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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 7. EMPLOYMENT BENEFITS |
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Chapter 7-1. [DELETED] |
Section 7-111. INITIAL DETERMINATIONS
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111.1The Program shall make an ID on a newly filed claim within thirty (30) days of the date the claim was first reported to the Program.
111.2In making its ID, the Program shall consider all relevant evidence in the claim file, including all relevant medical evidence received pursuant to §§ 123 and 124 of this chapter.
111.3An 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) The Program’s controversion of the claim for two (2) years, pursuant to § 112.7;
(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.
111.4A new claim shall be denied or controverted when an employee fails to cooperate by following the procedures set forth in this chapter.
111.5The 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; or
(b) The Program receives additional information after issuance of the ID that requires the Program to issue an amended ID.
111.6If one (1) of the circumstances in § 111.5 occurs, the Program shall issue an amended NOD.
111.7The Program shall issue an amended NOD pursuant to § 111.5(b) if the Program determines that a claimant is entitled to benefits for an additional body part or injury that is related to the original injury claim. A body part or injury shall be added to an accepted claim if the Program determines after considering all relevant factual evidence, including all relevant medical evidence received pursuant to §§ 123 and 124 of this chapter, that the injury or injury to the body part is directly related to the original injury for which the claim was initially accepted.
111.8Before the Program may issue an amended NOD pursuant to § 111.7, the claimant shall provide notice of the additional body part or injury within thirty (30) days of the new injury or within thirty (30) days of when the claimant first became aware or reasonably should have become aware that an additional body part or injury is directly related to the original claim.
111.9A claimant seeking to amend an NOD pursuant to §§ 111.7 and 111.8 shall make a claim for the additional body part or injury by completing a supplemental Form CA-7, Claim for Compensation, Part A, Employee Statement, in accordance with § 108.4 of this chapter; a Form 3, Physician’s Report of Employee’s Injury, pursuant to § 108.6; and any other medical or supplemental reports required pursuant to §§ 108.7 and 108.10. The claimant shall return the forms to the Program within fifteen (15) days of the date from which the forms are mailed to the employee.
111.10If a claimant suffers a new injury or an injury to an additional body part pursuant to § 111.8 while at work, the claimant’s official superior shall fill out the forms required in §§ 107.4 through 107.7 within fifteen (15) days of the date from which the forms are mailed to the employer.
111.11The Program shall issue an amended NOD either awarding or denying the claim for an amended NOD within thirty (30) days of the Program’s receipt of all forms required pursuant to §§ 111.8 through 111.10. The Program may controvert a claim for an amended NOD pursuant to §§ 112.3 through 112.7 of this chapter.