3131

PROCEDURES FOR NEW CLAIMS

3131.1

The District government is responsible for receiving first reports of injuries, administering claims and making compensability and continued eligibility determinations.

3131.2

Claims properly and timely reported by employees that meet the requirements of the Act shall be covered by the Program.

3131.3

The Program shall make IDs concerning new claims for compensation benefits, including decisions to accept or deny new claims.

3131.4

The employer shall report the claim to ORM, by telephone within twenty-four (24) hours of the incident, injury or death. No later than three (3) days after the initial report, the employer shall report the claim, in writing, within three (3) days using Form 1, the Employer and Employee First Report of Injury or Occupational Disease, and Form 2, Supervisor's Report.

3131.5

Form 1 shall contain the following information:

(a) The name and address of the employer;

(b) The name and address of the employee;

(c) The year, month, day and hour when the injury or death occurred;

(d) The name and telephone number of the employee's supervisor;

(e) The employee's occupation at the time of the injury or death;

(f) The employee's wage/base salary information;

(g) The length of employee's employment;

(h) The location of the accident; and

(i) A description of the events which resulted in the death, injury or disease; type of injury; and the body parts affected.

3131.6

Form 2 shall contain the following information:

(a) Whether the supervisor witnessed the accident;

(b) Whether the employee reported the accident or injury, and to whom;

(c) Whether an incident report was prepared in connection with the injury or death;

(d) The nature of the injuries the employee complained of;

(e) Whether the employee has been placed on Continuation of Pay (COP);

(f) Whether the employee was in the performance of duty at the time of injury or death;

(g) A description of the events which resulted in the death, injury or disease; and

(h) An attached copy of the employee's position description and all incident reports.

3131.7 The Employer shall complete and submit supplemental reports to the ORM as requested. Said reports shall contain:

(a) Statements from witnesses confirming or refuting the employee's allegations concerning the accident or injury;

(b) Statements, where requested, to give additional details of the accident or incident;

(c) Statements regarding whether the employee had a similar disability prior to the alleged injury, and, if so, full details of the prior disability or incident and associated medical reports; and

(d) Statements of other injuries or accidents of a similar character and the full details.

3131.8 The Employer shall complete Form CA-3, Report of Return to Duty.

3131.9 The Employee or his/her representative shall complete Form CA-7, Claim for Compensation, Part A, Employee Statement. The notice shall:

(a) Be in writing;

(b) State the name and address of the employee;

(c) State the year, month, day, and hour when and the particular locality where the injury or death occurred;

1. (d) State the cause and nature of the injury, or in the case of death, the employment factors believed to be the cause;
2. (e) State the employee's official job title, grade/step, and number of hours scheduled to work per day;
3. (f) State the employee's health benefit plan and code;
4. (g) State whether the employee has optional life insurance;
5. (h) State whether a claim has been made against a third party as a result of the injury, illness or death;
6. (i) State the names, relationship, and birth dates of employee's dependents, and/or the amount of support paid for dependents not living with the employee;
7. (j) Be signed by, and contain the address of, the individual giving the notice;
8. (k) In the case of the death of an employee, the individual filing the Form CA-7 shall provide documentation establishing the relationship to the deceased. Documentation may include a certified copy of a
9. 1 birth certificate,
10. 2 marriage license, or
11. 3 other documentation satisfactory to ORM.
12. (l) Have attached, proof of dependency, for example, birth certificates and court orders; and
13. (m) Have attached a copy of the employee's last pay stub.

3131.10 The employee shall complete a Medical Authorization and Release of Confidential Information Form as provided by ORM.

3131.11 The employee shall have his physician complete and return to the ORM, a Form 3, Physician's Report of Employee's Injury and Disability.

3131.12 The employee shall submit proper medical documentation as requested by the ORM to support the employee's ongoing injury and absence from work. These documents shall include, but are not be limited to the following:

(a) Statements and medical documentation regarding any similar injury that occurred prior to the alleged 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.

3131.13 ID benefits may be based, in whole or in part, upon the following factors:

(a) The employee's lack of a compensable injury;

(b) The employee's abandonment of the claim;

(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 demonstrate that the employee is not entitled to benefits under the Act.

3131.14 A new claim shall be denied or controverted when an employee fails to cooperate, by following the procedures set forth in this chapter.

3131.15 Within thirty (30) days after the Program receives a new claim for compensation benefits compensable under the Act, the Program shall issue an ID providing notice to the employee furnishing or authorizing payment for services, appliances, supplies, reasonable transportation, and expenses incidental thereto. Within thirty (30) days after the Program receives a new claim for compensation benefits that is not compensable under the Act, the Program shall issue an ID providing notice to the employee denying or controverting such claim.

3131.16 The ID is effective unless the employee succeeds on a request for hearing as provided in Chapter 1.

3131.17 Medical reports used in connection with an ID shall meet the requirements of subsection 3160.

SOURCE: Notice of Emergency and Proposed Rulemaking published at 52 DCR 5481(June 10, 2005) [Expired]; and Notice of Emergency and Proposed Rulemaking published at 52 DCR 5771(June 17, 2005) [Expired]; and Notice of Emergency and Proposed Rulemaking published at 52 DCR 8964(October 7, 2005) [Expired]; and Notice of Emergency and Proposed Rulemaking published at 53 DCR 940(February 10, 2006) [Expired];Final Rulemaking published at 53 DCR 4290 (May 26, 2006); 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, 12236 (December 24, 2010).