means an active, serious and continuing effort to seek Full-Time Work each week that the Member claims benefits. The concept of an active work search includes consideration of the customary methods of obtaining work for which the Member is suited by experience, education and/or training. A Member who is seeking employment will develop verifiable documentation of the reasonable efforts to find work without placing restrictions. Telephone inquiries are considered preliminary exploration of the job market and should be accompanied by appropriate follow-up contacts; personal visits; and submission of applications or résumés.

 

5.7.10 – INDEPENDENT MEDICAL EXAMINATIONS

 

(A) If requested by the Director, any Member potentially eligible to receive benefits under this program is required to undergo an Independent Medical Examination (IME) by one or more licensed physician or psychologist. 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) The Member may request a change in the IME appointment date, time or place for good cause.

 

(C) FPDR will mail a written notice to the Member by certified and regular mail at least fourteen (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 fourteen (14) days notice if the Member agrees.

 

(D) The Member’s notification of the medical examination shall include the following information:

 

(1) the name of the examiner and 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.

 

(E) 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.

 

(F) 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.

 

5.7.11 – SUSPENSION, REDUCTION OR TERMINATION OF BENEFITS

 

(A) Service-connected and Occupational Disability Benefits

 

The Director may determine to suspend, reduce or terminate benefits for service connected and occupational disability benefits, if the Director obtains evidence that:

 

(1) the Member is not cooperating in treatment;

 

(2) the Member is not cooperating in a designated examination under Charter Section 5-202(a), an Independent Medical Examination or other Director arranged medical or mental examination;

 

(3) the Member is not cooperating in the administration of the Claim and/or fulfilling the Member’s duties and obligations under the Charter and the FPDR Administrative Rules;

 

(4) the Member is no longer disabled or eligible;

 

(5) the Member’s service-connected injury/illness or occupational disability no longer arises out of and in the course of the Member’s employment with the Bureau of Fire and Rescue or the Police Bureau, as provided for in Section 5-306 of the Charter;

 

(6) the Member has engaged in fraud or a material misrepresentation;

 

(7) the Member has failed to seek Other Employment once he/she has been deemed capable of Substantial Gainful Activity, or has achieved his/her vocational rehabilitation goals;

 

(8) the Member has failed to provide notification and request approval to engage in Other Employment within the specified timeframe;

 

(9) the Member has failed to provide other wage information to allow for wage offset purposes within the specified timeframe; or

 

(10) the Member is not cooperating in vocational rehabilitation, including participating in a Substantial Gainful Activity assessment.

 

(B) The Director shall notify the Member of the Director’s decision to suspend, reduce or terminate benefits. A summary of the evidence and the decision shall be provided to the Member. By appointment and during regular business hours, the Member shall be entitled to review the non-privileged evidence upon which the recommendation is based. The Member will have fourteen (14) days to provide a written request for the Director’s reconsideration. The Member shall also be notified of the rights under Charter Section 5-202(h) to appeal the decision as provided for in Section 5.6 of the FPDR Administrative Rules. Any such written request must be filed with the Director within sixty (60) days after the date of the decision being appealed.

 

5.7.12 - OFFSET TO SERVICE-CONNECTED AND OCCUPATIONAL DISABILILTY BENEFITS PAYABLE UNDER ARTICLE 3 OF THE PLAN

 

(A) Members receiving service-connected or occupational disability benefits under Article 3 of the Plan who intend to enter the employ of any person, firm or corporation, or engage in any activity which will result in the Member receiving "wages earned in Other Employment" shall notify the Director in writing of the Member's intention. The notice shall be accompanied by a written statement reflecting an estimate of the Member's earnings from such activities. Thereafter, the Member shall furnish the Director with such information and at such intervals as the Director deems necessary to implement the wage offset provisions of this Administrative Rule.

 

(B) Guidelines for Wage Offset Administration

 

(1) A Member must complete the “Outside Employment” section of the “Disability in Line of Duty Report” (DILD) at the time of Claim filing. The Director may require an update on the Member’s Other Employment status periodically throughout the Member’s course of disability.

 

(2) If at any time during the Member’s disability he/she has engaged or wishes to engage in Other Employment, the Member will be required to submit a completed “Request to Engage in Outside Employment” form for the Director’s approval. Failure to do so may result in a reduction or suspension of benefits.

 

(3) Once the “Request to Engage in Outside Employment” has been approved by the Director, the Member will be required to submit a report of his/her outside earnings upon the request of and at intervals determined by the Director.

 

(4) A “Report of Earnings from Outside Employment” will be returned with proper documentation within the timeframe stated in the request. Failure to do so may result in a reduction or suspension of benefits.

 

(5) Documentation acceptable for reporting Other Employment wages include valid copies of payroll records, pay stubs, W-2 and income tax returns.

 

(C) Guidelines for Substantial Gainful Activity Wage Offset Administration

 

(1) When a Member who has been determined to be capable of Substantial Gainful Activity (SGA) chooses to pursue Self-Employment rather than seek regular employment:

 

(a) The Director will initially assume the Member’s Self-Employment wages as zero dollars. The Director will calculate an estimate of Self-Employment wages when sufficient wage, hour and expense documentation is available but no later than six (6) months after the Member’s Self-Employment started.

 

(b) The Member will be required to submit his/her tax returns and other wage, hour and expense documentation annually or when requested by the Director.

 

(c) After receipt of wage, hour and expense documentation, the Director will recalculate the wage offset for the past year and either pay the Member any additional benefits due or calculate an overpayment. The Director will also re-estimate the Member’s Self-Employment wages for the current and next year.

 

(d) The Director will recover any overpayment by offsetting one-twelfth of the overpaid amount from future overpayments until the overpayment is recovered in full.

 

(2) The Member will have the option of choosing to have future disability benefits reduced to the 25% minimum in lieu of submitting wage information to FPDR for purpose of wage offset.

 

5.7.13 – PERS OFFSET

 

FPDR disability benefits will be offset by Public Employees Retirement System (PERS) disability benefits pursuant to Chapter 5 of the City Charter.

 

5.7.14 – RECOVERY OF OVERPAYMENTS

 

(A) 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.

 

(B) Interim Disability Benefits paid to the Member under a Claim for service-connected or occupational disability benefits that is withdrawn by the Member or is denied by the Director and the denial becomes final shall constitute an overpayment and must be repaid in full. The Director shall arrange with the Member the method of repayment.

 

(1) The Member may issue a check payable to City of Portland, by and through FPDR, for the full amount of the overpayment;

 

(2) The Member may give authorization to his or her bureau to repay the amount due out of the Member’s pay check (either in full at the time accrued leave replaces FPDR paid time or otherwise within the time period authorized for repayment); or

 

(3) The Member may repay the overpayment through a repayment plan agreed to by the Director.

 

(C) The overpayment must be repaid in full within a period of time that is no greater than twice the number of weeks that Interim Disability Benefits were paid. The Director may extend the repayment period if the Director has determined that the repayment places an undue hardship on the Member and the Member and the Director have signed a repayment agreement. However, the extended repayment period shall not exceed twelve (12) months.

 

(D) The Director will pursue the appropriate legal action should the overpayment not be repaid in full according to these Administrative Rules.

 

5.7.15 – DISABILITY RETIREMENT AGE

 

(A) Service-connected injury/illness or occupational disability benefits payable to a FPDR Two Member shall cease at Disability Retirement Age except as provided in Section C hereof. A Member receiving service-connected injury/illness or occupational disability benefits shall be eligible to receive a retirement benefit at Disability Retirement Age, which shall be the earlier of the dates the Member is (1) credited with thirty (30) Years of Service for retirement benefit purposes or (2) the date the Member attains Social Security retirement age. For purposes of this rule, “Social Security retirement age” means the retirement age provided in 42USC § 416(l)(1).

 

(B) Service-connected injury/illness or occupational disability benefits payable to a FPDR Three Member shall cease at Normal Retirement Age under PERS except as provided in Section C hereof.

 

(C) If the Director determines the service-connected injury/illness or occupational disability to be temporary, benefits may continue after Disability Retirement Age for a FPDR Two Member or PERS Normal Retirement Age for a FPDR Three Member up to two (2) years from the date of such disability. A Member who is actively employed and suffers a service-connected injury/illness, or occupational disability after attaining Disability Retirement Age for a FPDR Two Member or PERS Normal Retirement Age for a FPDR Three Member, shall be eligible to receive disability benefits for a period of up to two (2) years from the date of such disability, if the Director determines the disability to be temporary.

 


HISTORY

 

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. 431 on March 23, 2009, Resolution No. 445 on October 27, 2009, Resolution No. 472 on November 27, 2012, Resolution Nos. 479 and 480 on September 24, 2013, Resolution Nos. 486, 487 and 488 on March 25, 2014, Resolution Nos. 491 and 494 on September 23, 2014, and Resolution Nos. 501 and 502 on September 22, 2015.


FPD-5.08 - Nonservice-Connected Disability Benefits Plan 2 & 3

NONSERVICE-CONNECTED DISABILITY BENEFITS PLAN 2 & 3

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.08


 

5.8.01 – 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 Oregon Medical Board, or a podiatric physician or surgeon licensed under ORS 677.805 to 677.840 by the Oregon Medical Board, an oral and maxillofacial surgeon licensed by the Oregon Board of Dentistry 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 thirty (30) days from the first visit on the initial Claim or for twelve (12) visits, whichever first occurs, a doctor or physician licensed by the State Board of Chiropractic Examiners for the State of Oregon or a similarly licensed doctor or physician in any country or in any state, territory or possession of the United States.

 

“Base Pay.” The term “Base Pay” means the Base Pay of the FPDR Two or FPDR Three Member’s position in the Bureau of Fire or Police, including premium pay but excluding overtime and payments for unused vacation, sick or other leave. When a Member is paid overtime for part of his or her regular work schedule as required by Fair Labor Standards Act provisions, the straight-time portion of the overtime hours in the Member’s regular work schedule shall be included in Base Pay.

 

“Base Pay in Effect at Disability.” The term “Base Pay in Effect at Disability” means the Member’s Base Pay amount at the time the disability payment is due.

 

“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 beneficiary of a deceased Member. This term may be used synonymously with the term “application.”

 

“Date of Disability.” The term “Date of Disability” means the date that the Member’s Attending Physician establishes that the Member is first unable to perform the Member’s required duties as a result of a nonservice-connected injury/illness.

 

“Director.” The term “Director” where used in these Administrative Rules shall mean the Fund Director and/or Fund Administrator or his or her designee.

 

“Documented Absence.” The term “Documented Absence” means documentation of the time missed from a scheduled work shift submitted to the Director demonstrating that the Member was not paid by the Bureau of Fire or Police for that time.

 

“Full-Time Work.” For the purpose of Other Employment, the term “Full-Time Work” means working an average of at least thirty-six (36) hours per week or the maximum work hours documented in the permanent restriction(s) placed by the Attending Physician.

 

“Independent Medical Examination (IME).” The term “Independent Medical Examination” means an examination by one or more licensed medical providers in order to provide an opinion of findings in connection with a service-connected injury/illness or an occupational disability Claim. A Physical Capacity Evaluation (PCE) or a Work Capacities Evaluation (WCE) is considered an “IME” under these rules.

 

“Monthly Disability Benefits.” The term “Monthly Disability Benefits” means benefits payable once per month on approved nonservice-connected disability Claims.

 

“Other Employment.” The term “Other Employment” means employment with any person, firm, company, corporation, government agency, municipality or Self-Employment, and does not include employment as an Active Member of the Bureau of Fire or Bureau of Police, or work performed as part of an approved Transitional Duty Return to Work Program in accordance with Administrative Rule 5.10.03.

 

“Pended.” The term “Pended” means the 60-90 day period following FPDR’s receipt of a complete application for benefits on an original Claim or for a Recurrence Claim during which FPDR is evaluating the Claim to determine if the injury or illness arose out of and in the course of the Member’s employment with the Bureau of Fire or Police.

 

“Self-Employment.” The term “Self-Employment” means the Member is working as:

 

•  a sole proprietor who conducts a trade or business;

•  an independent contractor;

•  a member of a partnership that conducts a trade or business; or

•  otherwise is in business for himself or herself

 

Self-Employment is considered Full-Time Work only when the Member is working an average of at least thirty-six (36) hours per week or the maximum work hours documented in the permanent restriction(s) placed by the Attending Physician.

 

“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.

 

“Substantial Gainful Activity.” The term “Substantial Gainful Activity” means the Member is qualified, physically and by education and experience, to pursue employment with earnings equal to or exceeding one-third of the Member’s rate of Base Pay in Effect at Disability.

 

“Suspension of Benefits.” The term “Suspension of Benefits” means the payment of disability benefits are stopped by the Director for the period of suspension when the Member has failed to comply with the provisions of Chapter 5 of the City Charter or Administrative Rules.

 

“Wages Earned in Other Employment.” The term “Wages Earned in Other Employment” includes:

 

(A) the gross salary, overtime pay, fees, commissions and other remuneration received by a Member for services rendered as an employee to an employer in Other Employment other than the Bureau of Fire or Bureau of Police;

 

(B) any salary, fees, commissions, profits and other remuneration that the Member receives from his or her Self-Employment in a profession, trade or business; and

 

(C) any rental income that the IRS requires to be reported as Self-Employment income.

 

The term “Wages Earned in Other Employment” does not include income from investments such as interest, dividends and capital gains.

 

“Years of Service.” The term “Years of Service” of a FPDR Two or FPDR Three Member shall mean the service credit for FPDR Two retirement benefits as defined in Charter Section 5-302 and these Administrative Rules.

 

5.8.02 – DISABILITY BENEFITS GENERALLY

 

(A) Payment of Disability Benefits - Disability benefits will be paid to a Member only during such time as the Member is unable to perform his or her required duties in the bureau of Fire and Rescue or Bureau of Police. 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.

 

A Member who is unable to perform his or her required duties but is able to do other work to which the Member may be assigned in his or her respective Bureau, is ineligible for disability benefits if such a job is available to the Member. For example, a police officer whose injury prevents him or her from performing police duties in the field will be ineligible for disability benefits if the officer is capable of performing more sedentary duties and such sedentary position is available to the officer.

 

(B) Changes Related to Member Employment Status While on Disability:

 

(1) If Member is demoted during the time that he/she is receiving disability benefits, his/her disability benefit will be based on the Base Pay of the position held at the time the Member first became disabled on the Claim.

 

(2) If Member is demoted and is not receiving disability benefits at the time of demotion, and later begins receiving disability benefits, said benefits will be based on the reduced base wage of the new classification.

 

(3) If Member is promoted during the time that he/she is receiving disability benefits, his/her disability benefit will be based on the Base Pay of the Member’s new position.

 

5.8.03 – APPLICATION OF 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 the Director deems necessary to carry out FPDR’s duties.

 

(C) Application 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 not later than thirty (30) days from the date of lost wages due to a Member’s nonservice-connected injury or illness unless the Member establishes 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 and/or capacity to engage in Substantial Gainful Activity.

 

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 the Director’s authorized representatives.

 

(F) All applications for nonservice-connected disability benefit shall contain a report of the Member’s Attending Physician.

 

(G) Although information comes from many sources, Claim evaluation is frequently based in part on information provided by the Fire and Police Bureaus. If the bureau designates a process for requesting documents, then FPDR 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 or the Member’s authorized representative, 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 to withhold the information.

 

(H) A Member is required to cooperate with FPDR staff in the investigation of an application for benefits. This includes submitting for and cooperating with personal or telephone interviews and gathering of information. Failure to cooperate with this Administrative Rule in an initial Claim for benefits may delay a compensability determination or result in a Claim denial.

 

5.8.04 - ELIGIBILITY

 

An Active Member shall be eligible for the nonservice-connected disability benefit if the Member has ten (10) or more Years of Service and is unable to perform the Member's required duties because of an injury or illness that does not qualify as a service-connected injury/illness or an occupational disability under subsection 5-306(a), (b) or (c) of Chapter 5 of the City Charter.

 

5.8.05 - CLAIM APPROVAL OR DENIAL

 

(A) No Member shall receive nonservice-connected disability benefits for disabilities resulting from the following:

 

(1) willful injuries;

 

(2) injuries sustained while, or illness contracted as a result of, willfully doing an unlawful act; or

 

(3) weakness, illness or disability resulting directly or indirectly from the habitual excessive use of or addiction to use of alcoholic beverages or illegal drugs.

 

(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 nonservice-connected disability claim has been approved.

 

(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 ninety (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.

 

5.8.06 - AMOUNT OF BENEFITS

 

(A) The benefit shall be 50 percent of the Member's Base Pay in Effect at Disability, reduced by 50 percent of any wages the Member earns in Other Employment during the period the benefit is payable. The Director may reduce, suspend or terminate the benefit if the Member does not cooperate in treatment of the disability or in vocational rehabilitation or does not pursue other employment.

 

(B) Notwithstanding any other provision of the Chapter or the City Charter, a disabled Member receiving or eligible to receive nonservice-connected disability benefits under Section 5-307, shall not receive any such benefit for periods of time during which the Member is incarcerated subsequent to and for the conviction of a crime. FPDR reserves the right to recover overpaid amounts in situations where a Member has been incarcerated for a period of time prior to conviction of a crime and the sentence is for time served.

 

5.8.07 - FORM OF BENEFITS

 

The nonservice-connected disability benefit shall be payable monthly from the Date of Disability. The Director may pay this benefit in some other form as deemed appropriate, but no less frequently than monthly. The amount shall be adjusted to reflect changes in the rate of Base Pay of the position held by the Member at disability. The benefit shall cease when the Member reaches Disability Retirement Age under subsection 5-304(a) and Section 5.8.16 of this Administrative Rule.

 

5.8.08 – TRANSITIONAL DUTY PROGRAM

 

Whenever the Director has medical evidence that a Member who is receiving disability benefits is capable of performing limited transitional duty, the Director shall notify the Member's bureau chief or designee of that fact. Included in the notification will be a report of the Member's limitations and a request that the bureau chief or designee provide the Member with a job that is compatible with the Member’s limitations. Member’s cooperation with the return-to-work program is a requirement of the nonservice-connected disability benefits program. Refer to Section 5.10 of these Administrative Rules for additional information on this program.

 

5.8.09 – AUTHORIZED HEALTHCARE 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 5.8.01 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.

 

5.8.10 – RECIPIENT OF DISABILITY BENEFITS

 

(A) 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. The purpose of the examination will be to determine if the Member’s approved nonservice-connected injury/illness condition(s) continue to prevent the Member from performing the Member’s required duties in the Fire or Police Bureau.

 

(B) Any Member receiving disability benefits under the Plan shall file with the Director a certificate from the Member’s Attending or Specialty Physician of the Member’s continued disability for each disability pay period, unless otherwise waived by the Director.

 

(C) A Member receiving nonservice-connected disability benefits under Article 3 of the Plan, who is released to modified duty and capable of Substantial Gainful Activity, but who is unable to return to the Bureau, shall pursue Other Employment within the Member’s restrictions. “Pursue Other Employment” means: an active, serious, and continuing effort to seek Full-Time Work each week that the Member claims benefits. The concept of an active work search includes consideration of the customary methods of obtaining work for which the Member is suited by experience, education and/or training. A Member who is seeking employment will develop verifiable documentation of the reasonable efforts to find work without placing restrictions. Telephone inquiries are considered preliminary exploration of the job market and should be accompanied by appropriate follow-up contacts; personal visits; and submission of applications or résumés.

 

5.8.11 – INDEPENDENT MEDICAL EXAMINATIONS

 

(A) If requested by the Director, any Member potentially eligible to receive benefits under this program is required to undergo an Independent Medical Examination (IME) by one or more licensed physician or psychologist. 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) The Member may request a change in the IME appointment date, time or place for good cause.

 

(C) FPDR will mail a written notice to the Member by certified and regular mail at least fourteen (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 fourteen (14) days notice if the Member agrees.

 

(D) The Member’s notification of the medical examination shall include the following information:

 

(1) the name of the examiner and 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.

 

(E) 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.

 

(F) 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.

 

5.8.12 – SUSPENSION, REDUCTION OR TERMINATION OF BENEFITS

 

(A) The Director may determine to suspend, reduce or terminate benefits for nonservice-connected disability benefits under Article 3 of the Charter, if the Director obtains evidence that:

 

(1) the Member is not cooperating in treatment;

 

(2) the Member is not cooperating in a designated examination under Charter Section 5-202(a), an Independent Medical Examination or other Director arranged medical or mental examination;

 

(3) the Member is not cooperating in the administration of the Claim and/or fulfilling the Member’s duties and obligations under the Charter and the FPDR Administrative Rules;

 

(4) the Member is no longer disabled or eligible;

 

(5) the Member has engaged in fraud or a material misrepresentation;

 

(6) the Member has failed to seek Other Employment once he/she has been deemed capable of Substantial Gainful Activity, or has achieved his/her vocational rehabilitation goals, if any;

 

(7) the Member has failed to provide notification and request approval to engage in Other Employment within the specified timeframe;

 

(8) the Member has failed to provide other wage information to allow for wage offset purposes within the specified timeframe; or

 

(9) the Member is not cooperating in vocational rehabilitation, including participating in a Substantial Gainful Activity assessment.

 

(B) The Director shall notify Member of the Director’s determination to suspend, reduce or terminate benefits. A summary of the evidence and the decision shall be provided to the Member. By appointment and during regular business hours, the Member shall be entitled to review the nonprivileged evidence upon which the recommendation is based. The Member will have fourteen (14) days to provide a written request for the Director’s reconsideration. The Member shall also be notified of the rights under Charter Section 5-202(h) to appeal the decision as provided for in Section 5.6 of the FPDR Administrative Rules. Any such written request must be filed with the Director within sixty (60) days after the date of the decision being appealed.

 

5.8.13 – OFFSET TO NONSERVICE-CONNECTED DISABILITY BENEFITS PAYABLE UNDER ARTICLE 3 OF THE PLAN

 

(A) Members receiving nonservice-connected disability benefits under Article 3 of the Plan who intended to enter the employ of any person, firm or corporation, or engage in any activity which will result in the Member receiving “wages earned in Other Employment” shall notify the Director, in writing, of the Member’s intention. The notice shall be accompanied by a written statement reflecting an estimate of the Member’s earnings from such activities. Thereafter, the Member shall furnish the Director with such information and at such intervals as the Director deems necessary to implement the wage offset provisions of this Administrative Rule.

 

(B) A Member’s failure to pursue Other Employment may result in a reduction or termination of benefits.

 

(C) Guidelines for Wage Offset Administration:

 

(1) A Member must complete the “Outside Employment” section of the “Nonservice-connected Disability Report” at the time of Claim filing. The Director may require an update on the Member’s Other Employment status periodically throughout the Member’s course of disability.

 

(2) If at any time during the Member’s disability he/she has engaged or wishes to engage in Other Employment, the Member will be required to submit a completed “Request to Engage in Other Employment” form for the Director’s approval. Failure to do so may result in a reduction or suspension of benefits.

 

(3) Once the “Request to Engage in Outside Employment” has been approved by the Director, the Member will be required to submit a report of his/her outside earnings upon the request of and at intervals determined by the Director.

 

(4) A “Report of Earnings from Outside Employment” will be returned with proper documentation within the timeframe stated in the request. Failure to do so may result in a reduction or suspension of benefits.

 

(5) Documentation acceptable for reporting Other Employment wages include valid copies of payroll records, paystubs, W-2 and income tax returns.

 

(6) When a Member chooses to pursue Self-Employment rather than seek regular employment:

 

(a) The Director will initially assume the Member’s Self-Employment wages as zero dollars. The Director will calculate an estimate of Self-Employment wages when sufficient wage, hour and expense documentation is available but no later than six months (6) after the Member’s Self-Employment started.

 

(b) The Member will be required to submit his/her tax returns and other wage, hour and expense documentation annually or when requested by the Director.

 

(c) After receipt of wage, hour and expense documentation, the Director will recalculate the wage offset for the past year and either pay the Member any additional benefits due or calculate an overpayment. The Director will also re-estimate the Member’s Self-Employment wages for the current and next year.

 

(d) The Director will recover any overpayment by offsetting one-twelfth of the overpaid amount from future overpayments until the overpayment is recovered in full.

 

5.8.14 – PERS OFFSET

 

FPDR disability benefits will be offset by Public Employees Retirement System (PERS) disability benefits pursuant to Chapter 5 of the City Charter.

 

5.8.15 – 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.

 

5.8.16 – DISABILITY RETIREMENT AGE

 

(A) Nonservice-connected disability benefits to a FPDR Two Member shall cease at Disability Retirement Age unless the Fund Administrator determines that the nonservice-connected disability is temporary. If the nonservice-connected disability is determined by the Fund Administrator to be temporary, a FPDR Two Member shall be eligible to receive disability benefits for a period of up to two (2) years from the date of such disability or the Disability Retirement Age, whichever is later. At the end of such period, the disabled FPDR Two Member shall be entitled to receive only a retirement benefit.

 

(B) Nonservice-connected disability benefits to a FPDR Three Member shall cease at Normal Retirement Age under PERS unless the Fund Administrator determines that nonservice-connected disability is temporary. If the nonservice-connected disability is determined by the Fund Administrator to be temporary, a FPDR Three Member shall be eligible to receive disability benefits for a period of up to two (2) years from the date of such disability or the Normal Retirement Age, whichever is later.

 


HISTORY

 

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. 439 on May 26, 2009, Resolution No. 462 on June 28, 2011, Resolution No. 472 on November 27, 2012, Resolution No. 479 on September 24, 2013, Resolution Nos. 486, 487 and 488 on March 25, 2014, Resolution Nos. 491 and 494 on September 23, 2014, Resolution No. 498 on January 27, 2015, and Resolution No. 501 on September 22, 2015.


FPD-5.09 - Medical Benefits Plan 2 & 3

MEDICAL BENEFITS PLAN 2 & 3

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.09


 

5.9.01 – DEFINITIONS

 

“Aggravation.” The term “Aggravation” means a Worsening of an approved service-connected injury/illness or occupational disability that occurs after the Member’s condition has been deemed Medically Stationary.

 

“Ancillary Services.” The term “Ancillary Services” means services that supplement the care provided by the Member’s physician or other authorized healthcare provider (e.g., physical therapy, occupational therapy, etc.).

 

“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 Oregon Medical Board, or a podiatric physician or surgeon licensed under ORS 677.805 to 677.840 by the Oregon Medical Board, an oral and maxillofacial surgeon licensed by the Oregon Board of Dentistry 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 thirty (30) days from the first visit on the initial Claim or for twelve (12) visits, whichever first occurs, a doctor or physician licensed by the State Board of Chiropractic Examiners for the State of Oregon or a similarly licensed doctor or physician in any country or in any state, territory or possession of the United States. All Members drawing disability benefits shall be examined at least once during each twelve-month period by the Member’s identified physician or a physician appointed by the Director, unless otherwise determined by the Director.

 

“Chart Note.” The term “Chart Note” means a chronological documentation in a Member’s medical record and includes subjective and objective findings, diagnosis, treatment rendered and proposed, status, and recovery and return-to-work objectives.

 

“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 beneficiary of a deceased Member. This term may be used synonymously with the term “application.”

 

“CPT.” The term “CPT” means Current Procedural Terminology published by the American Medical Association.

 

“Curative Care.” The term “Curative Care” means Medical Services required to diagnose, heal or permanently relieve or eliminate a medical condition.

 

“Customary Fee.” The term “Customary Fee” means a fee that falls within the range of fees normally charged in Oregon for a given service.

 

“Date of Disability.” The term “Date of Disability” means the date that the Member’s Attending Physician establishes that the Member is first unable to perform the Member’s required duties as a result of a service-connected injury/illness or occupational disability that has been determined to arise out of and in the course of the Member’s employment in the Bureau of Fire or Police.

 

“Director.” The term “Director” where used in these Administrative Rules shall mean the Fund Director and/or Fund Administrator or his or her designee.

 

“Elective Surgery.” The term “Elective Surgery” is surgery which may be necessary in the process of recovery from an injury or illness but need not be done as an emergency to preserve life, function or health.

 

“Independent Medical Examination” (IME). The term “Independent Medical Examination” means an examination by one or more licensed medical providers in order to provide an opinion of findings in connection with a service-connected injury/illness or an occupational disability Claim. A Physical Capacity Evaluation (PCE) or a Work Capacities Evaluation (WCE) is considered an “IME” under these rules.

 

“Medical Service.” The term “Medical Service” means any medical treatment including:

 

(A) surgery

(B) diagnostic procedures

(C) chiropractic

(D) dental

(E) in-patient and out-patient hospitalization

(F) professional nursing

(G) ambulance transport

(H) prescription drugs

(I) medicine

(J) durable medical equipment

(K) crutches

(L) braces and supports

(M) prosthetic appliances

(N) physical Restorative Services

 

“Medical Treatment.” The term “Medical Treatment” means the management and care of a Member by a licensed medical provider for the purpose of combating disease, injury or disorder.

 

"Medically Stationary." The term "Medically Stationary" means that no further material improvement can reasonably be expected from medical treatment or the passage of time.

 

“Nurse Case Manager.” A licensed nurse assigned by the Director to follow and monitor the progress of recovery of an injury/illness or occupational Claim.

 

“Original Injury.” The term “Original Injury” means the period from the first occasion of medical treatment or disability resulting from a service-connected injury/illness or occupational disability through the date the Member reaches a Medically Stationary status.

 

“Palliative Care.” The term “Palliative Care” means post-Medically Stationary Medical Services required to reduce or temporarily moderate the intensity of an otherwise stable condition. It does not include those Medical Services needed to diagnose, heal or permanently alleviate a medical condition.

 

“Physical Capacity Evaluation.” The term “Physical Capacity Evaluation” means an objective, directly observed measurement of a Member’s ability to perform a variety of physical tasks combined with subjective analyses of abilities by Member and evaluator. Physical tolerance screening, Blankenship’s Functional Evaluation and Functional Capacity Assessment will be considered to have the same meaning as Physical Capacity Evaluation.

 

“Physical Restorative Services.” The term “Physical Restorative Services” means services prescribed by the Member’s physician that are designed to restore and maintain the Member to the highest functional ability consistent with the Member’s condition.

 

“Preponderance of the Evidence.” The term “Preponderance of the Evidence” means the greater weight of the evidence.

 

“Proximate Cause.” The term “Proximate Cause” means a cause that directly produces an event and without which the event would not have occurred.

 

“Recurrence.” The term “Recurrence” means an Aggravation of a service-connected injury/illness or occupational disability that requires Claim reopening for additional disability benefits and/or medical benefits after the Member has reached Medically Stationary status with respect to the approved service-connected injury/illness or occupational disability.

 

“Significant Factor.” The term a “Significant Factor” means an important Proximate Cause.

 

“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.

 

“Usual and Customary Fee.” The term “Usual and Customary Fee” means a treatment service fee that falls within the range of fees normally charged for treatment of occupational injuries and illnesses in Oregon.

 

“Work Capacity Evaluation.” The term “Work Capacity Evaluation” means a physical capacity evaluation with special emphasis on the ability to perform a variety of vocationally oriented tasks based on specific job demands. Work Tolerance Screening will be considered to have the same meaning as Work Capacity Evaluations.

 

“Worsening.” The term “Worsening” means objective findings indicating a deterioration of the approved service-connected injury/illness or occupational disability based on expert medical opinion or an expert medical opinion explaining why the Member’s symptoms indicate a deterioration of the approved service-connected injury/illness or occupational disability.

 

5.9.02 – RECIPIENTS OF DISABILITY BENEFITS

 

All Members drawing disability benefits of whatever nature shall identify a physician as defined in and under the conditions prescribed for under “Attending Physician” in Section 5.9.01 of this Administrative Rule.

 

5.9.03 – MEDICAL SERVICES

 

(A) Reimbursement for actual, reasonable and necessary expenses, as determined by the Director, paid for or incurred by a Member as a result of a service-connected or occupational injury or illness shall be paid as provided below:

 

(1) Members shall be reimbursed for the actual, reasonable and necessary medical expenses they have paid for or incurred. Payment directly to the medical care provider shall be deemed to be reimbursement of the Member.

 

(2) Actual, reasonable and necessary costs for travel, prescriptions and other necessary expenses paid by the Member will be reimbursed upon request by the Member.

 

(3) All requests for reimbursement shall be made on forms provided by the Director and accompanied by itemized documentation which supports the request. For example, requests for reimbursement for prescriptions must be accompanied by a receipt from the provider identifying the prescription and its price and requests for mileage reimbursement must be accompanied by a statement reflecting the actual mileage traveled.

 

(4) Reimbursement for the cost of meals, lodging, public transportation or use of a private vehicle shall be at the rate of reimbursement paid to City employees when incurring such expenses.

 

(5) Reimbursement for the cost of meals, lodging or travel exceeding 50 miles will be paid only if such expenses are pre-approved by the Director.

 

(6) Expenses incurred for public transportation or the use of a private automobile will be reimbursed based on the most direct route between the Member's home and the facility where the service is to be performed.

 

(7) All requests for reimbursement for expenses paid by the Member must be submitted to and received by the Director within sixty (60) days of making payment for or incurring the expense for which reimbursement is sought.

 

(8) Initial determinations regarding actual, reasonable and necessary medical and other expenses shall be made by the Director. Members shall be advised in writing of any denials. In the event that a denial is issued by the Director, the Member may appeal such determination by filing with the Director a written notice of appeal requesting reconsideration before a hearings officer. However, the reconsideration shall not be granted unless the notice of appeal is received by the Director within sixty (60) days after the mailing of the determination, unless the Member can establish good cause why the notice of appeal was not received until after the required sixty (60) days.

 

(9) Medical or hospital service providers that have fee agreements with the Director. Notwithstanding the provisions of subsection (1) above, Members receiving disability benefits must obtain hospital and Medical Services for service-connected or occupational disability injuries or illnesses from providers or organizations that have fee agreements with the Director, except in those circumstances described in subsection (10) below. A listing of such providers shall be on file in and available from the Director’s office.

 

Medical or hospital service providers or organizations that have a fee agreement with the Director shall provide Medical Services to Members that are subject to the terms and conditions of said agreement.

 

(10) Medical or hospital service providers that do not have a fee agreement with the Director. Members may obtain and will be reimbursed for the actual and reasonable costs of necessary medical or hospital services received from providers who do not have fee agreements with the Director in the circumstances described below. Payment directly to the provider will be considered to be reimbursement to the Member.

 

(a) The Member has a life-threatening emergency requiring immediate medical care at the nearest emergency facility. Life-threatening emergencies include, but are not limited to, situations such as profuse bleeding, loss of consciousness, breathing difficulty or sudden severe head trauma.

 

(b) The Member is traveling in an area in which there are no providers who have a fee agreement with the Director and a service-connected injury or illness or occupational disability requires immediate medical treatment.

 

(11) Medical treatment and services provided by approved health care providers must be consistent with the nature of the approved service-connected injury or illness or occupational disability, and care that is reasonable and necessary to promote recovery.

 

(B) The Director reserves the right to request of the Member’s Attending or Specialty Physician, evidence of the frequency, extent and efficacy of treatment and services.

 

(C) Ancillary Services provided by a health care provider other than the Member’s Attending Physician will not be reimbursed unless prescribed by the Member’s Attending or Specialty Physician. These services must be according to a treatment plan that has been provided to the Member’s Attending or Specialty Physician within a reasonable time of when the ancillary treatment begins. The treatment plan must include the following:

 

(1) objectives of planned treatment;

 

(2) description of modalities to be provided;

 

(3) frequency of treatments; and

 

(4) duration of treatments.

 

The Member’s Attending or Specialty Physician shall sign off on the ancillary treatment plan and send a copy to the Director.

 

5.9.04 – MEDICAL SERVICES GUIDELINES

 

Medical Services provided to the injured Member must not be more than is reasonable and necessary to treat the approved service-connected injury/illness or occupational disability. The Director may deny services that are shown to be more than the nature of the approved service-connected injury/illness or occupational disability or the process of recovery requires. Accepted professional standards will be relied upon in making these determinations.

 

(A) The utilization and treatment standard for physical therapy included in any fee agreement with a medical or hospital service provider will be followed. If none exists, the number and duration of therapy visits covered will not exceed what is medically reasonable and necessary under accepted professional standards. The Member’s Attending or Specialty Physician will be required to provide the Director with a written explanation for visits exceeding this standard.

 

(B) Attending Physicians may prescribe treatment or services to be carried out by persons not licensed to provide a Medical Service or treat independently only when such services or treatment is rendered under the Attending or Specialty Physician’s direction.

 

(C) Massage therapy not administered under the direct oversight of an Attending Physician must comply with the requirements for “Ancillary Services” in these rules.

 

(D) Prescription drugs may be purchased by the Member at a pharmacy of the Member’s choice. The Director may ask that the Member access the services of providers that the Director has made fee agreements with. Except in an emergency, drugs and medicine for oral consumption supplied by an Attending Physician must not exceed that which is medically necessary to treat the Member.

 

(E) Post-Medically Stationary medical care may fall into one of the following categories:

 

(1) Curative Care: Medical care necessary to stabilize a temporary and acute flare up of symptoms of the Member’s condition; or

 

(2) Palliative Care: Medical care that is reasonable and necessary to reduce or temporarily moderate the intensity of an otherwise stable condition and/or is reasonable and necessary to enable the Member to continue current employment or a vocational training program.

 

In both cases, the Member’s Attending Physician will be required to submit to the Director a written request that provides the following:

 

(1) a description of the objective findings;

 

(2) the diagnosed medical condition for which the care is being requested, to include the appropriate ICD-9-CM diagnosis code;

 

(3) provide an explanation of how and why requested care is reasonable and necessary and will improve the Member’s condition; and/or is reasonable and necessary to enable the Member to continue current employment or a vocational training program; and

 

(4) a description of how the care is medically reasonable and necessary to treat the approved Claim.

 

5.9.05 – NONCOVERED SERVICES

 

(A) Medical treatment that is excessive, unscientific, unproven as to its effectiveness, outmoded, inappropriate or experimental in nature is not reimbursable. Accepted professional standards will be relied upon in making these determinations.

 

(B) Dietary supplements, unless prescribed by the Member’s Attending or Specialty Physician specifically as medical treatment for an approved dietary deficiency condition are not reimbursable.

 

(C) Articles including but not limited to beds, hot tubs, chairs, Jacuzzis and gravity traction devices are not covered unless a need is clearly justified by a report which establishes that the nature of the injury or the process of recovery requires the item be furnished. The report must specifically set forth why the Member requires an item not usually considered necessary in the great majority of workers with similar impairments.

 

(D) Trips to spas, resorts or retreats, whether prescribed or in association with a holistic medicine regimen, are not reimbursable unless special medical circumstances are shown to exist that render such treatment medically reasonable and necessary.

 

(E) Physical Restorative Services may include but are not limited to a regular exercise program, gym membership or swim therapy. Such services are not compensable unless the nature of the Member’s limitations requires specialized services to allow the Member a reasonable level of social and/or functional activity. The Attending Physician must justify by report why the Member requires services not usually considered necessary for the majority of injured workers.

 

(F) The Director may deny services that are shown to be more than the nature of the approved service-connected injury/illness or occupational disability or the process of recovery requires. Accepted professional standards will be relied upon in making these determinations.

 

5.9.06 – INDEPENDENT MEDICAL EXAMINATIONS

 

(A) If requested by the Director, any Member potentially eligible to receive benefits under this program is required to undergo an Independent Medical Examination (IME) by one or more licensed physician or psychologist. 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 examination has taken place.

 

(B) The Director is not required to schedule an IME appointment during a Member’s work hours. Members will be required to attend an IME during off-work hours, as well as work hours, if so scheduled, and unless there is good cause for not attending the IME. An IME scheduled during a Member’s off-work hours is not considered good cause, of and by itself, for not attending an IME.

 

(C) The Member may request a change in the IME appointment date, time or place for good cause.

 

(D) FPDR will mail a written notice to the Member by certified and regular mail at least fourteen (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 fourteen (14) days notice if Member agrees.

 

(E) The Member’s notification of the medical examination shall include the following information:

 

(1) the name of the examiner and 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.

 

(F) The Member must cooperate with a scheduled IME by arriving at the date and time of the scheduled appointment and cooperating with the examination unless the Member can show good cause for non-cooperation.

 

(G) Suspension or reduction of benefits may result from non-cooperation in participation with an IME.

 

(H) 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.

 

(I) 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.

 

(J) When Elective Surgery is recommended by the Member’s Attending or Specialty Physician, the Member may be required to attend an IME with an independent consultant prior to approval of the surgery.

 

(1) The Director will notify the Attending or Specialty Physician within seven (7) days of receiving a request to approve surgery that an IME will be required prior to approval of the surgery.

 

(2) The Director will arrange the IME as soon as possible, but no later than thirty (30) days following the request for surgery by the Member’s Attending Physician or Specialty Physician.

 

(3) The Director will issue a decision to approve or deny the request for surgery as soon as possible, but no later than twenty-one (21) days, following the date of the IME.

 

5.9.07 – MEDICAL MANAGEMENT PROGRAMS

 

(A) Clinical Case Management: Clinical case management is the use of a combination of medical professionals (nurses and physicians) to manage or assist in managing the medical and disability aspects of service-connected injury/illness and occupational disability Claims.

 

(1) Typical clinical case management providers and services may include telephonic and field nurse case management services, utilization management and physician advisor.

 

(2) A Nurse Case Manager may be assigned to monitor and track recovery of a Member’s approved Claim when deemed appropriate by the Director.

 

(a) Members are required to cooperate with the Nurse Case Manager assigned to their Claim. Cooperation includes submitting to personal and/or phone contact and answering relevant medical and vocational questions posed to them by the Nurse Case Manager.

 

(b) Members may decline to allow the Nurse Case Manager to accompany them to their medical appointments.

 

(c) Members may request a change of Nurse Case Manager. However, it is at the discretion of the Director to assign a new Nurse Case Manager.

 

(B) Utilization Review: FPDR may require the use of utilization review services to provide pre-certification of surgical and specialty care prior to approval of the Medical Service. The Director may deny a Medical Services request if utilization review services deny precertification of such request.

 

5.9.08 – MEDICAL FEES AND PAYMENTS

 

(A) The Director may contract with medical or hospital service providers or groups of providers for medical or hospital services and enter into fee agreements with such to reimburse medical fees of approved Claims under these rules.

 

(B) Health care providers will submit their fees for services rendered pursuant to current Charter and FPDR Administrative Rules. Billings must be itemized and include Chart Notes, and must be submitted directly to FPDR, no later than ninety (90) days from the date of service or in accordance with the terms of their provider panel agreement with whom FPDR is contracted. A health care provider must establish good cause if billing is submitted later than 90 days from the date of service or in accordance with the terms of their provider panel agreement with whom FPDR is contracted. Failure to show good cause may result in a reduction or nonpayment of allowable charges. Members will be held harmless by the health care provider for any costs that, if not for late submission, would have been covered by FPDR.

 

(C) Medical fees will be reimbursed according to the fee agreements made between the medical providers and FPDR.

 

(D) If no fee agreement has been made with the medical provider, and the service complies with these Administrative Rules in all other respects, FPDR will reimburse at the “Usual and Customary Fee” for the Medical Service.

 

(E) FPDR payment shall be considered payment in full. Members will be held harmless by the medical provider for any costs above the usual and customary rate, as defined in 5.9.01 of these Administrative Rules, or an agreed upon fee agreement amount payable by FPDR on an otherwise approved billing.

 

(F) FPDR will date stamp each medical bill received. Bills for services rendered on approved Claims will be adjudicated within thirty (30) days of receipt. Payments will be in accordance with adopted fee schedules.

 

(G) If there is a dispute concerning the amount of a bill, the appropriateness of the service rendered or the relationship of the services to the approved Claim, FPDR must pay any undisputed portion of the bill and notify the provider of the specific reasons for nonpayment or reduction of the remainder of the bill.

 

5.9.09 – MEDICAL PAYMENT LIMITATIONS

 

(A) Member shall not pay for any Medical Service that is related to an approved service-connected or occupational disability or any amount that has been reduced by the FPDR in accordance with these Administrative Rules. A medical provider shall not attempt to collect payment for any Medical Service from a Member, except as follows:

 

(1) when the Member seeks treatment for conditions not related to the approved Claim; or

 

(2) when the Member seeks treatment that has not been prescribed by the Attending Physician, or a Specialty Physician upon referral of the Attending Physician; or

 

(3) when the Member seeks treatment outside the provider panels which FPDR has contracted with, and said treatment was not pre-authorized by FPDR; or

 

(4) when the Member seeks treatment after being notified that such treatment has been determined to be unscientific, unproven, outmoded or experimental, or has been notified that the treatment is not approved or outside of these Administrative Rules.

 

5.9.10 – POST-RETIREMENT MEDICAL BENEFITS

 

(A) Retirement from Disability: Medical and hospital expenses arising from an approved service-connected injury/illness or occupational disability shall be reimbursable, if the Member’s disability benefits continued until the Member reached Disability Retirement Age.

 

(B) Retirement from active service: For Members who are retired as of January 1, 2007, medical and hospital expenses arising from an approved service-connected injury/illness or occupational disability shall not be reimbursable.

 

(C) Retirement from active service: For Members who are not retired before January 1, 2007, medical and hospital expenses arising from an approved service-connected injury/illness or occupational disability shall be reimbursable.

 

(D) The Director shall deny the Claim for medical or hospital expense if the Director determines by a Preponderance of the Evidence that a Claim under subsection (C) from a retired Member is due to the following:

 

(1) medical or hospital expenses related to an injury/illness that was based upon fraud, misrepresentation, an omission, or illegal activity by the Member; or

 

(2) medical or hospital expenses related to an injury/illness that was accepted in good faith, in a case not involving fraud, misrepresentation, an omission, or illegal activity by the Member, and within two (2) years of the initial acceptance the Director obtains evidence that the Claim is not a service-connected or occupational illness/injury or FPDR is not responsible for the injury/illness; or

 

(3) Medical or hospital expenses are not related to the service-connected injury/illness or occupational disability.

 

5.9.11 – DISABILITY RETIREMENT AGE

 

(A) Service-connected injury/illness or occupational disability benefits payable to a FPDR Two Member shall cease at Disability Retirement Age except as provided in Section C hereof. A Member receiving service-connected injury/illness or occupational disability benefits shall be eligible to receive a retirement benefit at Disability Retirement Age, which shall be the earlier of the dates the Member is (1) credited with 30 Years of Service for retirement benefit purposes or (2) the date the Member attains Social Security retirement age. For purposes of this rule, “Social Security retirement age” means the retirement age provided in 42USC§ 416(l)(1).

 

(B) Service-connected injury/illness or occupational disability benefits payable to a FPDR Three Member shall cease at Normal Retirement Age under PERS except as provided in Section C hereof.

 

(C) If the Director determines the service-connected injury/illness or occupational disability to be temporary, benefits may continue after Disability Retirement Age for a FPDR Two Member or PERS Normal Retirement Age for a FPDR Three Member up to two (2) years from the date of such disability. A Member, who is actively employed and suffers a service-connected injury/illness, or occupational disability after attaining Disability Retirement Age for a FPDR Two Member or PERS Normal Retirement Age for a FPDR Three Member, shall be eligible to receive disability benefits for a period of up to two (2) years from the date of such disability if the Director determines the disability to be temporary.

 


HISTORY

 

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. 432 on March 23, 2009, Resolution No. 438 on May 26, 2009, Resolution No. 472 on November 27, 2012, Resolution Nos. 479 and 480 on September 24, 2013, Resolution Nos. 486, 487 and 488 on March 25, 2014, Resolution No. 491 on September 23, 2014, and Resolution No. 501 on September 22, 2015.


FPD-5.10 - Return to Work and Vocational Rehabilitation Programs Plan 2 & 3

RETURN TO WORK AND VOCATIONAL REHABILITATION PROGRAMS PLAN 2 & 3

Adminsitrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.10


 

5.10.01 – PURPOSE

 

Return to Work programs and Vocational Rehabilitation services are designed to return a disabled Member to gainful employment and reduce the payment of disability benefits by the Fund. Vocational Rehabilitation Services are optional and are approved at the discretion of the Director.

 

5.10.02 – 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 Oregon Medical Board, or a podiatric physician or surgeon licensed under ORS 677.805 to 677.840 by the Oregon Medical Board, an oral and maxillofacial surgeon licensed by the Oregon Board of Dentistry 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 thirty (30) days from the first visit on the initial Claim or for twelve (12) visits, whichever first occurs, a doctor or physician licensed by the State Board of Chiropractic Examiners for the State of Oregon or a similarly licensed doctor or physician in any country or in any state, territory or possession of the United States. All Members drawing disability benefits shall be examined at least once during each twelve-month period by the Member’s identified physician or a physician appointed by the Director, unless otherwise determined by the Director.

 

“Base Pay.” The term “Base Pay” means the Base Pay of the Two or Three Member’s position in the Bureau of Fire or Police, including premium pay but excluding overtime and payments for unused vacation, sick or other leave. When a Member is paid overtime for part of his or her regular work schedule as required by Fair Labor Standards Act provisions, the straight-time portion of the overtime hours in the Member’s regular work schedule shall be included in Base Pay.

 

“Base Pay at Disability.” The term “Base Pay at Disability” means the Member’s base pay amount at the time the disability payment is due.

 

“Date of Disability.” The term “Date of Disability” means the date that the Member’s Attending Physician establishes that the Member is first unable to perform the Member’s required duties as a result of a service-connected injury/illness or occupational disability that has been determined to arise out of and in the course of the Member’s employment in the Bureau of Fire or Police.

 

“Full-Time Work.” For the purpose of Other Employment, the term “Full-Time Work” means working an average of at least thirty-six (36) hours per week or the maximum work hours documented in the permanent restriction(s) placed by the Attending Physician.

 

“Original Injury.” The term “Original Injury” means the period from the first occasion of medical treatment or disability resulting from a service-connected injury/illness or occupational disability through the date the Member first reaches a medically stationary status.

 

“Other Employment.” The term “Other Employment” means employment with any person, firm, company, corporation, government agency, municipality or Self-Employment, and does not include employment as an Active Member of the Bureau of Fire or Bureau of Police, or work performed as part of an approved Transitional Duty Return to Work Program in accordance with Administrative Rule 5.10.03.

 

“Pursue Other Employment.” The term “Pursue Other Employment” means an active, serious and continuing effort to seek Full Time Work each week that the Member claims benefits.

 

“Substantial Gainful Activity.” The term “Substantial Gainful Activity” means the Member is qualified, physically and by education and experience, to pursue employment with earnings equal to or exceeding one-third of the Member’s rate of Base Pay in Effect at Disability.

 

“Transferable Skills.” The term “Transferable Skills” means the knowledge, skills and abilities demonstrated in past training and employment which make a Member employable at work with a new employer and with earnings equal to or exceeding one-third (1/3) of the Member’s rate of Base Pay at Disability.

 

“Transitional Duty.” The term “Transitional Duty” means available tasks that allow a disabled Member to return to work at an assignment that is less physically/mentally demanding than the Member’s regular work for a limited period of time. Also known as “Limited Duty.”

 

“Vocational Assessment.” The term “Vocational Assessment” means an evaluation, performed by a certified vocational counselor, consisting of one or more tests conducted to determine if a Member has reached a level of Substantial Gainful Activity.

 

“Vocational Rehabilitation.” The term “Vocational Rehabilitation” means any services, goods or allowance intended to support the Member’s return to work efforts. A process initiated as early as possible for a Member who has been disabled and may require a different job or career as a result. May include Vocational Assessment, labor market surveys, developing alternative work plans, retraining and assistance with job-seeking skills.

 

5.10.03 – TRANSITIONAL DUTY RETURN TO WORK PROGRAM

 

The Transitional Duty Return to Work Program is a program designed to assist Members who are temporarily disabled due to an injury or illness.

 

(A) When a Member reports an injury or illness, he/she will be given certain forms to take to a doctor upon completion of an examination and/or treatment. If the doctor determines that the Member is not able to return to his/her regular duty but is capable of some level of work activity, the doctor will complete the appropriate forms indicating the restrictions and conditions for transitional work. FPDR will provide this information to the Member’s bureau which will then attempt to provide limited transitional work until the Member is able to resume regular duties.

 

(B) Members performing limited Transitional Duty will receive their regular rate of pay for hours worked. If they work their regular full shift, there will be no loss of wages. If they work less than their regular full shift, a disability benefit will be payable in accordance with Chapter 5 of the City Charter and these Administrative Rules. The Member’s bureau may modify, change or discontinue the Transitional Duty assignment or conditions of the program at any time.

 

(C) Whenever the Director has medical evidence that a Member who is receiving disability benefits is capable of performing Transitional Duty the Director shall notify the Member's bureau chief of that fact. Included in the notification will be a report of the Member's limitations and a request that the bureau chief provide the Member with a job that is compatible with the Member's limitations.

 

(D) Transitional Duty may include temporary changes in the work environment, assigned tasks or the manner by which assigned tasks are completed. The assignment is for a maximum ninety (90) consecutive days and will be monitored by staff and the bureau liaison.

 

(E) If it appears to staff that a Transitional Duty assignment will not be completed in ninety (90) consecutive days, the Member’s bureau and staff will review the assignment for possible extension beyond ninety (90) consecutive days. If a decision to extend the assignment beyond ninety (90) consecutive days is made, it will occur in accordance with and Fire and Police Bureau protocols. The Member’s particular circumstances as well as reliable medical information from a qualified medical professional will also be taken into account.

 

(F) The Director may provide a wage subsidy not to exceed 75% of the Member’s wage for a specified number of days, not to exceed 180 days, approved for the Transitional Duty assignment.

 

5.10.04 – VOCATIONAL REHABILITATION PROGRAM GOALS

 

The goals of a Vocational Rehabilitation program are to assess the feasibility and benefit of Vocational Rehabilitation services to the Fund and the disabled Member; and

 

(A) return the Member to his or her former job with the Bureau of Fire or the Bureau of Police;

 

(B) return the Member to the same (but modified) job with the Bureau of Fire or the Bureau of Police;

 

(C) return the Member to work, performing a different job that capitalizes on Transferable Skills with the Bureau of Fire or the Bureau of Police, or with another City of Portland agency;

 

(D) return the Member to work, performing a different job that capitalizes on Transferable Skills with a different employer; or

 

(E) return the Member to work, performing a different job that requires training with the Bureau of Fire or the Bureau of Police, another City of Portland agency or a different employer.

 

5.10.05 – VOCATIONAL ASSESSMENT

 

(A) The purpose of a Vocational Assessment is to determine if the Member is capable of Substantial Gainful Activity, as defined in these Administrative Rules; as well as to determine if the Member is eligible for Vocational Rehabilitation services.

 

(B) A Vocational Assessment of the feasibility of Vocational Rehabilitation will be done regarding a Member who:

 

(1) experiences a service-connected injury/illness or occupational disability or a nonservice-connected injury/illness; and

 

(2) has been declared or is reasonably expected to be declared Medically Stationary by the Member’s Attending Physician; or

 

(3) is treated Medically Stationary pursuant to Section 5-306(d)(2) and administratively placed in a Medically Stationary status by FPDR; or

 

(4) has been determined by the Member’s Attending Physician to have permanent restrictions or a reasonable expectation of permanent restrictions as a consequence of a service-connected injury/illness, occupational disability or a nonservice-connected injury/illness.

 

(C) Components of a Vocational Assessment may include but not be limited to:

 

(1) relevant work history for at least the preceding five (5) years;

 

(2) level of education, and proficiency in spoken and written English or other languages, where relevant;

 

(3) achievement or aptitude test data;

 

(4) permanent limitations due to the disability;

 

(5) an analysis of the Member’s Transferable Skills;

 

(6) a list of jobs for which the Member has the knowledge, skills and abilities and for which a reasonable labor market is documented to exist; and

 

(7) Consideration of the vocational impact of any permanent limitations which existed prior to the disability.

 

(D) For the purpose of determining Substantial Gainful Activity, labor market surveys will be confined to within a 50-mile radius of the location of the Member’s City of Portland employment or a 50-mile radius of the Member’s current residence if the labor market in which the Member currently resides offers more opportunity for gainful employment.

 

5.10.06 – VOCATIONAL REHABILITATION PROGRAM ELIGIBILITY

 

(A) A Member is eligible for Vocational Rehabilitation services when:

 

(1) the Member has fully participated in a Vocational Assessment as provided in these Administrative Rules; and

 

(2) vocational Rehabilitation services and associated costs are reasonably expected to reduce overall disability benefits that would likely be incurred until the Member reaches Disability Retirement Age.

 

(B) A Member shall participate in Vocational Rehabilitation services if the Member meets the eligibility criteria in this section and the Member is not capable of Substantial Gainful Activity as defined in these Administrative Rules.

 

(C) A Member who is determined to be capable of Substantial Gainful Activity may be approved for Vocational Rehabilitation services only if, after analysis, the Director determines that there is a reasonable likelihood that such services will result in a reduction in disability costs.

 

5.10.07– VOCATIONAL REHABILITATION PLAN

 

(A) A Member who is determined to be eligible for Vocational Rehabilitation services, along with a Vocational Rehabilitation specialist, will develop a specifically achievable Vocational Rehabilitation plan.

 

(B) The components of the Vocational Rehabilitation plan may include but not be limited to:

 

(1) written vocational goals and objectives;

 

(2) the actions that must be taken to achieve the goals and objectives;

 

(3) the services (including any recommended training) needed to fulfill the plan;

 

(4) the projected start date and completion date of the actions to be taken and services to be provided;

 

(5) the job-seeking and placement-related activities that will facilitate securing employment;

 

(6) the way in which progress towards completing the plan will be evaluated; and

 

(7) the cost of the services and other expenses associated with the plan.

 

(C) The Member will have the option of choosing to have future disability benefits reduced to the 25% minimum upon successful completion (or sixty (60) days after successful completion) of a vocational training program, in lieu of submitting wage information to for purpose of wage offset.

 

(D) Vocational Rehabilitation plan types include:

 

(1) Return to Work Plans: Services that are geared toward the Member being provided:

 

(a) a bona fide offer of return to work, performing a different job that capitalizes on Transferable Skills with the Bureau of Fire or the Bureau of Police; or

 

(b) a bona fide offer of return to work, performing a different job that capitalizes on Transferable Skills with another City of Portland agency.

 

(2) Direct Employment Plans: Services provided to a Member who has the necessary Transferable Skills to obtain suitable new employment with earnings equal to or exceeding one-third of the Member’s rate of Base Pay in Effect at disability. Direct Employment Services may consist of one or more of the following:

 

(a) employment counseling

 

(b) job search skills instruction

 

(c) job development

 

(d) job analysis

 

(3) Training Programs: Training programs shall consist of formal or informal instruction designed to teach a Member job skills which will enable the Member to obtain employment in or outside of the bureau which employed the Member.

 

(a) Training program services shall include plan development, training, monthly monitoring of training progress and job placement services if necessary.

 

(b) Training program services shall be limited to an aggregate of sixteen (16) months. As appropriate, the Director may allow an extension to twenty one (21) months, an additional five (5) months.

 

(c) Training plan objectives and the kind of training shall attempt to minimize the length and cost of training necessary to prepare the Member for suitable employment.

 

(4) Optional Services: Optional services are limited services which may be provided to a Member, an otherwise ineligible Member or to an eligible Member in excess of those services described in these Administrative Rules. Such services are provided at the discretion of the Director. The cost associated with such limited services shall not exceed ten (10) percent of the total expense limit provided in Section 5.10.11 (K) of these Administrative Rules.

 

5.10.08 – COOPERATION IN VOCATIONAL REHABILITATION

 

(A) A Member receiving disability benefits must cooperate in Vocational Rehabilitation processes as follows:

 

(1) fully participate in an assessment of Substantial Gainful Activity and the feasibility of Vocational Rehabilitation;

 

(2) if determined capable of Substantial Gainful Activity without retraining, participate in any Direct Employment or other Optional Services available in these Administrative Rules;

 

(3) if determined eligible for Vocational Rehabilitation, cooperate in the development of a reasonable and specifically achievable Vocational Rehabilitation plan consistent with the purpose and goals of Vocational Rehabilitation;

 

(4) fully participate in the approved Vocational Rehabilitation plan; and

 

(5) upon completion of an approved Vocational Rehabilitation plan, the Member “Pursues Other Employment,” as defined in these Administrative Rules, in the field for which the Vocational Rehabilitation services were provided.

 

(B) For service-connected injury/illness or occupational disability benefits, a Member’s failure to cooperate in any Vocational Rehabilitation services or plans may result in suspension or reduction of benefits.

 

(C) For nonservice-connected disability benefits, a Member’s failure to cooperate in any Vocational Rehabilitation services or plans may result in reduction or termination of benefits.

 

5.10.09 – SEEKING OHTER EMPLOYMENT

 

A Member receiving service-connected, occupational or nonservice-connected disability benefits who is released to modified duty and capable of Substantial Gainful Activity but who is unable to return to the bureau of which he or she was an employee at the time of becoming disabled, shall Pursue Other Employment within the Member’s restrictions.

 

(A) The concept of an active work search includes consideration of the customary methods of obtaining work for which the Member is suited by experience, education, and/or training.

 

(B) A Member who is seeking employment will develop verifiable documentation of the reasonable efforts to find work without placing restrictions. The Member will be required to provide verifiable documentation of his or her reasonable efforts to find gainful employment to the Director every other week. Telephone inquiries are considered preliminary exploration of the job market and should be accompanied by appropriate follow-up contacts, personal visits, and submission of applications or résumés.

 

5.10.10 – SUSPENSION, REDUCTION OR TERMINATION OF BENEFITS

 

(A) For service-connected and occupational disability benefits and for nonservice-connected disability benefits, if the Director obtains evidence that the Member is not cooperating in Vocational Rehabilitation or is not pursuing other employment, the Director shall notify Member of the Director’s determination to suspend, reduce or terminate benefits.

 

(B) The Member shall be notified of the rights under Charter Section 5-202(h)(3) to appeal the decision. Any such written request must be filed with the Director within sixty (60) days after the date of the decision being appealed.

 

5.10.11 - CESSATION OF ELIGIBILITY FOR VOCATIONAL REHABILITATION SERVICES

 

A Member's eligibility for Vocational Rehabilitation services will end when any of the following conditions have been met:

 

(A) The applicable purpose and goals of the Vocational Rehabilitation plan referred to in these Administrative Rules have been attained.

 

(B) The Member has been employed with the bureau of which he or she was a Member at the time of becoming disabled for sixty (60) days, has been employed by another bureau or employer or has been self-employed for sixty (60) days. This provision shall not apply if additional Vocational Rehabilitation services are required to overcome obstacles to the Member's continued employment.

 

(C) The Member's employment ends for a reason unrelated to the Member's service- connected, occupational or nonservice-connected disability.

 

(D) The Member has refused an offer of employment after he or she has been rehabilitated to the extent necessary that he or she possesses the physical capacities, knowledge, skills and abilities for such employment.

 

(E) The Member has declined Vocational Rehabilitation services, has become unavailable for Vocational Rehabilitation services or has retired.

 

(F) The Member has failed, after written warning, to fully participate in a Vocational Assessment of his or her eligibility for Vocational Rehabilitation services or to provide requested information.

 

(G) The Member has failed, after written warning, to fully comply with the Member's responsibilities under a Vocational Rehabilitation plan.

 

(H) The Member has stopped attending training without notifying either the Vocational Rehabilitation services provider or the Director.

 

(I) The Member's lack of employment or self-employment for which he or she has the necessary physical capacity, knowledge or skills and abilities cannot be resolved by Vocational Rehabilitation services.

 

(J) The Member has misrepresented a matter which was material to the assessment of eligibility or the provision of Vocational Rehabilitation services.

 

(K) Notwithstanding any other provision in these Administrative Rules, the period of time between plan implementation and plan completion reaches twenty four (24) months, or the total expenses associated with the plan reach the maximum allowance for the authorized plan, whichever comes first. The expense limit may be adjusted annually by the Director in keeping with similar annual adjustments made by the Oregon Department of Consumer and Business Services, Workers’ Compensation Division, and published in Bulletin 124.

 

5.10.12 – VOCATIONAL REHABILITATION EXPENSES

 

(A) Reimbursement will be consistent with the fee schedule established by the Oregon Workers’ Compensation Division Administrative Rule 436-120-0720 and Bulletin 124.

 

(B) To receive reimbursement for Vocational Rehabilitation services, a disabled Member must obtain such services from a provider of Vocational Rehabilitation services approved by the Director.

 

(C) Reimbursement for Vocational Rehabilitation services provided to a Member will be authorized only if the services are included in a Vocational Rehabilitation plan which has been approved in advance by the Director, subject to the limits provided in these Administrative Rules.

 

5.10.13 – RIGHT TO REQUEST A DIFFERENCE VOCATIONAL REHABILITATION SPECIALIST

 

A Member has the right to request a different Vocational Rehabilitation specialist providing Vocational Rehabilitation services. Any such request should be made to the Director, who shall review the request, and in the event good cause for the requested change is established, the Director shall authorize the Member to work with a different Vocational Rehabilitation specialist.

 

5.10.14 – RIGHT OF APPEAL

 

Any Member adversely affected by a decision of the Director has the right of appeal to a hearings officer. Any such written request must be filed with the Director within sixty (60) days after the date of the decision being appealed.

 


HISTORY

 

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. 433 on March 23, 2009, Resolution No. 446 on August 25, 2009, Resolution No. 472 on November 27, 2012, Resolution Nos. 479, 480 and 482 on September 24, 2013, Resolution No. 488 on March 25, 2014, and Resolution No. 491 on September 23, 2014.


FPD-5.11 - Service-Connected or Occupational Disability Benefits Plan 1

SERVICE-CONNECTED OR OCCUPATIONAL DISABILITY BENEFITS PLAN 1

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.11


 

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 thirty (30) days from the first visit on the initial claim or for twelve (12) visits, whichever first occurs, a doctor or physician licensed by the State Board of Chiropractic Examiners for the State of Oregon or 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 the 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 thirty (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 and 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 ninety (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/her 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 maybe, 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 (12) 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; be self-employed; 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, or 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 Attending 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 fourteen (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 fourteen (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.

 


HISTORY

 

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, Resolution No. 455 on June 28, 2011, and Resolution No. 491 on September 23, 2014.


FPD-5.12 - Non Service-Connected Disability Benefits Plan 1

NON SERVICE-CONNECTED DISABILITY BENEFITS PLAN 1

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.12


 

5.12.01 – 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 thirty (30) days from the first visit on the initial Claim or for twelve (12) visits, whichever first occurs, a doctor or physician licensed by the State Board of Chiropractic Examiners for the State of Oregon or 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, 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.

 

5.12.02 – DISABILTY BENEFITS GENERALLY

 

(A) Payment of Disability Benefits: Disability benefits will be paid to a Member pursuant to Section 5-116 and only during such time as the Member is incapacitated from performing his/her required duties on account of injury or sickness not service connected. Disability benefits shall cease when the Member is capable of performing the duties required of him or her by the Bureau of Police or the Bureau of Fire and Rescue.

 

(B) Cessation of Benefits: A disabled Member who is receiving nonservice-connected 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) If a Member reaches Compulsory Retirement Age while receiving nonservice-connected disability benefits under this Section, such benefits shall cease forthwith, and the Member shall be retired by the Board and shall receive his or her maximum earned pension. All applications for benefits under this Section shall be duly verified and accompanied by a certificate from a legally licensed physician setting forth the cause or basis of the disability claimed.

 

5.12.03 – 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 it deems necessary to carry out its duties.

 

(C) Application 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 thirty (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. 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 nonservice-connected 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 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.

 

5.12.04 – ELIGIBILITY AND AMOUNT OF BENEFITS

 

Any Active Member with at least one (1) year of active service who becomes incapacitated from performing his or her required duties on account of injury or sickness not service connected, and who at the time of said disability was either a recipient of disability benefits under Section 5-115 or was contributing to the Fund from his or her current salary in accordance with the provisions of Article 5 of the Plan, shall, upon the cessation of his or her sick leave benefits for such cause and upon cessation of his or her current salary other than vacation pay, be entitled to benefits equal to his or her maximum earned pension, but in no event less than twenty percent of the then current salary of a First Class Fire Fighter or First Class Police Officer, as the case may be, until he or she recovers, or if he or she has not recovered, until he or she reaches Compulsory Retirement Age. The Board, or designee, shall determine whether the applicant for benefits meets the requirements herein set forth.

 

5.12.05 – 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 (12) 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; and

 

(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 Attending 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 Board of Trustees, or designee, of the right of the Member to receive benefits from the Fund.

 

5.12.06 – 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. Authorization from an inpatient or outpatient hospital physician (emergency room physician or hospitalist) will be considered on a case-by-case basis.

 

5.12.07 – CLAIM APPROVAL OR DENIAL

 

(A) No Member shall receive nonservice-connected disability benefits for disabilities resulting from the following:

 

(1) willful injuries;

 

(2) injuries sustained while, or illness contracted as a result of, willfully doing an unlawful act; or

 

(3) weakness, illness or disability resulting directly or indirectly from the habitual excessive use of or addiction to use of alcoholic beverages or illegal drugs.

 

(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.

 

(2) Notice of Denial: A Notice of Denial shall be addressed to the Member, 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 ninety (90) days from of 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.

 

5.12.08 – 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 physician or psychologist. 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 fourteen (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 fourteen (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.

 

5.12.09 – 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.

 

5.12.10 – 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.

 


HISTORY

 

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. 441 on May 26, 2009, Resolution No. 456 on June 28, 2011, and Resolution No. 491 on September 23, 2014.


FPD-5.13 - Medical Benefits Plan 1

MEDICAL BENEFITS PLAN 1

Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority

ARB-FPD-5.13


 

5.13.01 – 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 thirty (30) days from the first visit on the initial claim or for twelve (12) visits, whichever first occurs, a doctor or physician licensed by the State Board of Chiropractic Examiners for the State of Oregon or 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.

 

5.13.02 – MEDICAL SERVICES

 

(A) Reimbursement for actual, reasonable and necessary expenses, as determined by the Director, incurred by a Member as a result of a service-connected injury/illness or occupational disability shall be paid as provided below:

 

(1) Members shall be reimbursed for the actual, reasonable and necessary medical expenses they have incurred. Payment directly to the medical care provider shall be deemed to be reimbursement of the Member.

 

(2) Actual, reasonable and necessary costs for travel, prescriptions and other necessary expenses paid by the Member will be reimbursed upon request by the Member.

 

(3) All requests for reimbursement shall be made on forms provided by the Director and accompanied by itemized documentation which supports the request. For example, requests for reimbursement for prescriptions must be accompanied by a receipt from the provider identifying the prescription and its price and requests for mileage reimbursement must be accompanied by a statement reflecting the actual mileage traveled.

 

(4) Reimbursement for the cost of meals, lodging, public transportation or use of a private vehicle shall be at the rate of reimbursement paid to City employees when incurring such expenses.

 

(5) Reimbursement for the cost of meals, lodging or travel exceeding fifty (50) miles will be paid only if such expenses are preapproved by the Director.

 

(6) Expenses incurred for public transportation or the use of a private automobile will be reimbursed based on the most direct route between the Member's home and the facility where the service is to be performed.

 

(7) All requests for reimbursement for expenses paid by the Member must be submitted to and received by the Director within sixty (60) days of incurring the expense for which reimbursement is sought.

 

(8) Initial determinations regarding actual, reasonable and necessary medical and other expenses shall be made by the Director. Members shall be advised, in writing, of any denials. In the event that a denial is issued by the Director, the Member may appeal such determination by filing with the Director a written notice of appeal requesting reconsideration before a hearings officer. However, the reconsideration shall not be granted unless the notice of appeal is received by the Director within sixty (60) days after the mailing of the determination, unless the Member can establish good cause why the notice of appeal was not received within the required sixty (60) days.

 

(B) Medical treatment and services provided by approved health care providers must be consistent with the nature of the approved injury or disease, and care that is reasonable and necessary to promote recovery.

 

(C) The Director reserves the right to request of the Member’s Attending or Specialty Physician, evidence of the frequency, extent and efficacy of treatment and services.

 

(D) Ancillary Services provided by a health care provider other than the Member’s Attending Physician will not be reimbursed unless prescribed by the Member’s Attending or Specialty Physician. These services must be according to a treatment plan that has been provided to the Member’s Attending or Specialty Physician within a reasonable time of when the ancillary treatment begins. The treatment plan must include the following:

 

(1) objectives of planned treatment;

 

(2) description of modalities to be provided;

 

(3) frequency of treatments; and

 

(4) duration of treatments.

 

The Member’s Attending or Specialty Physician shall sign off on the ancillary treatment plan and send a copy to the Director.

 

5.13.03 – MEDICAL SERVICES GUIDELINES

 

Medical Services provided to the injured Member must not be more than is reasonable and necessary to treat the approved injury/illness or occupational disability. The Director may deny services that are shown to be more than the nature of the approved injury/illness or the process of recovery requires. Accepted professional standards will be relied upon in making these determinations.

 

(A) The utilization and treatment standard for physical therapy included in any fee arrangement agreement with a medical or hospital service provider will be followed. If none exists, the number and duration of therapy visits covered will not exceed what is medically reasonable and necessary under accepted professional standards. The Member’s Attending or Specialty Physician will be required to provide the Director with a written explanation for visits exceeding this standard.

 

(B) Attending Physicians may prescribe treatment or services to be carried out by persons not licensed to provide a Medical Service or treat independently only when such services or treatment is rendered under the physician’s direction.

 

(C) Massage therapy not administered under the direct oversight of a physician must comply with the requirements for Ancillary Services in these rules.

 

(D) Prescription drugs may be purchased by the Member at a pharmacy of the Member’s choice. The Director may ask that the Member access the services of providers that the Director has made fee arrangements with. Except in an emergency, drugs and medicine for oral consumption supplied by a physician must not exceed that which is medically necessary to treat the Member.

 

(E) Post-Medically Stationary medical care may fall into one of the following categories:

 

Curative Care: Medical care necessary to stabilize a temporary and acute flare up of symptoms of the Member’s condition; or

 

Palliative Care: Medical care that is reasonable and necessary to reduce or temporarily moderate the intensity of an otherwise stable condition and/or is reasonable and necessary to enable the Member to continue current employment or a vocational training program.

 

In both cases, the Member’s Attending Physician will be required to submit to the Director a written request that provides the following:

 

(1) a description of the objective findings;

 

(2) the diagnosed medical condition for which the care is being requested, to include the appropriate ICD-9-CM diagnosis code;

 

(3) provide an explanation of how and why requested care is reasonable and necessary and will improve the Member’s condition; and/or is reasonable and necessary to enable the Member to continue current employment or a vocational training program; and

 

(4) a description of how the care is medically reasonable and necessary to treat the approved Claim.

 

5.13.04 – NON-COVERED SERVICES

 

(A) Medical treatment that is excessive, unscientific, unproven as to its effectiveness, outmoded, inappropriate or experimental in nature is not reimbursable. Accepted professional standards will be relied upon in making these determinations.

 

(B) Dietary supplements, unless prescribed by the Member’s Attending or Specialty Physician specifically as medical treatment for an approved dietary deficient condition are not reimbursable.

 

(C) Articles including but not limited to beds, hot tubs, chairs, Jacuzzis, and gravity traction devices are not covered unless a need is clearly justified by a report which establishes that the “nature of the injury or the process of recovery requires” the item be furnished. The report must specifically set forth why the Member requires an item not usually considered necessary in the great majority of workers with similar impairments.

 

(D) Trips to spas, to resorts or retreats, whether prescribed or in association with a holistic medicine regimen, are not reimbursable unless special medical circumstances are shown to exist that render such treatment medically reasonable and necessary.

 

(E) Physical Restorative Services may include but are not limited to a regular exercise program, gym membership or swim therapy. Such services are not compensable unless the nature of the Member’s limitations requires specialized services to allow the worker a reasonable level of social and/or functional activity. The Attending Physician must justify by report why the Member requires services not usually considered necessary for the majority of injured workers.

 

(F) The Director may deny services that are shown to be more than the nature of the approved injury/illness or the process of recovery requires. Accepted professional standards will be relied upon in making these determinations.

 

5.13.05 – 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 examination has taken place.

 

(B) The Director is not required to schedule an IME appointment during a Member’s work hours. Members will be required to attend an IME during off work hours, as well as work hours, if so scheduled, and unless there is good cause for not attending the IME. An IME scheduled during a Member’s off work hours is not considered good cause, of and by itself, for not attending an IME.

 

(C) FPDR will mail a written notice to the Member by certified and regular mail at least fourteen (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 fourteen (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.

 

(D) The Member may request a change in the appointment date, time or place for good cause.

 

(E) The Member must cooperate with a scheduled IME by arriving at the date and time of the scheduled appointment and cooperating with the examination unless the Member can show good cause for non-cooperation.

 

(1) Suspension or reduction of benefits may result from noncooperation in participation with an IME.

 

(F) When Elective Surgery is recommended by the Member’s Attending or Specialty Physician the Member may be required to attend an IME with an independent consultant prior to approval of the surgery.

 

(1) The Director will notify the physician within seven (7) days of receiving a request to approve surgery that an IME will be required prior to approval of the surgery.

 

(2) The Director will arrange the IME as soon as possible, but no later than thirty (30) days following the request for surgery by the Member’s Attending Physician or Specialty Physician.

 

(3) The Director will issue a decision to approve or deny the request for surgery as soon as possible, but no later than twenty-one (21) days following the date of the IME.

 

5.13.06 – MEDICAL MANAGEMENT PROGRAMS

 

(A) Clinical Case Management: the use of a combination of medical professionals (nurses and physicians) to manage or assist in managing the medical and disability aspects of service-connected and occupational disability Claims.

 

(1) Typical clinical case management providers and services may include telephonic and field nurse case management services, utilization management, and physician advisor.

 

(2) A Nurse Case Manager may be assigned to monitor and track recovery of a Member’s approved injury Claim when deemed appropriate by the Director.

 

(a) Members are required to cooperate with the Nurse Case Manager assigned to their injury Claim. Cooperation includes submitting to personal and/or phone contact and answering relevant medical and vocational questions posed to them by the Nurse Case Manager.

 

(b) Members may decline to allow the Nurse Case Manager to accompany them to their medical appointments.

 

(c) Members may request a change of Nurse Case Manager. However, it is at the discretion of the Director to assign a new nurse case manager.

 

(B) Utilization Review: FPDR may require the use of utilization review services to provide pre-certification of surgical and specialty care prior to approval of the medical service.

 

5.13.07 – MEDICAL FEES AND PAYMENTS

 

(A) The Director may contract with medical or hospital service providers or groups of providers for medical or hospital services and enter into fee arrangement agreements with such to reimburse medical fees of approved Claims under these Administrative Rules.

 

(B) Health care providers will submit their fees for services rendered pursuant to current Charter and Administrative Rules. Billings must be itemized and include chart notes, and be submitted directly to FPDR no later than ninety (90) days from the date of service. A health care provider must establish good cause if billing is submitted later than ninety (90) days from the date of service or in accordance with the terms of their provider panel agreement with whom FPDR is contracted. Failure to show good cause may result in a reduction or nonpayment of allowable charges.

 

(C) Medical fees will be reimbursed according to the fee arrangement agreements made between the medical providers and FPDR.

 

(D) If no fee arrangement agreement has been made with the medical provider, and the service complies with these administrative rules in all other respects, FPDR will reimburse at the usual and customary fee for the medical service.

 

(E) FPDR payment shall be considered payment in full. Members will be held harmless by the medical provider for any costs above the usual and customary fee schedule or an agreed upon fee arrangement amount payable by FPDR on an otherwise approved billing.

 

(F) FPDR will date stamp each medical bill received. Bills for services rendered on approved Claims will be adjudicated within thirty (30) days of receipt. Payments will be in accordance with adopted fee schedules.

 

(G) If there is a dispute concerning the amount of a bill, the appropriateness of the service rendered, or the relationship of the services to the approved Claim, FPDR must pay any undisputed portion of the bill and notify the provider of the specific reasons for non-payment or reduction of the remainder of the bill.

 

5.13.08 – MEDICAL PAYMENT LIMITATIONS

 

(A) Member shall not pay for any medical service that is related to an approved service- connected or occupational disability or any amount that has been reduced by the FPDR in accordance with these administrative rules. A medical provider shall not attempt to collect payment for any Medical Service from a Member, except as follows:

 

(1) when the Member seeks treatment for conditions not related to the approved Claim;

 

(2) when the Member seeks treatment that has not been prescribed by the Attending Physician, or a Specialty Physician upon referral of the Attending Physician;

 

(3) when the Member seeks treatment outside the provider panels which FPDR has contracted with, and said treatment was not pre-authorized by FPDR; or

 

(4) when the Member seeks treatment after being notified that such treatment has been determined to be unscientific, unproven, outmoded or experimental, or has been notified that the treatment is not approved or outside of these Administrative Rules.

 

5.13.09 – POST-RETIREMENT MEDICAL BENEFITS

 

(A) Service-connected Disability: Medical and hospital expenses arising from an approved service-connected disability claim shall be reimbursable, if the Member’s disability benefits continued until the Member reached Compulsory Retirement Age.

 

(B) Occupational Disability: Medical and hospital expenses arising from an approved occupational disability claim shall be reimbursable, until the expiration of one (1) year from the Member’s retirement, if the Member’s disability benefits continued until the Member reached Compulsory Retirement Age.

 


HISTORY

 

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. 442 on May 26, 2009, Resolution No. 457 on June 28, 2011, and Resolution No. 491 on September 23, 2014.