EEOICPA/SWC Coordination of Benefits Worksheet

(For internal DEEOIC use only)

 

 

Covered Part E Employee:

 

Claimant:

 

Claim Number:

 

1.  Gross dollar amount of SWC received for the covered

illness or illnesses accepted by DEEOIC............$_____________

                                                                                                        

2.  Does amount listed on Line 1 include medical and/or

vocational rehabilitation benefits?........................YES/NO

 

a.  If “YES”, complete Step 3 of the Worksheet

 

b.  If “NO”, skip Step 3 and go directly to Step 4

 

3.  Deductions from amount of SWC received:

 

a.  SWC paid as medical benefits..............$____________

 

b.  SWC paid as vocational rehabilitation.....$____________

 

c.  Add Lines 3a and 3b.......................$____________

 

d.  Net SWC (Subtract Line 3c from Line 1)....$____________

 

4.  Deductions for costs of suit and attorney fees:

 

a.  Total costs of suit.......................$____________

 

b.  Determine costs percentage (Line 4a/Line 1)......_____%

  

c.  Deductible costs of suit (Line 4b x either

Line 1 or Line 3d)............................$____________

 

d.  Attorney fees paid........................$____________

 

e.  Determine fees percentage (Line 4d/Line 1)......._____%

 

f.  Deductible attorney fees (Line 1 or Line 3d x the

LESSER of Line 4e or 40%).....................$____________    

 

g.  Allowable deductions (Line 4c + Line 4f)..$____________

 

5.   Amount of SWC requiring coordination (Subtract

Line 4g from either Line 1 or Line 3d)..............$____________             

6.   Current Part E entitlement.....................$___________

 

7.   Coordinate current Part E benefits (Subtract

Line 5 from Line 6).................................$____________ 

 

8.   Is the amount entered on Line 7 a positive amount?...YES/NO

 

a.  If “YES”, this is the amount of the Part E award.

 

b.  If “NO”, this is the amount of the Part E surplus

that must be absorbed from future Part E benefits.

 

 

 

 

 

 

 

 

 


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Instructions for Completing the Worksheet

 

Determining the amount of SWC received.  Enter the gross dollar amount of SWC the claimant received as of the date of the recommended decision on Line 1, less any amounts previously coordinated with prior Part E payments.  SWC received by someone other than the claimant is not used to coordinate the claimant’s Part E benefits and must not be included in the amount entered on Line 1.  For example, SWC received by a worker who is now deceased is not used to coordinate Part E benefits payable to that worker’s survivor(s).  If the amount on Line 1 includes SWC  that was received for a medical condition other than the covered illness(es) accepted by DEEOIC in the claim, DO NOT COMPLETE THE WORKSHEET.

 

If the amount entered on Line 1 does not include medical and/or vocational rehabilitation benefits, the CE circles “NO” at Step 2 and skips Step 3.  However, if the amount on Line 1 does include medical and/or vocational rehabilitation benefits, the CE circles “YES” at Step 2 and performs the calculations listed at Step 3.  On Line 3a, the CE enters the amount of medical benefits paid to both the employee and any providers.  On Line 3b, the CE enters the total amount of vocational rehabilitation expenses paid to both the employee and any providers.  These amounts are added at Line 3c, and this total is subtracted from the amount listed on Line 1, leaving the “net” SWC listed on Line 3d.

 

Costs of suit that may be listed on Line 4a of the Worksheet are reasonable out-of-pocket costs and expenses involved in bringing a SWC lawsuit, but do not include any fees paid to co-counsel or normal office expenses like secretarial or paralegal services or in-house record copying costs.  To be deductible from the amount of SWC received by the claimant, the costs MUST be itemized so each individual cost may be evaluated by the CE to ensure that it is allowable and authentic.  Costs that are routinely allowable are filing fees, travel expenses, record copy services, witness fees, postage, court reporter costs for transcripts of hearings and depositions, and long distance telephone calls.  Once the costs percentage has been calculated and entered on Line 4b, the CE multiplies that percentage by the amount listed on Line 1, or the amount listed on Line 3d if “YES” was circled at Step 2, and enters this amount on Line 4c.  Attorney fees supported by bills or other appropriate documentation are entered on Line 4d of the Worksheet.  In general, attorney fees that exceed 40% of the SWC amount entered on Line 1 will be considered unreasonable.  If the fees percentage entered on Line 4e is greater than 40%, the CE must inform the claimant of this matter and provide him or her an opportunity to show (to the CE’s satisfaction) that the attorney fees paid were reasonable.  If the claimant is unable to do so, the CE uses 40% to calculate the amount entered on Line 4f.

 

To determine the amount of SWC requiring coordination, the CE subtracts the amount entered on Line 4g from the SWC entered on Line 1, or the “net” SWC entered on Line 3d if Step 3 of the Worksheet was used, and enters the result on Line 5.  The amount entered on Line 5 is the amount of SWC to be used to coordinate the claimant’s current Part E benefits.

 

Coordinating the Part E benefits.  To perform the required coordination of Part E benefits, the CE enters the amount of Part E benefits that are currently payable to the claimant on Line 6 of the Worksheet, and subtracts the amount of SWC entered on Line 5 of the Worksheet from the amount entered on Line 6.  The result of this coordination is entered on Line 7.  If Line 5 is LESS than Line 6, the amount on Line 7 is the compensation payable to the claimant under Part E of EEOICPA, reduced to reflect the benefits previously received under a SWC program.  This is also the amount of Part E compensation that must be referenced in the recommended decision.  If Line 5 is MORE than Line 6, the amount on Line 7 will be a negative number that represents the amount of the “surplus” of SWC that must be absorbed from any future Part E benefits payable to the claimant.

 

Upon completion, the CE staples the Worksheet to the inside of the file folder.