Section 7-112. CLAIMS DEEMED ACCEPTED AND CONTROVERSION

 

112.1A newly filed claim for benefits shall be deemed accepted by the Program if the Program does not issue an initial notice of determination or notice of controversion within thirty (30) days of the date the claim was first reported to the Program.  This subsection only applies to newly filed claims and does not apply to any other request for compensation or benefits under this chapter, including claims for amended NODs under § 111.5(b) or claims of recurrences of injuries under § 120 of this chapter. 

112.2When a claim is deemed accepted pursuant to this section, payment of compensation shall become effective on the thirty-first (31st) day. 

 

112.3In the event that the Program does not have sufficient information to make an initial determination regarding compensability within thirty (30) days, the Program shall issue a notice of controversion to the employee. 

 

112.4The Program shall issue the notice of controversion before the thirtieth (30th) day following the date the claim was reported, shall explain the reasons a determination cannot be made, and shall describe the information or actions needed to make a determination.  Reasons for a controversion may include:

 

(a) The employee has not submitted all the required forms or information;

 

(b) The Program does not have sufficient medical evidence to make a determination; or

 

(c) The employee has not attended an orientation program pursuant to § 108.11 or has failed to cooperate pursuant to § 111.4.

 

112.5If the notice of controversion is issued because the employee has not submitted all the required forms or information, the notice shall inform the employee that he or she has fifteen (15) days to send the Program the required forms or information.  The notice shall further state that if the Program does not receive the required forms or information, the employee’s claim will be held in abeyance until the required forms or information is received. 

 

112.6If the employee does not send the Program the required forms or information within fifteen (15) days of the request in § 112.5, the Program shall issue a second notice of controversion.  If the required forms or information is not received after the second notice, the Program shall take no further action on the claim until it receives the required forms or information. 

 

112.7If a claim is controverted and held in abeyance for two (2) years after the date of injury or death and the employee has not sent the Program the required forms or information, the Program shall issue a notice to the employee denying the claim pursuant to section 2322(a) of the Act.

authority

Chief Risk Officer of the Office of Risk Management (ORM), Executive Office of the Mayor, pursuant to the authority set forth in section 2344 of the District of Columbia Government Merit Personnel Act of 1978 (CMPA), effective March 3, 1979 (D.C. Law 2-139; D.C. Official Code § 1-623.44 (2012 Supp.)); section 7 of Reorganization Plan No. 1 of 2003 for the Office of Risk Management, effective December 15, 2003; and Mayor’s Order 2004-198, effective December 14, 2004

source

Notice of Final Rulemaking published at 28 DCR 2307 (May 22, 1981); as amend by Notice of Final Rulemaking published at 29 DCR 5196 (November 26, 1982); as amended by Notice of Final Rulemaking published at 47 DCR 7484 (September 15, 2000); 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, 12231 (December 24, 2010); repealed and replaced by Final Rulemaking published at 59 DCR 8766, 8778 (July 27, 2012).