D.C. Mun. Regs. r. 7-199
The definitions set forth in Section 2301 of Title 23 (Workers' Compensation) of the District of Columbia Government Comprehensive Merit Personnel Act of 1978, effective March 3, 1979 (D.C. Law 2-139; D.C. Official Code §§ 1-623.01et seq. (2016 Repl. & 2019 Supp.)) shall apply to this chapter. In addition, for purposes of this Chapter, the following definitions shall apply and have the meanings ascribed:
The Act - the District of Columbia Comprehensive Merit Personnel Act of 1978, effective March 3, 1979 (D.C. Law 2-139; D.C. Official Code §§ 1-623.01et seq. (2016 Repl. & 2019 Supp.)), as amended and as it may be hereafter amended.
Administrative Law Judge or ALJ - a hearing officer of the Office of Hearings and Adjudication in the Administrative Hearings Division of the Department of Employment Services or Administrative Law Judge in the Office of Administrative Hearings.
Aggravated injury - the exacerbation, acceleration, or worsening of a pre-existing disability or condition caused by a discrete event or occurrence and resulting in substantially greater disability or death.
Alive and well check - an inquiry by the Program to confirm that a claimant who is receiving benefits still meets the eligibility requirements of the Program.
Award of Compensation - a Program determination or Compensation Order issued pursuant to Section 2324 of the Act (D.C. Official Code § 1-623.24 ) and shall not include calculations set forth in a Notice of Benefits or adjustments to benefits made pursuant § 145 of this chapter.
Beneficiary - an individual who is entitled to receive death benefits under the Act.
Claim - an assertion properly filed and otherwise made in accordance with the provisions of this chapter that an individual is entitled to compensation benefits under the Act.
Claim file - all program documents, materials, and information, written and electronic, pertaining to a claim, excluding that which is privileged or confidential under District of Columbia law.
Claimant - an individual who receives or claims benefits under the Act (D.C. Official Code §§ 1-623.01et seq.).
Claimant's Representative - means an individual or law firm properly authorized by a claimant of this Chapter, in writing, to act for the claimant in connection with a claim under the Act or this chapter.
Controversion - means to dispute, challenge or deny the validity of a claim for Continuation of Pay.
Disability - means the incapacity, because of an employment injury, to earn the wages the employee was receiving at the time of injury. It may be partial or total.
Earnings - for the purposes of § 138 of this chapter, any cash, wages, or salary received from self-employment or from any other employment aside from the employment in which the worker was injured. It also includes commissions, bonuses, and cash value of all payments and benefits received in any form other than cash. Commissions and bonuses earned before disability but received during the time th e employee is receiving workers' compensation benefits do not constitute earnings that must be reported.
Eligibility Determination (ED) - a decision concerning, or that results in, the termination or modification of a claimant's existing Public Sector Workers' Compensation benefits that is brought about as a result of a change to the claimant's condition.
Employee - means
Employee's Representative - means an individual or law firm properly authorized by an employee of this chapter, in writing, to act for the employee in connection with a request for continuation of pay under the Act or this chapter.
Employing agency - the agency or instrumentality of the District of Columbia government which employs or employed an individual who is defined as an employee by the Act.
Good cause - omissions caused by "excusable" neglect or circumstances beyond the control of the proponent. Inadvertence, ignorance or mistakes construing law, rules and regulations do not constitute "excusable" neglect.
Healthcare provider - means any person or organization who or that renders medical services, appliances or supplies directly to claimants or employees and is licensed to practice or operate in the jurisdiction where care is provided.
Healthcare organization - an organization comprised of allied health professionals, as defined under Section 2301 of the Act (D.C. Official Code § 1-623.01 ).
Immediate supervisor - the District government officer or employee having responsibility for the supervision, direction, or control of the claimant, or one acting on his or her behalf in such capacity.
Indemnity - See Wage-loss Compensation.
Initial Determination (ID) - a decision regarding initial eligibility for benefits under the Act, including decisions to accept or deny new claims, pursuant to this Chapter.
Judicial Entity - any court or administrative group that issues a final decision that results in a complete and final disposition of a case.
Latent disability - a condition, disease or disability that arises out of an injury caused by the employee's work environment, over a period longer than one workday or shift and may result from systemic infection, repeated physical stress or strain, exposure to toxins, poisons, fumes or other continuing conditions of the work environment.
Marriage - both civil marriage, which is represented by a marriage license, and common- law marriage, which must be proved by a preponderance of the evidence based on the law of the applicable jurisdiction.
Maximum Medical Improvement (MMI) - a point in time in the recovery process after an injury when:
Mayor - the Mayor of the District of Columbia or a person designated to perform his or her functions under the Act.
Medical opinion - a statement from a physician, as defined in Section 2301 of the Act (D.C. Official Code § 1-623.01 ) that reflects judgments about the nature and severity of impairment, including symptoms, diagnosis and prognosis, physical or mental restrictions, and what the employee or claimant is capable of doing despite his or her impairments.
Notice of Benefits - a notice provided to a claimant that sets forth the Program's calculation of a claimant's benefits as a result of an initial award or subsequent change in benefits.
Office of Administrative Hearings (OAH) - the office where Administrative Law Judges adjudicate public sector workers' compensation claims under Sections 2323(a-2)(4), 2324(b)(1), and (d)(2) of the Act (D.C. Official Code §§ 1-623.23 (a-2)(4), 1-623.24(b)(1) and (d)(2)), pursuant to jurisdiction under D.C. Official Code § 2-1831.03(b)(1) (2016 Repl.), Section 2306a of the Act, and rules set forth in this chapter.
Office of Hearings and Adjudication (OHA) - the office in the Administrative Hearings Division of the Department of Employment Services where Administrative Law Judges adjudicate workers' compensation claims, including public sector workers' compensation claims under Sections 2323(a-2)(4), 2324(b)(1), and (d)(2) of the Act (D.C. Official Code §§ 1-623.23 (a-2)(f), 1-623.24(b)(1) and (d)(2)), a nd rules set forth in this Chapter.
Office of Risk Management (ORM) - the agency within the Government of the District of Columbia that is responsible for the District of Columbia's Public Sector Workers' Compensation Program (PSWCP).
Panel physician - means a physician approved by the Program pursuant to §§ 124 and 125 of this chapter to provide medical treatment to persons covered by the Act.
Pay rate for compensation purposes - means the employee's pay, as determined under Section 2314 of the Act, at the time of injury, the time disability begins, or the time compensable disability recurs if the recurrence begins more than six months after the injured employee resumes regular full-time employment with the District of Columbia government, whichever is greater, except as otherwise determined under Section 2313 of the Act (D.C. Official Code § 1-623.13 ) with respect to any period. Consideration of additional remuneration in kind for services shall be limited to those expressly authorized under Section 2314(e) of the Act (D.C. Official Code § 1-623.14(e) ).
Permanent disability compensation - schedule award compensation payable when a qualified physician has determined that a claimant has reached maximum medical improvement and has full or partial loss of use of a body part or disfigurement pursuant to Section 2307 of the Act (D.C. Official Code 1-623.07) and § 140 of this chapter.
Permanent total disability payment (PTD) - schedule award and wage- loss compensation payable to a completely disabled claimant, when a qualified physician has determined that a claimant has reached maximum medical improvement and is unable to work on a permanent basis. PTD has been repealed since February 26, 2015. However, claimants who were awarded PTD prior to the repeal may continue to receive PTD benefits.
Program - the Public Sector Workers' Compensation Program of the Office of Risk Management, including a third party administrator thereof.
Provider agreement - a working agreement developed by the Program in accordance with Section 2302b of the Act (D.C. Official Code § 1-623.02 b) with a healthcare provider or other public or private organization comprised of healthcare providers to furnish medical care or services (including transport incident to such care or services) to an employee. Disputes regarding fees or the necessity, character or sufficiency of services pursuant to such agreements shall be resolved in accordance with Section 2323 of the Act (D.C. Official Code § 1-623.23 ) and § 156.6 and 156.7 of this chapter.
Qualified health professional - means a physician, as that term is defined by section 2301 of the Act (D.C. Official Code § 1-623.01 ) and includes a surgeon, podiatrist, dentist, clinical psychologist, optometrist, orthopedist, neurologist, psychiatrist, chiropractor, or osteopath practicing within the scope of his or her practice as defined by state law. The term includes a chiropractor only to the extent that reimbursable services are limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by x-ray to exist and subject to guidelines established by the Program. For purposes of initial treatment or emergency care, or with respect to of a managed care organization, as that term is defined by Section 2301 of the Act (D.C. Official Code § 1-623.01 ), the term also includes physician assistants and nurse practitioners who are authorized by the jurisdiction where they practice and who are performing within the scope their practice as defined by said jurisdiction.
Recurrence of disability - means a disability that reoccurs within one (1) year after the date wage-loss compensation terminates or, if such termination is appealed, within one (1) year after the date of the final order issued by a judicial entity, caused by a spontaneous change in a medical condition which had resulted from a previous compensable injury or illness without an intervening injury or new exposure to the work environment that caused the illness.
Recurrence of medical condition - means a documented need for further medical treatment after release from treatment for the accepted condition or injury when there is no accompanying work stoppage. Continuous treatment for the original condition or injury is not considered a "need for further medical treatment after release from treatment," nor is an examination without treatment.
Traumatic injury - means a condition of the body caused by a specific event or incident, or series of events or incidents, within a single workday or shift. Such condition must be caused by external force, including physical stress or strain, which is identifiable as to time and place of occurrence and member or function of the body affected.
Temporary partial disability payment (TPD) - wage- loss compensation payable to a claimant, who has a wage-earning capacity and has not reached maximum medical improvement, calculated pursuant to Section 2306 of the Act (D.C. Official Code § 1-623.06 ) and § 130 of this chapter.
Temporary total disability payment (TTD) - wage- loss compensation payable to a claimant, who has a complete loss of wage earning capacity and has not reached maximum medical improvement, calculated pursuant to Section 2305 of the Act (D.C. Official Code § 1-623.05 ) and § 129 of this chapter.
Treating physician - the physician, as defined in Section 2301 of the Act (D.C. Official Code § 1-623.01 ), who provided the greatest amount of treatment and who had the most quantitative and qualitative interaction with the employee or claimant.
Wage-loss compensation - the money allowance paid to a claimant by the Program to compensate for the wage- loss experienced by the claimant as a result of a disability directly arising out of an injury sustained while in the performance of his or her duty, calculated pursuant to the provisions of this chapter.
Working agreement - means a provider agreement or other agreement developed by the Program in accordance with Section 2302b of the Act (D.C. Official Code § 1-623.02 b) with:
D.C. Mun. Regs. r. 7-199