West Virginia Code of State Rules › Agency 102 - Workers' Compensation Board Of Review › Title 102 - PROCEDURAL RULE WORKERS' COMPENSATION BOARD OF REVIEW › Series 102-01 - Rules of Practice and Procedure and Litigation of Protests › Section 102-1-19 - Disputes Between Claim Administrators: Reopening Versus New Injury Issues

Current through Register Vol. XLI, No. 28, July 12, 2024
19.1. Scope. W.
				Va. Code § 23-5-1a(b)(2)(A) provides that the Board of Review resolves
				disputes between claim administrators, without prejudicing the right of the
				injured worker to immediate workers' compensation benefits, in claim filings in
				which the claim is otherwise compensable but the only matter of dispute is
				whether the claim should have been filed as a new injury application or an
				application to reopen an old claim.
19.2. Initiation of process. When a claim
				administrator determines to deny a request for benefits and the only basis for
				denial of benefits is the determination that the application was improperly
				filed as a new claim or a reopening of an old claim, the claim administrator
				shall issue a decision denying benefits and providing the right of the claimant
				to object. If the claimant files a timely protest, then the following
				subsections apply. The Board of Review shall acknowledge the protest and enter
				a time frame as provided for in any other type of protest.
19.3. Administration of claim and conditional
				payment of benefits. Upon receipt of notice of the filing of a protest to the
				denial of the claim, the claim administrator shall begin conditional payment of
				benefits within fifteen (15) working days. Conditional payment of benefits
				shall continue until affected by subsequent order or decision of the Board of
				Review.
19.4. Notice from claim
				administrator to Board of Review. After the claim administrator receives notice
				of the filing of a protest to the denial of the claim, the claim administrator
				shall promptly notify the Board of Review that another identifiable person may
				be liable. The burden is on the claim administrator to provide sufficient claim
				identifying information in order for the Board of Review to determine to change
				the responsible administrator.
19.5. Notice to other allegedly liable
				person; new claim defenses
19.5.1. Form of
				notice. Upon receipt of sufficient information from the claim administrator,
				the Board of Review will join the other potential claim administrator to the
				proceeding. The Board of Review will notify the alleged responsible claim
				administrator of the existence of the claim for benefits, of the existence of
				the protest, the allegation that the claim is otherwise compensable, the
				possibility that the claim responsibility may ultimately be assigned to the new
				claim administrator, the possibility that conditional payments being made may
				ultimately be transferred to the new administrator, and of any time limit for
				raising any claim defenses not raised by the initial claim administrator, or
				for filing evidence.
19.5.2. New
				claim defenses. Although the claim administrator with whom the claim was
				initially filed has determined that no basis exists for the denial of the claim
				other than that the application was filed with the wrong claim administrator,
				the process cannot limit the rights of the potentially responsible claim
				administrator to offer its own claim defenses. The Board of Review will provide
				a reasonable time period for the new claim administrator to investigate the
				circumstances of the claim and issue a notice raising any additional reasons
				for denying the claim. If the new claim administrator raises other reasons that
				the claim should have been denied, then the Board of Review shall address those
				issues in any final decision on the protest.