19 Del. Admin. Code § 2007-11.0

Current through Reigster Vol. 28, No. 6, December 1, 2024
Section 2007-11.0 - Appeals - STD Claim Determinations
11.1 Claimants whose STD claims are not in an approved status are entitled to file an appeal with the DIP insurance carrier or third-party administrator. Claimants who file an appeal are required to immediately advise the employee's supervisor and Human Resource Benefits Office of the status of the appeal for benefits. The DIP insurance carrier or third-party administrator will provide notice that an appeal has been received to the claimant, Human Resource Benefits Office, and to the SBO.
11.2 In accordance with 29 Del.C. § 5258, within 90 days of the postmark date of the carrier's written notice of its determination regarding STD benefits, a claimant may appeal a determination of disability benefits by filing a written petition setting forth with particularity the grounds for appeal with the DIP insurance carrier or third-party administrator. The DIP insurance carrier or third-party administrator has the authority to reverse or amend its initial STD benefit determination and will notify the claimant, the employing organization and the SBO in writing by certified mail, return receipt requested within 10 days of the determination.
11.3 In accordance with 29 Del.C. § 5258, within 20 days of the postmark date of the DIP insurance carrier or third-party administrator's determination of benefits being appealed, a claimant may file a second level appeal by filing a written petition setting forth with particularity the grounds for second appeal to the Appeals Administrator at the SBO, who will conduct an informal review, and who has the authority to reverse or amend the decision of the DIP insurance carrier or third-party administrator to deny benefits.

Once the review is finished, the Appeals Administrator or designee, will issue a final written decision and will mail it to the claimant by certified mail, return receipt requested, within 30 days of speaking with the claimant.

11.4 In accordance with 29 Del.C. § 5258, if the Appeals Administrator affirms the DIP insurance carrier or third-party administrator's decision to deny or amend disability benefits, a claimant may file an appeal to the SEBC within 20 days of the postmark date of the notice of the determination from the Appeals Administrator by filing a written petition with the SEBC setting forth with particularity the grounds for the appeal.

The SEBC may designate an appropriate representative from the Department of Human Resources as a Hearing Officer to hear evidence presented by the employee or, in its sole discretion, it may decide to hear the appeal directly. The SEBC or the Hearing Officer, as the case may be, will determine whether the determination to deny benefits complies with the applicable disability plan adopted by the SEBC. The Hearing Officer and SEBC shall have all of the following powers in respect to the conduct at the hearing:

11.4.1 To issue subpoenas and administer oaths in a proceeding. A subpoena process order or notice or paper requiring service will be sent by certified mail, return receipt requested;
11.4.2 To examine persons as witnesses, take evidence, require the production of documents, and do other things in accordance with law which are necessary to determine the appeal. In proceedings before the SEBC or its Hearing Officer, if a person neglects to produce a pertinent document, neglects or refuses to appear after having been subpoenaed, refuses to testify or be examined, disobeys or resists a lawful order or process, or intentionally obstructs the hearing, the SEBC will certify facts under the signature of its chairperson or the Hearing Officer to a judge of the Superior Court, which judge will then hear evidence as to the acts complained of. The judge will, if the judge deems the evidence so warrants, issue an order requiring the persons to testify or produce documents or otherwise follow the requirements of the SEBC, as the case may require. Refusal to follow the order of the Court will be contempt of Court;
11.4.3 Where the SEBC assigns the matter to the Hearing Officer, the Hearing Officer will decide the matter and prepare a report containing the findings of fact, and conclusions of law, within 60 days of the hearing, and will transmit the report, with the full record of the hearing, to the SEBC. The SEBC may accept or modify the Hearing Officer's final report, and will notify the parties of its action by certified mail, return receipt requested within 60 days.
11.4.4 If the SEBC chooses to hear the matter directly and not to assign it to the Hearing Officer, it will issue its final decision containing findings of fact and conclusions of law, within 60 days of the hearing, and will notify the parties of its action by certified mail, return receipt requested.
11.5 In accordance with 29 Del.C. § 5258, within 30 days of the postmark date of the SEBC's determination to deny benefits on appeal, a claimant may file a final action to Superior Court. The appeal will be on the record.

19 Del. Admin. Code § 2007-11.0

18 DE Reg. 79 (7/1/2014)
19 DE Reg. 78 (7/1/2015)
20 DE Reg. 70 (7/1/2016)
20 DE Reg. 660 (2/1/2017)
21 DE Reg. 234 (9/1/2017)
22 DE Reg. 861 (4/1/2019)
28 DE Reg. 57 (7/1/2024) (Final)