Section EMP.04.06 — Worker's Compensation Claims Procedure

(a) Claim. If the worker feels that he or she is eligible for benefits under this Ordinance, the worker shall file a written request for benefits with the insurer.

(1) The claim request must be made within one year after the worker or the worker's beneficiaries learn of the worker's rights under this Ordinance regarding a reported injury or the claim shall be barred.

(2) Unless evidence to the contrary is shown, a worker learns of his or her rights one week after the insurer sends the notice of the worker's rights under this Ordinance.

(3) To limit the effect of any intervening events, the worker must receive medical treatment within 30 days of the accident or the claim shall be barred.

(b) Investigation. After receiving an application for compensation, the insurer shall promptly investigate the reported injury and administer valid claims for compensation arising from the reported injury. The insurer shall develop a written record of the claim.

(1) The insurer shall conduct an initial investigation promptly, so that a preliminary decision is made as to whether the worker shall receive compensation. In claims where compensation is payable, the insurer shall make the first payment thereof within 14 days after receipt of the claim. This preliminary decision is not a binding determination of any obligations for compensation.

(2) The insurer may continue to investigate the injury to ascertain the accuracy of the preliminary decision and the extent of the insurer's liability for compensation, so that a determination as to the worker's rights to compensation may be reached.

(3) The insurer shall pay such compensation, including temporary disability, permanent disability, and death benefits, as is due to the worker under this Ordinance. No benefits shall be paid until the injury is reported, unless circumstances prevented prompt reporting.

(4) If the worker is eligible to receive mileage for transportation expenses related to medical examination or treatment, the mileage rate shall be based on the federal mileage rate in effect at that time.

(d) Communication with Employer. The worker shall maintain contact with his or her employer throughout the worker's compensation process. This includes providing all required notices and documents, as well as regular updates on the worker's condition and prognosis.

(1) The worker shall contact the employer at least two (2) times per month during the healing period. Compensation will not be paid for any period during which the worker fails to maintain this contact.