24.29.816    DECISIONS WHICH MUST BE MADE BY A CERTIFIED CLAIMS EXAMINER

(1) Except as provided by ARM 24.29.818 and this rule, only a certified claims examiner may perform the tasks identified by 39-71-116, MCA, as being the responsibility of a claims examiner. As provided by 39-71-116, MCA, those tasks are to:

(a) determine liability;

(b) apply the requirements of the Workers' Compensation Act;

(c) settle workers' compensation or occupational disease claims; and

(d) determine survivor benefits.

(2) After an insurer or its agent has accepted liability for the claim or has begun paying benefits under a reservation of rights (including pursuant to 39-71-608, MCA), a certified claims examiner is responsible for making any decision that denies, reduces, or changes the type or level of benefits being provided to an injured worker or the survivors of an injured worker.

(3) Examples of decisions made under (2) include, but are not necessarily limited to:

(a) changing the disability status of a worker; and

(b) denying medical benefits.

(4) A person does not violate this rule if under the following circumstances, a person not certified as a claims examiner denies initial liability on a new claim, when the first report of injury clearly shows that the alleged incident has not resulted in:

(a) professional medical evaluation or treatment;

(b) loss of work exceeding the shift during which the accident occurred; or

(c) anything other than mere notice of a possible exposure to a potentially harmful substance or condition.

(5) A claim denied under the circumstances described in (4) must identify in the denial letter the certified claims examiner who is accountable for the decision to deny the claim.

 

History: 39-71-203, 39-71-320, MCA; IMP, 39-71-107, 39-71-116, 39-71-320, MCA; NEW, 2019 MAR p. 2119, Eff. 12/1/19.