115 CLAIM FOR PSWCP BENEFITS; EMPLOYEE OR REPRESENTATIVE ACTION

115.1 The employee or employee's representative shall provide all information required by the Program to make a determination on the claim.

115.2 A claim for disability compensation is deemed filed only upon the Program's receipt of the following completed documents:

1. (a) Form CA7, Part A – Claim for Compensation (Employee Statement);
2. (b) Form 3 – Physician's Report of Employee's Injury;
3. (c) Form 3A – Employee's Statement of Medical History;
4. (d) Form 4 – Employee Authorization for Release of Medical Records;
5. (e) Form 5 – Employee Authorization for Release of Earnings; and
6. (f) Form CA7, Part B – Claim for Compensation (Employing Agency Statement).

115.3 Forms shall be deemed incomplete for the purpose of § 115.2, if any information is omitted or incomplete upon submission.

115.4 The employee or employee's representative shall complete Form CA7 Claim for Compensation, Part A (Employee Statement), which shall:

1. (a) Be in writing;
2. (b) State the name and address of the employee;
3. (c) State the time, date and location where, the injury or death occurred;
4. (d) Describe the activities the employee was engaging in at the time of the injury;
5. (e) State the cause, mechanism and nature of the injury, or if a recurrence of disability, the causal relationship of the recurrence to the original injury, or in the case of death, the employment factors believed to be the cause;
6. (f) State the employee's official job title, grade and step, duties, shift and number of hours scheduled to work per day;

(g) State the employee's benefits deductions, if any, as listed in § 128 of this chapter;

(h) State whether a claim has been made against a third party as a result of the injury, disease, or death;

(i) If hired prior to January 1, 1980, or applying for death benefits, state the names, relationship, and birth dates of employee's dependents, and the amount of support paid for dependents not living with the employee;

(j) Be signed by, and contain the address of, the individual giving the notice;

(k) Have attached proof of dependency, if applicable, for example, tax returns, birth certificates and court orders;

(l) Have attached a copy of the employee's last pay stub; and

(m) In the case of the death of an employee, the employee's representative shall file the Form CA7 and provide documentation establishing the relationship to the deceased. Documentation may include:

(1) A certified copy of a birth certificate;

(2) A certified copy of a marriage license;

(3) Documentation of the executor of the employee's estate; or

(4) Other documentation satisfactory to the Program.

115.5 The employee or employee's representative shall complete and submit:

(a) Form 4 – Employee Authorization for Release of Medical Records; and

(b) Form 5 – Employee Authorization for Release of Earnings and Tax Records.

115.6 The employee or employee's representative shall have the employee's health care professional complete and return to the Program a Form 3, Physician's Report of Employee's Injury, which shall comport with the requirements of §§ 125.2 and 137.3.

115.7 The employee or employee's representative shall complete, sign, notarize and return to the Program, Form 3A, Employee's Statement of Medical History, which shall:

(a) Describe any and all accidents the employee was involved in, or physical disability or illness the employee suffered, prior or subsequent to the reported injury;

(b) For each accident, illness or disability, identify the time, date, circumstance and location of the accident, the parties involved, the disposition of any subsequent trial or legal action(s), any injuries relating from the previous accident(s), and the hospital, medical facilities, doctors, physicians, dentists, or any other individual that treated any injury;

(c) Identify the physician who treated the employee and the approximate dates of such treatments, if employee alleges aggravation of a previous injury or condition;

(d) Describe in detail each instance during the past five (5) years that employee has been absent from employment due to illnesses or injuries, including the nature and dates of such injuries or illnesses. The employee or employee's representative shall specify the date and time for all absence from employment due to injury claimed; and

(e) Describe any similar condition, disability, injury that occurred prior to the alleged injury or any pre-existing condition that may be related to the condition or disability caused by the injury.

115.8 The employee or employee's representative shall submit proper medical documentation as requested by the Program to document the employee's ongoing injury and substantiate the employee's absence from work to justify continued payment of indemnity compensation. These documents shall include, but are not limited to, the following:

(a) Statements and medical documentation regarding any similar condition, disability, injury that occurred prior to the alleged injury or any pre-existing condition that may be related to the injury;

(b) Statements and medical documentation regarding any other injury or accident of a similar character; and

(c) A written statement showing why there was a delay in seeking medical care, if applicable.

115.9 The employee or employee's representative shall complete the applicable section of Form CA7, Part B and provide a copy to the Program and the original to the immediate supervisor for review and signature.

115.10 The employee or employee's representative shall make supplemental reports when required by the Program or when there is any change in information provided to the Program.

115.11 An employee seeking to supplement his or her original claim to add additional disability or conditions arising out of the same incident, but not already reported, shall:- (a) File a supplement to his or her claim pursuant to §§ 115.1 through § 115.10;

- (b) Include a notarized and sworn affidavit explaining the cause for delay in reporting the additional disability or condition; and

- (c) Report the additional disability or condition within two (2) years of the original injury.115.12 Claims for aggravated injury shall be filed pursuant to Section 2321 of the Act and this §§115.1 through 115.10 of this chapter within two (2) years from the discrete event or occurrence that aggravated, worsened or exacerbated the employee's pre-existing disease, illness or condition.115.13 Claims for latent disability, where the claimant shall be filed pursuant to Section 2322 of the Act and §§ 115.1 through 115.10 of this chapter within two (2) years of the earlier of:- (a) The date on which the employee first sought medical attention for the employee's condition and was aware or, by the exercise of reasonable diligence should have been aware, of the causal relationship between the claimant's condition and employment, whether or not the employee ceased work; or

- (b) The date on which the employee became disabled and was aware or, by the exercise of reasonable diligence should have been aware, of the causal relationship between the claimant's disability and employment.115.14 Claims for the recurrence of disability shall include medical evidence to establish that the recurrence is for the same condition and injury for which the claim was originally accepted and be filed pursuant to §§ 115.1 through 115.10 within one (1) year after the date indemnity compensation terminates or, if such termination is appealed, within one (1) year after the date of the final order was issued by a judicial entity, unless- (a) The inability to work occurred because a modified duty assignment made specifically to accommodate the employee's physical limitations due to his or her work-related injury or illness is withdrawn or when the physical requirements of such an assignment are altered so that they exceed his or

her established physical limitations.

115.15 All other claims for compensation for disability or death arising out of a single injury shall be filed within two (2) years after the injury or death pursuant to Section 2321 of the Act and § 115 of this chapter.

SOURCE: Final Rulemaking published at 28 DCR 2307 (May 22, 1981); as amended by Emergency and Proposed Rulemaking published at 57 DCR 9540 (October 8, 2010)[EXPIRED]; as amended by Final Rulemaking published at 57 DCR 12224, 12229 (December 24, 2010); as amended by Final Rulemaking published at 59 DCR 8766, 8771 (July 27, 2012); as amended by Final Rulemaking published at 64 DCR 6325 (July 7, 2017).