West Virginia Code of State Rules › Agency 115 - Risk And Insurance Management › Title 115 - LEGISLATIVE RULES STATE BOARD OF RISK AND INSURANCE MANAGEMENT › Series 115-07 - Patient Injury Compensation Fund › Section 115-7-7 - Application for Compensation

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. A claim for reimbursement of
				uncollectible economic damages shall be made by filing an original and two (2)
				copies of a verified written application for compensation. An application for
				compensation must be signed by the claimant or his or her legal
				representative.
7.2. As a condition
				of receiving compensation from the fund, the claimant shall execute appropriate
				confidentiality or privacy waivers granting the agency access to all of his or
				her medical records.
7.3. All
				applications for compensation must be received by the Board or, if mailed,
				postmarked on or before June 30, 2016, in order to be eligible for review or
				payment from the fund._
7.4. The
				verified application for compensation shall set forth and provide the following
				information:
7.4.a. The name and address of
				the claimant and other identifying information which the agency may
				require;
7.4.b. The name and
				address of the legal representative of the claimant and the basis for his or
				her representation of the claimant;
7.4.c. The date(s), time(s) and place(s)
				where the underlying medical injury occurred;
7.4.d. A statement of the facts and
				circumstances regarding the underlying medical injury leading to and ultimately
				giving rise to the submission of the application for compensation.
7.4.e. A detailed description of the economic
				damages for which the claim is made;
7.4.f. Documentation of expenses and services
				incurred to date, indicating whether such expenses and services have been paid
				for, and if so, by whom;
7.4.g.
				Documentation of any applicable private or government source of services or
				reimbursement relative to the underlying medical injury;
7.4.h. A schedule listing all liability
				insurance, policy limits, and amounts collected by claimant to date from
				responsible persons with respect to the medical injury and the underlying
				medial liability civil action. Copies of all applicable liability insurance
				policies or policy declaration pages shall be attached to the
				application;
7.4.i. A detailed
				statement of the facts and circumstances, including any declaratory judgments
				or rulings, demonstrating how the claimant exhausted all reasonable means to
				recover economic damages from all applicable liability insurance
				coverages;
7.4.j. If the underlying
				medical injury claim was the subject of a civil action, the court (federal or
				state) in which it was filed, the docket or civil action number, the parties to
				such action, and its present status, including certified copies of court
				documents including complaint, answer, judgment, special jury interrogatories,
				verdict forms, declaratory rulings and dispositive motion orders;
7.4.k. Appropriate and relevant assessments,
				evaluations, and prognoses and other records and documents the agency deems
				reasonably necessary for the determination of the amount of compensation to be
				paid to, or on behalf of, the claimant.
7.4.l. All available relevant medical records
				relating to the claimant and the underlying medical injury and an
				identification of any unavailable medical records known to the claimant and the
				reasons for the unavailability.