 |
D.C. Municipal Regulations (Last Updated: September 13, 2017) |
 |
Title 7. EMPLOYMENT BENEFITS |
|
Chapter 7-1. [DELETED] |
Section 7-128. APPEAL OF INITIAL DETERMINATIONS AND ELIGIBILITY DETERMINATIONS
-
128.1An employee or claimant who is not already receiving benefits and is dissatisfied with an ID may request a hearing under § 129 of this chapter.
128.2An employee or claimant who is already receiving benefits and is dissatisfied with an ED may either submit a request for reconsideration to the ORM, or appeal the ED as provided in the Act, but not both at the same time.
128.3In the event an employee or claimant submits both a request for reconsideration to the Program and a request for a hearing to the OHA, the employee shall be entitled only to the appeal process with the agency that first received the request. The other request shall not be considered by the other agency.
128.4A claimant shall be entitled to receive continued benefits pending a decision on a request for reconsideration unless:
(a) The award for compensation was for a specific period of time which has expired;
(b) The claimant has died;
(a) The claimant has returned to work;
(b) The claimant has been released to return to work and the requirements of § 127.5 have been met;
(c) The claimant has been convicted of fraud in connection with the claim;
(d) The claimant has been released to or has returned to work on a part-time or modified duty basis notwithstanding individuals directed to undergo vocational rehabilitation under section 2304 of the Act.
(e) The claimant’s compensation benefits have been suspended due to the claimant’s failure to participate in vocational rehabilitation, failure to cooperate with the Program's request for a physical examination by a treating or AME physician, failure to follow prescribed and recommended courses of medical treatment;
(f) The claimant has failed to cooperate with the subrogation process pursuant to § 143 of this chapter;
(g) The claimant has voluntarily retired and been awarded retirement benefits in lieu of workers’ compensation benefits; or
(j) The claimant knowingly and willfully received benefits to which he or she was not entitled under the Act.
128.5If a Request for Reconsideration is properly and timely submitted pursuant to this section, the ORM may affirm, modify, vacate, or remand the ED for further examination by the claims examiner, in full, or in part.
128.6A request for reconsideration shall be written and shall contain medical, vocational, or factual justification.
128.7A Request for Reconsideration shall be delivered to the ORM by hand, or by first-class mail, postage prepaid, within thirty (30) days of the date of issuance of the ED that is the subject of the Request for Reconsideration. If a Request for Reconsideration is hand-delivered, the ORM shall provide the claimant with a dated receipt. Requests for Reconsideration shall not be accepted by facsimile or email.
128.8If the ORM receives a Request for Reconsideration after the thirtieth (30th) day following the issuance of the ED, it shall deny the Request for Reconsideration as untimely without ruling on the merits.
128.9A claimant may request a waiver of the filing deadline in § 128.7 on the grounds that good cause existed during the thirty (30) days following the ED decision sufficient to justify the ORM's late receipt of the Request for Reconsideration. The claimant shall provide factual justification and supporting documentation required by ORM to support the request for the waiver. In no event shall a request for a waiver of the deadline be considered after one hundred eighty (180) days from the date of issuance of an ED.
128.10The ORM shall rule on the merits of a Request for Reconsideration. The standard to prevail on a Request for Reconsideration shall be preponderance of the evidence, based on the Act, best practices, and applicable case law. If the ORM's decision on the Request for Reconsideration is based in whole or in part on medical information, the ORM shall, in making its ruling, adhere to the requirements of § 123.13.
128.11The ORM shall, using a standard form developed by the ORM, provide a brief written explanation of its decision and mail the decision to the employee.
128.12If the ORM grants a Request for Reconsideration, ORM shall remand the claim back to the claims examiner and instruct the claims examiner to issue a new NOD that is consistent with the Reconsideration decision.
128.13If the ORM grants a Request for Reconsideration and the claimant has been receiving continued benefits during the pendency of the ORM's decision, such benefits shall continue without interruption. If ORM grants a Request for Reconsideration and the claimant has not been receiving benefits during the pendency of the ORM's decision, all current and any retroactive benefits due to the claimant shall be paid within thirty (30) days.
128.14If the ORM denies a Request for Reconsideration, ORM shall issue a reconsideration decision from which the claimant shall have thirty (30) calendar days to appeal to the OHA. A claimant shall not be entitled to receive continuing benefits pending a hearing.
128.15The ORM decision shall not be binding upon a OHA Administrative Law Judge (ALJ).