Page images
PDF
EPUB

basis, the fee approved shall be reasonably commensurate with the actual necessary work performed by such representative, with due regard to the capacity in which the representative appeared, the amount of compensation involved, and the circumstances of the beneficiary. § 61.21 Assignments; creditors.

The right of any person to benefits under this subchapter and the applicable provisions of Title I of such Public Law, pursuant to section 207 thereof, is not transferable or assignable at law or in equity except to the United States, and none of the moneys paid or payable (except money paid as reimbursement for funeral expenses), or rights existing under such title, are subject to execution, levy, attachment, garnishment, or other legal process or to the operation of any bankruptcy or insolvency law. § 61.22 Contracts for service facilities of insurance carriers.

(a) Under the provisions of section 106(a) of such Public Law the Bureau is authorized to contract with insurance carriers for the use of the service facilities of such carriers for the purpose of facilitating administration. The Bureau under this authority may enter into contracts for the use of service facilities which may be available and can be utilized in the processing of claims arising directly under section 101 and under section 104, Title I of such Public Law.

(b) Contracts for the use of service facilities will be arranged directly with insurance carriers or carrier groups as the Bureau finds to be necessary to facilitate administration.

(c) Compensation for the use of service facilities shall be based upon the services rendered for the Bureau with reimbursement for such items of claims expense (see § 62.6 of this subchapter) as may be necessarily incurred or authorized by the Bureau, unless the service charge agreed upon includes all items of the carriers expense. The compensation for services shall be such amount as the Bureau and the carrier shall agree upon as reasonable for services rendered.

PART 62-REIMBURSEMENT OF EM-
PLOYERS, INSURANCE CARRIERS,
OR COMPENSATION FUNDS

Sec.
62.1 General reimbursement provisions.
62.2 Claims for reimbursement.

Sec.

62.3 Approval of claims.

62.4

62.5

62.6

Examination of records of claimant.
Reimbursement of claims expense.

Claims for reimbursement of claims
expense.

62.7 Same; approval of claims. 62.8 Direct payment of benefits.

AUTHORITY: The provisions of this Part 62 issued under sec. 106, 56 Stat. 1033; 42 U.S.C. 1706, unless otherwise noted.

SOURCE: The provisions of this Part 62 appear at 8 F.R. 6811, May 25, 1943, unless otherwise noted.

§ 62.1 General reimbursement provisions.

(a) Where any employer or his insurance carrier or compensation fund pays or is required to pay benefits:

(1) To any person or fund on account of injury or death of any person coming within the purview of Title I of Public Law No. 784, 77th Congress, entitled "An Act to provide benefits for the injury, disability, death, or enemy detention of employees of contractors with the United States, and for other purposes," approved December 2, 1942, or of Public Law No. 208, 77th Congress, extending the Longshoremen's and Harbor Workers' Compensation Act to certain persons employed at military. air, and naval bases, and upon Federal public works, outside the continental United States, approved August 16, 1941, as amended, if such injury or death arose from a war risk hazard (as defined in section 201 (b), Title II of such Public Law No. 784), which are payable under any workmen's compensation law of the United States or of any State, Territory, or possession of the United States, or other jurisdiction.

(2) To any person by reason of any agreement outstanding on the date of enactment of such Public Law No. 784 (such date being December 2, 1942) made in accordance with a contract between the United States and any contractor therewith (including any subcontractor or subordinate contractor with respect to the contract of such contractor), (i) to pay benefits with respect to the death of any employee of suco contractor occurring under circumstances not entitling such person to benefits under any workmen's compensation law, or (ii) to pay benefits with respect to the failure of the United States or its contractor to furnish transportation, upon the completion of the employment of any employee of such contractor,

to his home or to the place where he was employed

(3) To any person by reason of an agreement approved or authorized by the United States under which a contractor with the United States has agreed to pay workmen's compensation benefits or benefits in the nature of workmen's compensation benefits to an injured employee or his dependents on account of detention by the enemy or on account of injury or death arising from a war-risk hazard;

such employer, carrier, or fund shall be entitled to be reimbursed for all benefits so paid or payable, including funeral and burial expenses, medical, hospital, or other similar costs for treatment and care; and reasonable and necessary claims expense in connection therewith.

(b) No reimbursement shall be made in any case in which the Bureau finds that the benefits paid or payable were on account of injury, detention, or death which arose from a war-risk hazard for which a premium (which included an additional charge or loading for such hazard) was charged; or where an insurance carrier has been compensated by its premium charge for the risk which it has assumed; or where the claimant has been reimbursed, paid, or compensated for the loss for which reimbursement is claimed.

(c) Reimbursement under this section, with respect to benefits, shall be made only of amounts which will discharge such liability or obligation as arises under applicable workmen's compensation law or pursuant to the terms of the applicable contract.

§ 62.2

of

Claims for reimbursement. (a) Claims for reimbursement benefits and expense shall be made upon a form which the Bureau has prescribed, shall be signed and sworn to by the person, firm, or corporation entitled to reimbursement or the duly authorized representative of such person, firm, or corporation, and shall be filed with the Bureau of Employees' Compensation, United States Department of Labor, Washington 25, D.C. Where the claimant is a corporation, or an agency authorized by the law of a State or other political jurisdiction, such corporation or agency shall advise the Bureau of the name and designation of its officer or officers authorized to execute such claims.

(b) Such claims shall contain a schedule showing the names and addresses of the persons to whom or on whose account benefits, payments, or expenses have been paid. In such schedule with respect to such persons there shall be stated the nature of the payment made; that is, whether for workmen's compensation benefits paid under any applicable law or for benefits under such agreements as are referred to in § 62.1. In the cases of such persons as are named in such schedule, the purpose of such payments shall be stated; that is, whether for compensation or benefits for disability or death, for medical, hospital or other similar costs for treatment and care, for funeral and burial expenses, for failure of the United States or the contractor to furnish transportation, for detention of an employee by the enemy, or for such other purpose within the purview of § 62.1. Expenses classed as reasonable and necessary claims expense in connection with the handling of such cases may be included in such claim, as provided for by § 62.5. With respect to each case listed in such schedule, where injury or death is involved, the cause thereof shall be stated; if payment is on account of detention or failure to furnish such transportation, the facts in relation thereto shall be stated.

(c) All payments as listed in such schedule shall be itemized, with identity of the payee shown. If necessary in specific cases listed in such schedule, where payments have been made to numerous payees, a supplementary sheet, properly identified, as an exhibit to the case or cases, may be used to show items and payees. Each item in excess of $10, with respect to which reimbursement is claimed in any claim shall be supported by a sufficient receipt signed by the payee showing that the amount claimed has been paid and the date thereof and the purpose of payment. Where a payee

fails or refuses to furnish such receipt upon request therefor, in lieu of such receipt the Bureau may accept the certificate of the person claiming reimbursement that the item has been paid as claimed (such certificate identifying the payee and service rendered or benefit paid) and that receipt has been requested, but that the payee has failed or refused to furnish same, and that a canceled check covering the payment is in the claimant's possession. The Bureau may also accept such certificate where

for other satisfactory reason such receipt can not be obtained; or the Bureau may accept other satisfactory evidence of payment. The Bureau reserves the right, when satisfactory receipts have not been furnished, to examine the vouchers, canceled checks, and other evidence of payment in the possession of the claimant. All supplementary sheets, as above referred to, receipts for items paid, and certificates in lieu of receipts, or other evidence, shall be marked with the case number appearing in the schedule (as provided in paragraph (d) of this section), the case name, as listed in such schedule, and identified as exhibits to the respective cases and lettered alphabetically with respect to each case.

(d) Where claim for reimbursement includes more than one case, the schedule attached thereto (referred to in paragraph (b) of this section) shall be arranged alphabetically and cases shall be numbered consecutively in the schedule. Each separate claim of an employer, insurance carrier, or compensation fund shall be numbered consecutively for prompt identification. Claimants shall make and retain a copy of the claim and accompanying schedule.

(e) In the schedule provided for in paragraph (b) of this section, there shall be set forth, in relation to each case as listed, a reference to the workmen's compensation law or agreement under which payment was made, sufficiently identifying the applicable law and section thereof pertaining to the separate amounts listed for reimbursement. Where payment was made pursuant to an award or settlement agreement under such applicable law, a copy of the award or agreement shall be attached as an exhibit to the case. Where continued payments have been made under an award or agreement, copy of which has been furnished by the claimant in connection with a prior claim, further copy thereof need not be furnished in connection with a later claim for reimbursement involving the same case. Sufficient reference thereto should be given to facilitate identification. Where an award or agreement has been modified, evidence of such modification should be submitted in applicable cases. Copies of awards under any law administered by the Bureau need not be attached, but reference thereto may be made in the schedule or in a separate sheet marked as a case exhibit. In all cases where an insurance carrier is a claimant, it

shall attach as a case exhibit a copy of the insurance contract under which its liability or obligation has accrued. Where payment was made pursuant to a contract or agreement between the United States and the contractor, a copy of such contract, or a sufficient excerpt therefrom or information sufficient to enable the Bureau to obtain a copy or excerpt thereof, including a copy of the applicable insurance contract issued thereunder, if any, shall be furnished as a case exhibit to the case or cases to which it applies. Such contract or excerpt should be supplemented by an explanatory statement of the claimant, or by other supporting papers, if the 11ability of the claimant for the payment with respect to which reimbursement is claimed is not otherwise clearly apparent. Where liability of an employer, insurance carrier or compensation fund has accrued in more than one case, copies of insurance contracts, awards or settlement agreements, or other agreements or contracts (or excerpts) relied upon as basis for reimbursement need be furnished to the Bureau only once as a case exhibit; thereafter, in other cases in the same reimbursement claim, or in future reimbursement claims, reference thereto may be made sufficiently identifying the case name, number upon claim schedule, and number and date of the claim (if the exhibit accompanied an earlier claim).

(f) Claims for reimbursement shall be filed quarterly; that is, as of the first of January, April, July, and October, unless otherwise authorized by the Bureau.

(Sec. 104, 56 Stat. 1031; 42 U.S.C. 1704; 1950 Reorg. Plan No. 19, § 1, 3 CFR, 1949-1953 Comp., p. 1010; 64 Stat. 1271) [8 FR. 6811, May 25, 1943, as amended at 25 F.R. 10795, Nov. 15, 1960]

§ 62.3 Approval of claims.

(a) If upon examination and audit of a claim under this part the Bureau finds that insufficient or inadequate information or proof has been supplied with the claim, further information or proof shall be submitted as required by the Bureau, and failure to supply available information and proof, upon request, may result in disallowance of items not adequately supported as justly reimbursable.

(b) No item shall be approved for reimbursement with respect to which there has been failure by the claimant to justify such item as a liability or obligation

of such claimant arising under the provisions of applicable workmen's compensation law or under the provisions of an agreement or contract relied upon as basis for such liability. Claims for reimbursement for funeral and burial expenses, medical, hospital, or other similar costs for treatment and care, or other necessary expenses, shall be approved only to the extent that they have been shown to be reasonable, and unreasonable or excessive items shall be reduced accordingly for purpose of such reimbursement. The Bureau will not withhold payment of any part of a claim approved, because of denial of any part of such claim. The Bureau will regard awards, decisions, and approved settlement agreements of workmen's compensation jurisdictions, which have become final in the cases to which they pertain, as establishing, prima facie, the right of the beneficiary named therein to the payment awarded or provided for.

(c) The claimant shall be advised or the action taken upon the claim filed and the amount approved for reimbursement. Where the claim has been denied in whole or in part, or where reimbursement as to any item has been reduced from the amount claimed, the claimant shall be advised thereof together with the reasons for the action taken. Claimants within the United States shall be allowed sixty days, and claimants outside the United States six months, unless unusual circumstances in either case are found to require a longer time, from date of the Bureau's action, within which to file objections to the disallowance of any claim or part thereof, or reduction in any item of a claim. Such objections properly filed will be considered by the Bureau. After such period of time, objections shall not be considered, unless the Bureau for reasonable cause shown shall consider such objections.

(d) A part or an item of a claim may be disapproved if the Bureau should find that the claimant or those whom he represented or those who represent him by contract or otherwise (1) failed to contest, reasonably questionable liability; or (2) failed to take advantage of set-off against the claim of any person whose case is referred to in such schedule; or (3) failed to take advantage of any right accruing by assignment, subrogation or otherwise (except as against the United States, directly or indirectly, its employees, or members of its armed

forces) because of the liability of a third party, unless the financial condition of such third party or facts and circumstances in respect of such liability justified such failure; or (4) failed to take reasonable measures to reduce or terminate his liability by appropriate available procedures under workmen's compensation law or otherwise; or (5) failed to make reasonable and adequate investigation or inquiry as to the right of any person to any benefit or payment, or the continuation thereof. In considering whether there has been a failure to do any of the foregoing things, the Bureau will have regard for and weigh such matters as bona fides, good judgment, unusual circumstances, reasonable cause, or such similar basis for justification as may be relied upon to avoid the effect of any such failure. Claimants will be held to the same degree of care and prudence in respect of the matters set forth in this paragraph, as under the law any individual or corporation in the protection of its interests or the handling of its affairs would be expected to exercise under similar circumstances.

§ 62.4 Examination of records of

claimant.

(a) Whenever it shall be deemed necessary, the Bureau or its representative may request submission of case records or may inspect the records and accounts of a claimant (or any party whom he represents or who represents him, by contract or otherwise) for the purpose of verifying any allegation, fact or payment stated in his claim or papers in support thereof, and such claimant shall furnish such record and permit or authorize any such inspection as the Bureau shall require. Such right of inspection shall also relate to records and data used for rate making or premium establishing purposes kept by a claimant or supplied by him to any rate making or similar agency or authority to determine whether any premium or other charge has been made with respect to the reimbursement claimed.

(b) If required by the Bureau, a claimant shall furnish copies of drafts, vouchers, releases, or other instruments relating to payments on account of which reimbursement is claimed, by photostat or other means of facsimile reproduction. § 62.5 Reimbursement of claims ex

pense.

(a) Under the provisions of section 104(a) Title I, of such Public Law No.

784, the Bureau is authorized to reimburse an employer, carrier, or compensation fund for reasonable and necessary claims expense in connection with cases within the purview of such section, for which reimbursement is claimed.

(b) In the adjustment of claims expense of employers (other than claims expense arising under insurance policles), reimbursement of reasonable and necessary claims expense will be made on the basis of item reimbursement. Items of such expense which will be recognized by the Bureau are only those items which can be directly allocated to claims, when necessary to determine liability. If in the adjustment of such claims expense, allocation thereof to a specific claim is impracticable, reimbursement of such expense or part thereof may be made by the Bureau on the basis of agreement with the claimant, or on such other equitable basis as will accomplish reimbursement for reasonable and necessary claims expense.

(c) The adjustment of claims expense arising under insurance policies to which are attached endorsements under the comprehensive insurance rating plan, or similar plan, of the Army or Navy Department, or other department or agency of the United States using the same or similar plan, shall be consistent with the method provided under such plan for determining payment of claims expense. In addition to reimbursement for allocated claims expense, as provided for and defined in such endorsement the Bureau may apply the same factor as is contained in such endorsement for determining claims expense, by applying such factor to the sum of paid losses arising under the policy containing such endorsement, as may be approved for reimbursement by the Bureau under the particular claim filed under § 62.2 to which such claims expense relates. In such situations the reimbursement of claims expense shall be upon the basis of such allocated claims expense plus the application of such factor, as provided. If the application of such factor would not result in reimbursement of reasonable and necessary claims expense, the Bureau may apply such method of determining such claims expense, or may adjust such expense upon such basis with the claimant, as will result in fair and equitable reimbursement. In cases in which no benefit payments have been made, but claims expense has been necessarily incurred, reimbursement of rea

sonable and necessary claims expense will be made with respect to proper items thereof as established by the claimant and approved by the Bureau, or upon such other equitable basis as may be agreed upon by the Bureau and the claimant. The adjustment of claims expense arising under other insurance policies or agreements shall be consistent with the plan or method, if any, provided for therein in the determination of reimbursable claims expense, if the application of such plan or method in relation to the amount of benefit reimbursement results in reimbursement of reasonable and necessary claims expense; otherwise, the manner of determining such reimbursable expense, as provided above with respect to cases in which no benefit payments have been made, shall be applied.

(d) In the adjustment of claims expense the Bureau will not in any case consider as a claims expense any distribution of administrative, general office maintenance, rent, insurance, taxes, or other similar general expenses. Except as defined otherwise by an applied endorsement, plan or method, the term "allocated claims expense", when considered as such by the Bureau, shall include payments made for reasonable attorneys' fees, court and litigation costs, expenses of witnesses and expert testimony, examinations, autopsies and such other items of expense as can be directly allocated to specific claims, when necessary to determine liability. The term "unallocated claims expense", when considered as such by the Bureau, shall mean that expense which can properly and definitely be allocated to claims, where necessary to determine liability, but can not be directly allocated to specific claims.

(e) No employer, insurance carrier or compensation fund shall be entitled to reimbursement under this section for any claims expense where it has been paid such expense, or has been paid for any service which included or contemplated payment of the expense for which reimbursement hereunder is sought, the cost of which has been or will be borne by the United States. Any charge made or paid, contemplating expenses other than allocated or unallocated claims expense shall not be considered as a claims expense within the meaning of this subsection. Every claimant applying for reimbursement of claims expense shall in his claim expressly disclaim and waive

« PreviousContinue »