D.C. Mun. Regs. r. 7-120

Current through Register Vol. 71, No. 24, June 14, 2024

Rule 7-120 - DECISIONS ON ENTITLEMENT TO BENEFITS

120.1

The Program shall make an Initial Determination (ID) on a newly filed claim within thirty (30) days of the date the claim was first filed with the Program.

120.2

The ID shall contain findings of fact and a statement of reasons. It shall be accompanied by information about the claimant's appeal rights, which may include the right to a hearing, and/or a review by the Department of Employment Services, Office of Hearings and Adjudication or Office of Administrative Hearings, as provided in § 155 of this chapter.

120.3

In making an ID, the Program shall consider all relevant evidence in the claim file, including all relevant medical evidence, and issue awards for or against medical, temporary or permanent disability benefits, where appropriate.

120.4

An ID may deny benefits, in whole or in part, based upon the following factors:

(a) The employee's lack of a compensable injury pursuant to Section 2302 of the Act;

(b) Insufficient proof;

(c) The employee's failure to cooperate with treatment or rehabilitation recommendations or with Program requirements for providing information; or

(d) Any other grounds, such as fraud, that reasonably demonstrates that the employee is not entitled to benefits under the Act.

120.5

The ID is effective unless the employee succeeds on a request for hearing as provided in this chapter, or unless one (1) of the following circumstances occurs:

(a) The Program decides that the ID was issued in error;

(b) The Program receives additional information after issuance of the ID that requires the Program to issue an amended ID;

(c) The Program issued the ID based on fraudulent information provided by the employee;

(d) The Program issued the ID under any other circumstance that would deem the ID legally invalid ; or

(e) The Program accepts a supplemental claim filed pursuant to § 115.11.

120.6

If one (1) of the circumstances in § 120.5 occurs, the Program shall issue an amended ID.

120.7

The Program shall issue an amended Initial Determination (ID), if the claimant files a supplemental claim pursuant to § 115.11 and the Program determines that a claimant is entitled to benefits for the additional disability or condition pursuant to § 119.3.

120.8

The Program shall issue a Determination of Recurrent Disability (DRD) pursuant to §§ 120.2 through 120.6 if the claimant files a claim for recurrence of disability pursuant to § 115.14 and the claimant meets the requirements of § 119.2.

120.9

The Program shall issue an Amended ID or DRD either awarding or denying the supplemental claim or claim for recurrence of disability, respectively, filed pursuant to §§ 115.11 or 115.14, within thirty (30) days of the Program's receipt of all forms required pursuant to §§ 115.1 through 115.10 of this chapter.

120.10

The Program shall issue a Notice of Benefits within fourteen (14) days of an ID or DRD granting an award of compensation. The Notice of Benefits shall set forth the calculation of benefits pursuant to the award.

D.C. Mun. Regs. r. 7-120

Final Rulemaking at 43 DCR 1466 (March 22, 1996); as amended by Notice of Emergency and Proposed Rulemaking published at 57 DCR 9540 (October 8, 2010)[EXPIRED]; as amended by Notice of Final Rulemaking published at 57 DCR 12224, 12233 (December 24, 2010); repealed and replaced by Final Rulemaking published at 59 DCR 8766, 8786 (July 27, 2012); amended by Final Rulemaking published at 64 DCR 6325 (7/7/2017); amended by Final Rulemaking published at 66 DCR 4246 (4/5/2019)

Authority: Chief Risk Officer of the Office of Risk Management (ORM), Executive Office of the Mayor, pursuant to the authority set forth in section 2344 of the District of Columbia Government Merit Personnel Act of 1978 (CMPA), effective March 3, 1979 (D.C. Law 2-139; D.C. Official Code § 1-623.44 (2012 Supp.)); section 7 of Reorganization Plan No. 1 of 2003 for the Office of Risk Management, effective December 15, 2003; and Mayor's Order 2004-198, effective December 14, 2004