7 CCR 1106-1-2 - Claims
2-1 Notice to the
Board
(A) The CUE Board shall be notified by
the Division monthly of any claim deemed or appearing to be
uninsured.
(B) Any Application for
Hearing or Response to Application for Hearing filed in a claim in which the
issue of insurance coverage is endorsed or which is considered uninsured by the
Division or which has been accepted by the Board for payment of benefits shall
be served upon the Board or its designated representative at the time of
filing.
(C) At the discretion of
the board, an order issued without proper notice to the board may be accepted
for purposes of an application for benefits.
(D) The Board may notify all parties of its
intent to join the claim by filing a Response to the Application for Hearing or
upon motion and order to join the claim. If the deadline for filing a response
to the application for hearing has expired, an extension shall be granted by a
prehearing administrative law judge upon good cause shown.
2-2 Initial Application
(A) Application for payment of benefits from
the Fund may only be made after issuance of a final order finding the claim to
be compensable and the employer to be uninsured. Any such application shall be
made within 90 days of the order becoming final. The Board shall notify the
claimant of the 90 day deadline for application.
(B) Where the Board participated in the
hearing, the application for benefits may not be rejected unless the Fund is
closed pursuant to 3-2(B).
(C)
Where the Board received notice and did not participate in the hearing, it is
bound by the final order with regard to compensability of the claim.
Applications for benefits may only be denied if:
(1) The Board or its agents determine an
insured entity such as a statutory employer is responsible for payment of
benefits.
(2) The application for
benefits appears to be fraudulent.
(3) The Fund has been temporarily closed
pursuant to the Board's authority under Rule 3-2
(D) Upon rejection of an initial application
for entry into the Fund the Applicant may file an application for hearing to
contest the determination of the Board. Any such application for hearing shall
be filed within 90 days of the date the Board issues notice the application for
benefits was rejected. Notice shall include a statement of the right to apply
for hearing within 90 days. Failure to file an application for hearing within
the time provided shall be deemed a waiver of the right to appeal.
2-3 Benefits
(A) At the time of initial acceptance into
the Fund a Claimant shall be entitled to receive payment for all benefits which
accrued prior to the date of acceptance, subject to the benefit levels set by
the Board in the annual report required by Rule 3-1 which were applicable at
the time the benefits accrued.
(B)
At the time of initial acceptance into the Fund all reasonable and necessary
medical provider bills which remain unpaid will be paid pursuant to Workers'
Compensation Rule of Procedure 16. The injured worker will be reimbursed for
any such payments made out of pocket. Any medical bills more than three years
old at the time of application must be reviewed by the Board and will be paid
only upon a majority vote.
(C)
Following acceptance into the Fund, benefits shall be paid in the same manner
as workers' compensation benefits paid pursuant to the Workers' Compensation
Act, except that:
(1) The Board may modify,
terminate or suspend payments from the CUE Fund pursuant to
8-67-107(1)(b).
(2) For any period where payments are so
modified, terminated or suspended, the Claimant shall have no claim to accrued
payments from the Fund other than medical benefits.
(a) Nothing in this section shall be
construed as reducing the liability of the non-insured employer to pay the full
amount of benefits as required by the Workers' Compensation Act.
(b) Any bills for medical services which
accrue during a period of reduced benefits shall have first priority upon any
subsequent increase or resumption of benefits.
(D) Any claimant seeking benefits from the
cue fund must file a notice of entitlement to such benefits with the board for
benefits between February 1 and April 1 of each year.
(1) The Board shall send each claimant that
received benefits the prior year a notice form to complete.
(2) Failure to properly file the required
notice will result in the suspension of payment of indemnity benefits from the
Fund.
(E) Any medical
bills authorized and approved and not paid due to a limitation of funds shall
be retained by the Board and paid first in the following fiscal year.
2-4 Adjusting Procedures
(A) At any point after acceptance into the
Fund the Board may take any action permitted by the Workers' Compensation Act
on behalf of the employer.
(1) The employer
may object to any action by following the same procedure set forth by statute
for claimant to object. Where statute does not provide a procedure for
objecting, the employer may request a prehearing conference.
(2) Nothing in this section shall be
construed so as to prohibit or prevent the uninsured employer from filing an
application for hearing on any contested issues.
(B) The Board will be the only entity
permitted to file admissions of liability for accepted claims with the Division
of Workers' Compensation
(C) Any
admissions filed by the Board shall represent the benefits to which the injured
worker is legally entitled under the Workers' Compensation Act, without regard
to restrictions on payments from the Fund imposed by the Board due to
funding.
(D) Twice a year the Board
shall provide the injured worker and Division, on a form designated by the
Division, a statement of benefits actually paid by the Board and owed by the
employer.
Notes
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