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West Virginia Code of State Rules › Agency 84 - Board Of Review › Title 84 - PROCEDURAL RULE BOARD OF REVIEW › Series 84-01 - Procedural rules to govern the initiation and conduct of hearings in contested unemployment compensation claims before the Board of Review and its subordinate tribunals › Section 84-1-2 - Basic Provisions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. Delegation of
				Authority. -- The Board of Review may delegate authority necessary for the fair
				and efficient administration of the office to the Chief Administrative Law
				Judge or to such other person as the Board deems fit. These powers shall
				include, but are not limited to, ruling on motions, continuance requests and
				fee petitions.
2.2. Purpose. -- The
				purpose of the hearing process shall be to receive and consider, as
				expeditiously and as fairly as possible, evidence and information relevant to
				the determination of the rights of the parties and to provide a review of the
				Deputy's decisions and determinations with regard to the granting or denial of
				any award, or the entry of any Order, or the granting or denial of any
				modification or change with respect to former findings. Orders or awards are
				made pursuant to the West Virginia Unemployment Compensation Law, W. Va. Code,
				§
									21A-1-1 et
				seq., as amended.
2.3. Appeal
				Tribunal.-- An Administrative Law Judge or a panel of Administrative Law Judges
				or the Board of Review in unemployment compensation claims or labor dispute
				cases.
2.4. Special Provisions.--
				The Board and its subordinate tribunals shall take reasonable measures to
				accommodate persons appearing before them with impairments or language
				barriers.
2.5. The Unemployment
				Compensation Division of Workforce West Virginia is referred to as the
				Unemployment Compensation Claims Office.
West Virginia Code of State Rules › Agency 84 - Board Of Review › Title 84 - PROCEDURAL RULE BOARD OF REVIEW › Series 84-01 - Procedural rules to govern the initiation and conduct of hearings in contested unemployment compensation claims before the Board of Review and its subordinate tribunals › Section 84-1-3 - General Appeals

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. Right of
				Appeal.-- Any party wishing to appeal a Deputy's decision may do so by filing
				an appeal with the local office of the Unemployment Compensation Claims Office
				where the claim was originally filed or where the claimant last
				reported.
3.2. Appeal in Writing.--
				An appeal from a Deputy's determination shall be made either in person at the
				local office using the appropriate appeal forms or by letter mailed or faxed to
				the local office. All such letters should include the following elements:
3.2.1. Name of the claimant and the
				employer.
3.2.2. Date of the
				Deputy's decision.
3.2.3. Statement
				of intention to appeal the decision.
3.2.4. Signature of the requesting party or
				counsel.
West Virginia Code of State Rules › Agency 84 - Board Of Review › Title 84 - PROCEDURAL RULE BOARD OF REVIEW › Series 84-01 - Procedural rules to govern the initiation and conduct of hearings in contested unemployment compensation claims before the Board of Review and its subordinate tribunals › Section 84-1-4 - Labor Dispute Cases

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Notice of
				Hearing.-- Notice of the date, time, and place of the hearing shall be sent to
				all interested parties at least ten (10) days in advance of the hearing date.
				This notice shall also inform the parties of their respective rights and duties
				in relation to the pending proceeding. In labor dispute cases involving more
				than ten claimants, where all or some claimants are represented by counsel,
				then notice to the represented claimants shall be sufficient if mailed to the
				represented claimant=s counsel.
4.2. Composition of Labor Dispute Appeal
				Tribunal.-- All cases relating to a labor dispute or to a disqualification
				under West Virginia §
									21A-6-3(4)
				shall be heard by an appeal tribunal composed either of three Administrative
				Law Judges or of the Board itself, as the Board may direct. W. Va. Code §
									21A-7-7.
4.3. Time Period for Decision.-- Upon
				consideration of all evidence, the appeal tribunal shall make a decision within
				fourteen (14) days after the date of the hearing and shall notify all
				interested parties of its findings and decision. W. Va. Code §
									21A-7-7a.
West Virginia Code of State Rules › Agency 84 - Board Of Review › Title 84 - PROCEDURAL RULE BOARD OF REVIEW › Series 84-01 - Procedural rules to govern the initiation and conduct of hearings in contested unemployment compensation claims before the Board of Review and its subordinate tribunals › Section 84-1-5 - General Hearing Procedures and Policies

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. Time, Place, and Manner of Hearing.--
				Upon receipt of a duly filed appeal of the decision of a deputy commissioner,
				or following the Commissioner's referral of a labor dispute case, the Board
				shall set the date, time, and place at which a hearing will be conducted.
				Location of the hearings shall be set by the Board at its discretion to achieve
				judicial efficiency.
5.1.1. Notice of
				Hearings.-- Notice of the date, time, and place of hearing shall be sent to all
				interested parties at least ten (10) days in advance of the hearing
				date.
5.1.2. If a continuance of
				the hearing is granted, the ten (10) day notice requirement may be
				waived.
West Virginia Code of State Rules › Agency 84 - Board Of Review › Title 84 - PROCEDURAL RULE BOARD OF REVIEW › Series 84-01 - Procedural rules to govern the initiation and conduct of hearings in contested unemployment compensation claims before the Board of Review and its subordinate tribunals › Section 84-1-6 - Appeal From Appeal Tribunal's Decision

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. Right to Appeal.-- Any party wishing to
				appeal an appeal tribunal's decision may do so by filing a written notice of
				appeal with the Board or with the local office of the Unemployment Compensation
				Claims Office where the claim was originally filed or where the claimant last
				reported.
6.2. Appeal in writing.--
				An appeal under this section shall be made either in person or by letter mailed
				to the Unemployment Compensation Claims Office or to the Board office. All such
				letters should include the following elements:
6.2.1. Name of the claimant, the employer,
				and case number.
6.2.2. Date of the
				decision.
6.2.3. Statement of
				intention to appeal the appeal tribunal=s decision.
6.2.4. Signature of the appealing party or
				counsel.
West Virginia Code of State Rules › Agency 84 - Board Of Review › Title 84 - PROCEDURAL RULE BOARD OF REVIEW › Series 84-02 - Implementation Of A Pilot Employment Supplemental Matching Program › Section 84-02-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.01.
Scope
- These regulations, establish general rules for
				the creation of an Emergency Employment Supplemental Matching
				Program.
1.02.
Authority
- These regulations are issued under
				authority of West Virginia Code, Chapter 21A, Article 2A, Section 5 as amended
				by Senate Bill 16 enacted June 2, 1983.
1.03.
Filing Date
-
				These regulations are promulgated on the 2nd day of September, 1983, and filed
				on 2nd day of September, 1983, in the Secretary of State's Office.
1.04.
Effective Date
- These regulations become effective from filing on the 2nd day of September,
				1983.
West Virginia Code of State Rules › Agency 84 - Board Of Review › Title 84 - PROCEDURAL RULE BOARD OF REVIEW › Series 84-02 - Implementation Of A Pilot Employment Supplemental Matching Program › Section 84-02-2 - General Plan of Program

Current through Register Vol. XLI, No. 28, July 12, 2024
2.01.
General Purpose
-The general purpose of these rules is
				to implement a pilot project of the Emergency Employment Supplemental Matching
				Program with funds designated for that purpose by the West Virginia Legislature
				on August 17, 1983.
2.02.
Scope of Pilot Project
- An estimated 100 jobs can be
				supplemented under this program. Due to limited funds, the estimated duration
				of incentive is approximately 440 hours per employee, which may be waived by
				the Commissioner or his representative. At no time shall an incentive extend
				beyond the six month limit, as set forth in Enrolled Senate Bill No.
West Virginia Code of State Rules › Agency 84 - Board Of Review › Title 84 - PROCEDURAL RULE BOARD OF REVIEW › Series 84-02 - Implementation Of A Pilot Employment Supplemental Matching Program › Section 84-02-3 - Specifications

Current through Register Vol. XLI, No. 28, July 12, 2024
3.01.
Program Priorities
- Top priority is given to West
				Virginia residents who are unemployed, heads of household, and have exhausted
				all unemployment benefits available to them. Second priority is given to West
				Virginia residents who are unemployed and have exhausted all unemployment
				benefits available to them.
3.02.
Definitions
(a)
HEAD OF HOUSEHOLD
"Head of Household" means any person who:
(1) Claims one or more persons, other than
				the filing taxpayer, as a dependent on his or her federal income tax return;
(2) has living in the same
				household one or more dependents; and
(3) receives no income for the household and
				does not have a spouse or dependent living in the same household who is
				employed in regular full-time employment:
Provided
,
				that participation in any public assistance benefits shall not disqualify any
				person from entitlement to head of household status.
West Virginia Code of State Rules › Agency 84 - Board Of Review › Title 84 - PROCEDURAL RULE BOARD OF REVIEW › Series 84-02 - Implementation Of A Pilot Employment Supplemental Matching Program › Section 84-02-4 - Distribution of Pilot Project Funds

Current through Register Vol. XLI, No. 28, July 12, 2024
4.01.
Initial
				Allocations
- Initial allocations will be divided equitably among
				the three pilot project areas, as delineated in Section 3.6.
4.02.
Slot
				Reallocation
- After 30 days, any unused allocations may be
				redistributed at the discretion of the Commissioner or his representative.
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. - This
				exempt legislative rule establishes the requirements and procedures to be
				followed by the Insurance Commissioner, private carriers, self-insured
				employers, third-party administrators, claimants, health care providers,
				vocational professionals, and others involved in the administration of
				claims.
1.2. Authority. " W. Va.
				Code §§
									23-2C-22;
				33-2-10(b);
				and
				33-2-21(a).
				Pursuant to W. Va. Code §§
									23-2C-5(c)(2)
				and
				33-2-10(b),
				workers' compensation rules proposed by the Insurance Commissioner and approved
				by the Industrial Covmcil are not subject to legislative approval as would
				otherwise be required imder W. Va. Code § 29A-3-l et seq. Public notice
				requirements of that chapter and article, however, must be followed.
1.3. Filing Date. - October 9,
				2009.
1.4. Effective Date. -
				November 8, 2009.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in this exempt legislative rule, the following terms
				  have the stated meanings unless the context of a specific use clearly indicates
				  another meaning is intended.
2.1.
				"Acted upon" means, but is not limited to, any one of the following:
1) received and processed;
2) contacted a claimant, employer, or medical
				provider in any fashion requesting more information;
3) reviewed and examined by medical
				personnel;
4) conducted a
				potential overpayment analysis;
5)
				cross-checked with other state agencies for relevant information; and
6) and other similar administrative
				steps which must be taken before a request can be ruled upon.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-3 - Claimant's Report of Injury and Application for Compensation

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1.
				General.
Immediately after sustaining an occupational injury, a
				  claimant should 1) seek necessary medical care; 2) immediately on the
				  occurrence of the injury or as soon as practicable thereafter give or cause to
				  be given to the employer or any of the employer's agents a written notice of
				  the occurrence of the injury; and 3) file a workers' compensation claim or
				  request that one be filed on his or her behalf. Failure to immediately give
				  notice to the employer of the injury weighs against a finding of compensability
				  in the weighing of the evidence mandated by W. Va. Code § 23-4-Ig and
				  dilutes the credibility and reliability of the claim. Notice provided to the
				  employer within two (2) working days of the injury shall be deemed immediate
				  notice:
Provided,
That under no circumstances shall the fact
				  that notice of an occupational injury was provided by the claimant later than
				  two (2) working days from the time of the injury be the sole basis for denial
				  of a claim. Enforcement of an employer's personnel policy requiring that a
				  claimant report an injury immediately is not a discriminatory practice imder
				  chapter twenty-three of the West Virginia Code.
3.2. Benefit rate calculation; wage
				information.
It is the joint responsibility of the claimant and the
				  employer to ensure that the correct wage information is provided to the
				  Insurance Commissioner or private carrier so that the correct benefit rate can
				  be paid the claimant. If the responsible party receives inaccurate wage
				  information, the responsible party will, upon receipt of accurate wage
				  information, adjust prospectively the benefit rate. The submission of
				  inaccurate wage information by the employer or the receipt of benefits based on
				  inaccurate wage information by the claimant may serve as evidence of abuse or
				  fraud under the applicable provisions of the West Virginia
				  Code.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-4 - Employer's Report of Injuries

Current through Register Vol. XLI, No. 28, July 12, 2024
The claimant's employer shall report to the private carrier
				  every injury sustained by any person in its employ within five (5) days of the
				  employer's receipt of the notice of an employee's desire to file a
				  claim.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-5 - Special Rules for Temporary Total Disability Claims

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. To qualify for temporary total
				disability benefits, the claimant must be unable to work as a result of the
				compensable injury more than three (3) consecutive calendar days following the
				date of injury before benefits become payable. To receive temporary total
				disability benefits for the first three (3) days of disability, the claimant
				must be unable to work as a result of the compensable injury more than seven
				(7) consecutive calendar days following the date of injury.
5.2. If an individual retires, as long as the
				individual remains retired, he or she is disqualified from receiving temporary
				total disability indemnity benefits as a result of an injury received from the
				place of employment from which he or she retired, unless the application for
				benefits was received prior to his or her retirement. An individual who has
				retired is also barred from reopening for temporary total disability indemnity
				benefits an earlier claim filed in connection with an injury received at the
				place of employment from which he or she retired. This section does not
				preclude payments of benefits otherwise due a claimant if the retiree has
				returned to employment and suffers a compensable injury or payment of benefits
				if the compensable injury causes the individual to retire.
5.3. If a period of disability includes a
				reasonably ascertainable period of time during which the claimant would not
				have been performing work for any employer, then temporary total disability
				indemnity benefits shall not be paid during that period. This section does not
				apply to periods of time caused by a reduction in force, lay-off, or time-off
				provided in connection with an employee benefit.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-6 - Special Rules for Permanent Partial Disability Claims

Current through Register Vol. XLI, No. 28, July 12, 2024
[RESERVED]
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-7 - Notice and Litigation

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. In all
				workers' compensation claims, the parties shall be limited to:
(1) the claimant or the claimant's
				dependants;
(2) the employer; and
(3), in claims involving funds
				created by article two-c, chapter twenty-three of the West Virginia Code, the
				Insurance Commissioner.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-8 - Special Rules for Permanent Total Disability Claims

Current through Register Vol. XLI, No. 28, July 12, 2024
[RESERVED]
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-9 - Special Rules for Non-Awarded Partial Benefits

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1. Non-awarded partial disability benefits
				pursuant to W. Va. Code §
									23-4-7a
				are payable only if the preponderance of the evidence indicates that a
				permanent impairment exists.
9.2.
				Non-awarded partial disability benefits are not payable in a claim that has
				been reopened only for temporary total disability benefits if a permanent
				partial disability award was previously made in the claim.
9.3. Non-awarded partial disability benefits
				paid prior to entry of the permanent disability award are to be deducted from
				the permanent partial disability award when it is granted. If the non-awarded
				partial disability benefits exceed the amount of the award, the claimant is not
				entitled to any further benefits from the award. The excess is considered to be
				an overpayment and may be collected by the responsible party pxirsuant to
				section 12. of this rule.
9.4. The
				responsible party may cease paying non-awarded partial disability benefits if
				the responsible party concludes that the amount of non-awarded partial
				disability benefits already paid will likely exceed the expected partial
				disability award and may, as soon as practicable thereafter, enter a permanent
				partial disability award based on the most current information available and
				the guidelines set forth in W. Va. Code St. R. §
									85-20-1 et
				seq., if appHcable.
9.5. If the
				claimant begins to receive rehabilitation benefits, non-awarded partial
				disability benefits shall not be paid until the rehabilitation process is
				completed.
9.6. Non-awarded partial
				disability benefits shall be immediately suspended if the claimant fails,
				without good cause, to present for an examination or rating. If suspended with
				good cause, benefits can be reinstated, without back pay, once the claimant
				presents for the examination or rating.
9.7. Non-awarded partial disability benefits
				are paid at the same rate as the permanent partial disability rate.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-10 - Time Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
10.1.
				Injiuy and occupational disease claims. -- The responsible party shall rule on
				claims based upon injuries and occupational diseases other than occupational
				pneumoconiosis that are properly executed and filed on prescribed forms with
				the responsible party within fifteen (15) working days from the receipt of all
				required information by the responsible party. The responsible party shall
				consider all information and proof properly submitted in connection with each
				claim. Whenever a claim has not been adequately or properly developed for
				consideration, the responsible party may require the production of additional
				evidence. The fifteen (15) working days to rule on the claim shall be tolled
				during this evidence gathering process.
10.2. Occupational Pneumoconiosis claims. "
				The responsible party shall enter nonmedical decisions in occupational
				pneumoconiosis claims vdthin ninety (90) days from the date the responsible
				party receives properly executed, prescribed forms. The responsible party shall
				consider all information and proof properly submitted in connection with each
				claim. Whenever the responsible party is of the opinion that a claim has not
				been adequately or properly developed for consideration, it may require the
				production of additional evidence. The ninety (90) days shall be tolled for no
				more than thirty (30) additional days during this evidence gathering
				process.
10.3. Medical treatment,
				medications, appHances, devices and supplies. -- The responsible party shall
				act upon an injured worker's request for authorization of medical treatment,
				medications, appliances, devices and supplies within fifteen (15) working days
				from the date the request was received by the responsible party.
10.4. Medical evaluations.
10.4.a. The responsible party shall refer
				claimants to physicians for examinations and evaluations as required by W. Va.
				Code §
										23-4-7a
				within twenty (20) days of the end of the one hundred twenty (120) day period
				of temporary total disability:
Provided,
That if the period of
				expected temporary total disability exceeds one himdred twenty (120) days, the
				responsible party shall make the referral within twenty (20) days of the end of
				the expected period of disability.
10.4.b. Examinations and evaluations to be
				performed by the Occupational Pneumoconiosis Board shall be scheduled and
				notice of the scheduling shall be transmitted to the parties within sixty (60)
				days after issuance of a non-medical decision directing referral to the
				Board.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-11 - Child Support and Spousal Support Orders

Current through Register Vol. XLI, No. 28, July 12, 2024
11.1. W. Va. Code §
									23-4-18
				allows child and/or spousal support payments to be withheld from a claimant's
				compensation and sent to the Bureau for Child Support Enforcement. The term
				"compensation" refers to temporary total disability benefits, temporary partial
				rehabilitation benefits, non-awarded partial benefits, permanent partial
				disability benefits and permanent total disability benefits only.
11.2. The amounts to be withheld by the
				responsible party from a claimant's compensation are the amounts which are set
				out in the withholding notice issued pursuant to the West Virginia Domestic
				Relations Act.
11.3. When an award
				of compensation is for permanent partial or non-awarded partial benefits, the
				responsible party shall withhold 100% of those benefits to collect payment of
				child and/or spousal support benefits.
11.4. When compensation is for temporary
				total, temporary partial, rehabilitation temporary total, permanent total, or
				dependent benefits, the responsible party may only withhold the amount or
				amounts specified on the withholding notice, subject to the limitations set out
				in Table 1a.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-12 - Overpayments

Current through Register Vol. XLI, No. 28, July 12, 2024
12.1. Overpayments
				include any monies received from, or paid on a claimant's behalf by, the
				responsible party to which it is subsequently determined by the responsible
				party that the injured worker was not entitled. Overpayment may include, but
				shall not be limited to, the payment of temporary total disability benefits,
				permanent partial disability benefits, permanent total disability benefits,
				non-awarded partial disability benefits, temporary total rehabilitation
				benefits, temporary partial rehabilitation benefits, dependents benefits, fatal
				(104 week) benefits, travel reimbursement, and medical benefits.
12.2. The responsible party may collect
				overpayments to claimants by withholding future disability benefits payable to
				the claimant or the worker's dependents in the same claim or other claims which
				are pending with the same responsible party to whom the overpayment is due. The
				overpayment specifically can be withheld from temporary total disability
				benefits, permanent partial disability benefits, permanent total disability
				benefits, non-awarded partial disability benefits, temporary total
				rehabilitation benefits, temporary partial rehabilitation benefits, and travel
				reimbursement.
12.3. Collection of
				overpayments from temporary total disability benefits, permanent total
				disability benefits, temporary total rehabilitation benefits and temporary
				partial rehabilitation benefits is limited to thirty percent (30%) of the
				periodic benefit amount (i.e. weekly, bi-weekly, monthly, etc.):
Provided,
That if the overpayment was based upon fraud, abuse
				or mistake, caused in whole or in part, by the claimant or his or her agent,
				then the amount of the overpayment may be recovered in full by withholding 100%
				of the periodic benefit amount until the overpayment is recaptured.
12.4. Collection of overpayments from travel
				reimbursement, permanent partial disability benefits and non-awarded partial
				disability benefits are not limited and may be withheld in full until the
				overpayment is satisfied.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-13 - Occupational Pneumoconiosis and Occupational Disease Claims

Current through Register Vol. XLI, No. 28, July 12, 2024
13.1. In any claim
				involving an occupational disease, other than occupational pneumoconiosis,
				resulting from inhalation of minute particles of dust over a period of time in
				the course of and resulting from employment:
(1) which is filed as an occupational disease
				claim (as opposed to being filed as an occupational pneumoconiosis claim); and
(2) in which a permanent
				disability determination is required, the claim shall be referred by the
				responsible party to the Occupational Pneumoconiosis Board for a determination
				of whole body medical impairment:
Provided,
That this
				subsection in no event affects the applicability of benefits or any other
				procedures available under the West Virginia Code for occupational disease
				claims other than occupational pneumoconiosis claims. In the claims described
				in this subsection, the Occupational Pneumoconiosis Board's findings and
				conclusions regarding whole body medical impairment have the same legal force
				and effect as any other findings and conclusions issued by the Board:
Provided,
That in such claims, the jurisdiction of the
				Occupational Pneumoconiosis Board is limited solely to the determination of
				whole body medical impairment.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-14 - Procedures for Suspension for Claimant Abuse

Current through Register Vol. XLI, No. 28, July 12, 2024
14.1. When evidence is obtained justifying a
				finding that a claimant has engaged or is engaging in abuse, including, but not
				limited to, engaging in physical activities inconsistent with his or her
				compensable workers' compensation injury, or when evidence is obtained
				establishing a failure to undergo examinations or needed treatment, the
				responsible party will suspend the claimant's temporary total disability
				benefits.
14.2. Abuse may also
				include working at an unreported job while drawing temporary total disability
				benefits, making false or misleading statements to the responsible party or a
				health care provider for the purpose of securing any benefit, and altering,
				falsifying, destroying, or concealing workers' compensation related
				records.
14.3. Any claimant found
				to be engaging in abuse or who fails to undergo examinations or needed
				treatment shall receive a notice of benefit suspension. This notice is not
				protestable. The claimant has thirty (30) days to submit evidence justifying
				the reinstatement of benefits. If justification is not established, then the
				claimant will receive notice that the claim has been closed for temporary total
				disability payments. This notice is protestable. If justification is
				established, benefits will be reinstated with back benefits awarded.
14.4. In claims pending prior to approval of
				a managed health care plan, the claimant's failure to select a treating
				physician from an approved managed health care plan within sixty (60) days of
				notification to do so will result in a suspension of medical and indemnity
				benefits until the claimant's selection is made, unless the claimant is
				eligible to opt out of the managed care plan network.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-15 - Travel Expenses-Medical Examination and Treatment

Current through Register Vol. XLI, No. 28, July 12, 2024
15.1. General.
Claimants are entitled to reasonable travel, meals and
				  lodging expenses actually incurred in connection with an authorized medical
				  examination or treatment. In determining the reasonableness of such expenses,
				  the responsible party shall utilize the travel regulations for State employees
				  as a guide, unless specific provisions to the contrary are otherwise contained
				  herein.
15.2. For purposes
				of this rule, authorized medical examination or treatment includes medical
				examination or treatment provided by the claimant's authorized treating
				physician. If a claimant is required to travel in a personal vehicle for
				medical examinations or treatment, the mileage reimbursement rate provided for
				in the West Virginia Department of Administration's Purchasing Division Travel
				Rules as authorized by W. Va. Code §
									12-3-11
				shall apply. For purposes of reimbursement rates pursuant to this subsection,
				all examinations or treatment provided to the claimant shall be considered to
				have been authorized on the date of the examination or treatment, regardless of
				whether the treatment was provided by the claimant's authorized treating
				physician or whether prior authorization was required. The reimbursement rate
				shall be the rate in effect on the date of the examination or
				treatment.
15.3. Mileage
				reimbursement as described in subsection 15.2. of this section shall be
				determined based upon the shortest practicable route between the claimant's
				residence and the provider.
15.4. A
				responsible party is not required to reimburse a claimant for travel expenses
				more frequently than once every three (3) months, unless:
15.4.a. An amount in excess of $ 100 in total
				reimbursement owed is involved; or
15.4.b. Action is taken to administratively
				close the claim.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-16 - Complaints

Current through Register Vol. XLI, No. 28, July 12, 2024
Upon receiving any inquiry from the Insurance Commissioner
				  regarding a complaint filed with the Commissioner, a private carrier or
				  self-insured employer shall, within fifteen (15) working days of the date
				  appearing on the inquiry, fiimish the Commissioner with a complete written
				  response. A "complete written response" addresses all issues raised by the
				  complainant or the Commissioner and includes copies of any documentation
				  requested. This subsection is not intended to permit delay in responding to
				  inquiries by the Commissioner or the Commissioner's staff in conjunction with a
				  scheduled examination.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-17 - Expert Witness Appearances

Current through Register Vol. XLI, No. 28, July 12, 2024
17.1. An
				authorized treating physician, or an authorized consulting physician acting
				upon referral from an authorized treating physician, appearing at a hearing to
				give testimony regarding an examination of a claimant will be paid a fee by the
				responsible party commensurate with the service rendered for such appearance
				and testimony, not to exceed $100 per quarter hour.
17.2. All other expert witness appearance
				fees, including, but not limited to, any physician other than those physicians
				mentioned in subsection 17.1. of this section, medical vendors, rehabilitation
				providers, physical therapists or vocational specialists, shall be paid for by
				the party wishing to examine or cross-examine the expert witness at an amount
				agreed to by the parties based upon usual and customary rate for the profession
				involved, not to exceed $100 per quarter hour. If the expert witness demands an
				amount in excess of $100 per quarter hour to appear, it is the sole
				responsibility of the party who has retained the services of the expert or
				submitted a report or records of the expert as evidence in the case to pay for
				the difference.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-18 - Implementation and Stay of Orders from the Office of Judges

Current through Register Vol. XLI, No. 28, July 12, 2024
18.1. The responsible party may move for stay
				of any order entered by the Office of Judges for the payment of indemnity
				benefits, or which will necessarily require or result in the payment of such
				benefits, including, but not limited to, an order which finds a claim to be
				compensable, by filing a motion with either the Administrative Law Judge who
				entered the order or with the Board of Review.
18.2. A motion as described in subsection
				18.1. of this section filed with the Office of Judges must be filed within ten
				(10) days of the date of entry of such order. A motion as described in
				subsection 18.1. of this section filed with the Board of Review must be filed
				contemporaneously with the notice for appeal. Any motion that is not timely
				filed in accordance with this subsection shall be dismissed with prejudice. In
				either case, the claimant may file a response to the motion within ten (10)
				days of the date on which the motion was filed, and the Office of Judges or
				Board of Review, whichever is applicable, shall enter an order granting or
				denying the motion within the ten (10) days from the end of the response
				period.
18.3. Any motion as
				described in subsection 18.1. of this section must include the following
				minimum content:
(1) A statement of the
				reasons the stay is being sought; and
(2) a statement of the grounds for the
				underlying appeal. Failure to include the minimum content described in this
				section is grounds for summary denial of the motion.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-19 - Miscellaneous Administrative Matters

Current through Register Vol. XLI, No. 28, July 12, 2024
If mail sent by the responsible party to a claimant, an
				  employer, a vendor or any other party to a claim is returned due to an
				  incorrect address, a reasonable effort will be made to determine the correct
				  address. If after reasonable effort and due diligence a correct address cannot
				  be located, the responsible party shall cease mailing correspondence to the
				  party until such time as a correct address is provided.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-01 - Claims Management And Administration › Section 85-1-20 - Preferred Drug List

Current through Register Vol. XLI, No. 28, July 12, 2024
20.1. In
				accordance with the provisions of the Workers' Compensation Act [23-4-3(a)(3)]
				that require pharmacists filling a prescription for medication for a workers'
				compensation claimant to dispense a generic brand of the prescribed medication
				if the generic brand exists, the responsible party may establish a Preferred
				Drug List (PDL) for the purposes of:
20.1.a.
				Improving the quality of care of claimants by utilizing a PDL of generics and
				brand medications in the absence of generics;
20.1.b. Affecting cost savings in the
				provision of health care services by determining what is reasonably required;
				and
20.1.c. Optimizing
				pharmaceutical care and cost effectiveness.
TABLE 1a
Family
Arrears
Percentage
Not supporting another family
Less than 12 weeks old
Maximum of 50%
Not supporting another family
Greater than 12 weeks old
Maximum of 55%
Supporting another family, even just a spouse
Less than 12 weeks old
Maximum of 40%
Supporting another family, even just a spouse
Greater than 12 weeks old
Maximum of 45%
PUBLIC HEARING JULY 30, 2009
OFFICES OF THE WEST VIRGINIA INSURANCE COMMISSIONER
				  WORKERS' COMPENSATION INDUSTRIAL COUNCIL
TITLE 85, SERIES 1
CLAIMS MANAGEMENT AND ADMINISTRATION
Transcript of the Public Hearing held on Thursday, July 30,
				  2009, at 3:00 p.m., Offices of the West Virginia Insurance Commissioner, 1124
				  Smith Street, Room 400, Charleston, West Virginia.
Industrial Council Members Present:
Bill Dean, Chairman
Kent Hartsog
Dan Marshall
Walter Pellish (via telephone)
Chairman Bill Dean: This is Title 85, Series 1, Claims
				  Management and Administration. Ryan, do you have anything you want to say
				  before we get started?
Ryan Sims (Associate Counsel, QIC): No. We did not receive
				  any written comments on Title 85, Series 1.
Chairman Dean: Does anybody from the general public have
				  anything they would like to comment on regarding Title 85, Series 1? We will
				  close the public hearing.
[There were no comments'.]
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-02 - Workers' Compensation Claims Index › Section 85-2-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				rule governs the administration of the West Virginia Workers' Compensation
				Claims Index established pursuant to W. Va. Code §
									23-2C-5(c)(8).
1.2. Authority. -- W. Va. Code §§
									23-2C-22;
				33-2-10(b);
				and
				33-2-21(a).
				Pursuant to W. Va. Code §§
									23-2C-5(c)(2)
				and
				33-2-10(b),
				workers' compensation rules proposed by the Insurance Commissioner and approved
				by the Industrial Council are not subject to legislative approval as would
				otherwise be required under W. Va. Code §
									29A-3-1
				et seq. Public notice requirements of that chapter and article, however, must
				be followed.
1.3. Filing Date. --
				July 18, 2008.
1.4. Effective Date.
				-- August 17, 2008.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-02 - Workers' Compensation Claims Index › Section 85-2-2 - Purpose

Current through Register Vol. XLI, No. 28, July 12, 2024
The purpose of this rule is to establish guidelines to
				  govern the administration of the Workers' Compensation Claims Index pursuant to
				  W. Va. Code §
									23-2C-5(c)(8).
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-02 - Workers' Compensation Claims Index › Section 85-2-3 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in this exempt legislative rule, the following terms
				  have the stated meanings unless the context of a specific use clearly indicates
				  another meaning is intended.
3.1.
				"Commissioner" means the Insurance Commissioner of West Virginia as provided in
				W. Va. Code §
									33-2-1,
				or any designated third-party administrator of the Insurance
				Commissioner.
3.2. "EDI" is the
				Electronic Data Interchange Project of the International Association of
				Industrial Accident Boards and Commissions ("IAIABC"), Release 3
				standards.
3.3. "Industrial
				Council" means the Industrial Council created pursuant to W. Va. Code §
									23-2C-5.
3.4. "Private carrier" means any insurer
				authorized by the Commissioner to provide workers' compensation insurance
				pursuant to chapters twenty-three and thirty-three of the West Virginia Code
				and any third-party administrator designated by the private carrier to adjust
				West Virginia workers' compensation claims.
3.5. "Self-insured employer" means an
				employer who is eligible and has been granted self-insured status pursuant to
				the provisions of W. Va. Code §
									23-2-9
				and the rules promulgated thereunder, and any third-party administrator
				designated by the self-insured employer to adjust West Virginia workers'
				compensation claims.
3.6. "Special
				Funds," mean all workers' compensation related funds created in W. Va. Code
				§
									23-2C-1 et
				seq., and administered by the Commissioner, which are responsible for paying
				certain West Virginia workers' compensation benefits, and any third-party
				administrator designated by the Commissioner to adjust West Virginia workers'
				compensation claims on behalf of such funds.
3.7. "WV OIC EDI IG" is the West Virginia
				Offices of the Insurance Commissioner's EDI Implementation Guide.
3.8. "Workers' Compensation Claims Index" or
				"claims index" is a method for indexing claims of injured workers filing for
				West Virginia workers' compensation benefits that will make information
				concerning West Virginia's injured workers available to insurers or
				self-insured employers, as required by the Industrial Council pursuant to W.
				Va. Code §
									23-2C-5(c)(8).
3.9. "West Virginia workers' compensation"
				means workers' compensation coverage which provides workers' compensation
				benefits to injured employees consistent with chapter twenty-three of the West
				Virginia Code and the rules promulgated thereunder.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-02 - Workers' Compensation Claims Index › Section 85-2-4 - Claims Index

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Consistent
				with the provisions of W. Va. Code §
									23-2C-5(c)(8),
				a West Virginia Workers' Compensation Claims Index shall be maintained in the
				form of an electronic database and administered by staff of the Commissioner,
				utilizing selected data reported by private carriers, special funds and
				self-insured employers to the Commissioner through EDI. The purpose of the
				claims index is to make basic information regarding claims filed by injured
				workers available to private carriers, self-insured employers and the
				Commissioner.
4.2. The claims index
				shall contain basic information on all West Virginia workers' compensation
				claims reported consistent with this rule, including the following minimum
				requirements, based upon the best information available to the private carrier,
				self-insured employer or Commissioner:
a.
				Claim number;
b. Accident date/Date
				of injury or last exposure;
c.
				Claimant's full name;
d. Claimant's
				social security number;
e. Name,
				address and phone number of a contact person for the private carrier,
				self-insured employer or third-party administrator, as applicable;
f. Body part that is the subject of the
				claim;
g. The percentage of
				permanent partial disability award granted in the claim; and h. Any other
				fields of information as the Commissioner deems necessary.