144 MODIFICATION, FORFEITURE, SUSPENSION OR TERMINATION OF BENEFITS

144.1 A claimant's benefits shall be modified if the Program has reason to believe that the claimant's PSWCP file and records establish the following:

1. (a) The disability for which compensation was paid has ceased or lessened;
2. (b) The disabling condition is no longer causally related to the employment;
3. (c) The claimant's condition has changed from total disability to partial disability;
4. (d) The employee has been released to return to work in a modified or light duty basis; or
5. (e) The Program determines based on strong compelling evidence that the initial decision was in error.

144.2 A claimant's benefits shall be forfeited if substantial evidence in the claimant's PSWCP file establishes that claimant failed to complete a report of earnings pursuant to § 138.

144.3 A claimant's benefits shall be terminated if the Program has reason to believe that the claimant's PSWCP file establishes the following:

1. (a) The disability for which compensation was paid has ceased;
2. (b) The disabling condition is no longer causally related to the employment;
3. (c) The employee has been released to return to work or has returned to work based upon clear evidence;
4. (d) The claimant has failed to complete a report of earnings for more than ninety (90) days; or
5. (e) The claimant has been offered a modified duty assignment and has elected not to accept the modified duty assignment.

144.4 A claimant's benefits shall be suspended if the Program has reason to believe that the claimant's PSWCP file establishes the following:

1. (a) The claimant failed to attend an appointment for Additional Medical Examination (AME), bring medical records under the claimant's

possession and control, or any other obstruction of the examination;

(b) The claimant failed to follow prescribed and recommended course of medical treatment from the treating physician; or

(c) A claimant hired on or after January 1, 1980, without good cause failed to apply for or undergo vocational rehabilitation when so directed by the Program.

144.5 If substantial evidence in the claimant's PSWCP file establishes that a claimant hired before January 1, 1980, without good cause fails to apply for or undergo vocational rehabilitation, when directed by the Program:

(a) The Program may propose a reduction of indemnity compensation and present the proposed reduction to the Compensation Review Board (CRB) for review; and

(b) The CRB shall affirm the reduction in benefits, if it determines that there is substantial evidence in the record to show that the wage-earning capacity of the individual would probably have substantially increased, absent the claimant's failure to attend vocational rehabilitation, as directed by the Program.

(1) "Substantially increase" means an increase in wage-earning capacity by fifty percent (50%) or more.

(2) The claimant's wage-earning capacity is computed by conducting a labor market research based on the assumption the claimant has enrolled in vocational rehabilitation to arrive at the claimant's "average annual earning potential." The average annual earning potential shall be divided by twelve to arrive at the claimant's monthly wage-earning capacity. The claimant's monthly wage earning capacity shall be compared against the claimant's monthly pay. If the claimant's wage earning capacity exceeds the claimant's monthly pay by fifty percent (50%), the Program may propose a reduction of indemnity compensation.

144.6 Failure to apply for or undergo vocational rehabilitation shall include failure to attend meetings with the vocational rehabilitation case worker, failure to apply for jobs that have been identified for the claimant, or failure to otherwise participate in good faith in the job application process.

144.7 Prior written notice need not be given when an employee's benefits are suspended or forfeited pursuant to this section.

144.8 In all claims, the claimant is responsible for continual submission, or arranging for the continual submission of, a medical report from the attending physician as evidence supporting the reason for continued payment of compensation.

144.9 For indemnity compensation benefits, “reason to believe” that the disability for which compensation was paid has ceased pursuant to §§ 144.1(a) and 144.3(a) of this chapter includes a claimant’s failure to provide contemporaneous medical evidence to show that

(a) The accepted condition remains disabling; and

(b) The nature and extent of the ongoing disability necessitate a claimant’s continued absence from work or restriction from performing the full scope of pre-injury duties.

144.10 For medical compensation benefits, “reason to believe” that the disability for which compensation was paid has ceased pursuant to §§ 144.1(a) and 144.3(a) of this chapter includes a claimant’s lack of treatment for the accepted condition for one year or more.

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).