cfr_sections
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185 rows where part_number = 725 and title_number = 20 sorted by section_id
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| section_id ▼ | title_number | title_name | chapter | subchapter | part_number | part_name | subpart | subpart_name | section_number | section_heading | agency | authority | source_citation | amendment_citations | full_text |
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| 20:20:4.0.2.2.8.1.83.1 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | A | Subpart A—General | § 725.1 Statutory provisions. | DOL | [78 FR 59115, Sept. 25, 2013] | (a) General. Subchapter IV of the Federal Coal Mine Health and Safety Act of 1969, as amended by the Black Lung Benefits Act of 1972, the Federal Mine Safety and Health Amendments Act of 1977, the Black Lung Benefits Reform Act of 1977, the Black Lung Benefits Revenue Act of 1977, the Black Lung Benefits Amendments of 1981, the Black Lung Benefits Revenue Act of 1981, the Black Lung Consolidation of Responsibility Act of 2002, and the Patient Protection and Affordable Care Act of 2010 (together comprising the Black Lung Benefits Act ( see § 725.101(a)(1)) provides for the payment of benefits to certain disabled coal miners and their survivors. See § 725.201. (b) Part B. Part B of subchapter IV of the Act provided that claims filed before July 1, 1973 were to be filed with, and adjudicated and administered by, the Social Security Administration (SSA). If awarded, these claims were paid by SSA out of appropriated funds. The Black Lung Consolidation of Administrative Responsibility Act ( see paragraph (h) of this section) transferred all responsibility for continued administration of these claims to the Department of Labor. (c) Part C. Claims filed by a miner or survivor on or after January 1, 1974, are filed, adjudicated, and paid under the provisions of part C of subchapter IV of the Act. Part C requires that a claim filed on or after January 1, 1974, shall be filed under an applicable approved State workers' compensation law, or if no such law has been approved by the Secretary of Labor, the claim may be filed with the Secretary of Labor under Section 422 of the Act. Claims filed with the Secretary of Labor under part C are processed and adjudicated by the Secretary. Individual coal mine operators are primarily liable for benefits; however, if the miner's last coal mine employment terminated before January 1, 1970, or if no responsible operator can be identified, benefits are paid by the Black Lung Disability Trust Fund. Claims adjudicated under part C are subject to certain incorporated provisions of… | |||
| 20:20:4.0.2.2.8.1.83.2 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | A | Subpart A—General | § 725.2 Purpose and applicability of this part. | DOL | [78 FR 59117, Sept. 25, 2013] | (a) This part sets forth the procedures to be followed and standards to be applied in filing, processing, adjudicating, and paying claims filed under part C of subchapter IV of the Act. (b) This part applies to all claims filed under part C of subchapter IV of the Act on or after June 30, 1982. Publication of certain provisions or parts of certain provisions that apply only to claims filed prior to June 30, 1982, or to claims subject to Section 435 of the Act, has been discontinued because those provisions affect an increasingly smaller number of claims. The version of Part 725 set forth in 20 CFR, parts 500 to end, edition revised as of April 1, 2010, applies to the adjudication of all claims filed prior to June 30, 1982, as appropriate. (c) The provisions of this part reflect revisions that became effective on January 19, 2001. This part applies to all claims filed after January 19, 2001 and all benefits payments made on such claims. With the exception of the following sections, this part also applies to the adjudication of claims that were pending on January 19, 2001 and all benefits payments made on such claims: §§ 725.101(a)(31), 725.204, 725.212(b), 725.213(c), 725.214(d), 725.219(d), 725.309, 725.310, 725.351, 725.360, 725.367, 725.406, 725.407, 725.408, 725.409, 725.410, 725.411, 725.412, 725.414, 725.415, 725.416, 725.417, 725.418, 725.421(b), 725.423, 725.454, 725.456, 725.457, 725.458, 725.459, 725.465, 725.491, 725.492, 725.493, 725.494, 725.495, 725.547, 725.701(e). The version of those sections set forth in 20 CFR, parts 500 to end, edition revised as of April 1, 1999, apply to the adjudications of claims that were pending on January 19, 2001. For purposes of construing the provisions of this section, a claim will be considered pending on January 19, 2001 if it was not finally denied more than one year prior to that date. | |||
| 20:20:4.0.2.2.8.1.83.3 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | A | Subpart A—General | § 725.3 Contents of this part. | DOL | (a) This subpart describes the statutory provisions which relate to claims considered under this part, the purpose and scope of this part, definitions and usages of terms applicable to this part, and matters relating to the availability of information collected by the Department of Labor in connection with the processing of claims. (b) Subpart B contains criteria for determining who may be found entitled to benefits under this part and other provisions relating to the conditions and duration of eligibility of a particular individual. (c) Subpart C describes the procedures to be followed and action to be taken in connection with the filing of a claim under this part. (d) Subpart D sets forth the duties and powers of the persons designated by the Secretary of Labor to adjudicate claims and provisions relating to the rights of parties and representatives of parties. (e) Subpart E contains the procedures for developing evidence and adjudicating entitlement and liability issues by the district director. (f) Subpart F describes the procedures to be followed if a hearing before the Office of Administrative Law Judges is required. (g) Subpart G contains provisions governing the identification of a coal mine operator which may be liable for the payment of a claim. (h) Subpart H contains provisions governing the payment of benefits with respect to an approved claim. (i) Subpart I describes the statutory mechanisms provided for the enforcement of a coal mine operator's liability, sets forth the penalties which may be applied in the case of a defaulting coal mine operator, and describes the obligation of coal operators and their insurance carriers to file certain reports. (j) Subpart J describes the right of certain beneficiaries to receive medical treatment benefits and vocational rehabilitation under the Act. | ||||
| 20:20:4.0.2.2.8.1.83.4 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | A | Subpart A—General | § 725.4 Applicability of other parts in this title. | DOL | (a) Part 718. Part 718 of this subchapter, which contains the criteria and standards to be applied in determining whether a miner is or was totally disabled due to pneumoconiosis, or whether a miner died due to pneumoconiosis, shall be applicable to the determination of claims under this part. Claims filed after March 31, 1980, are subject to part 718 as promulgated by the Secretary in accordance with section 402(f)(1) of the Act on February 29, 1980 (see § 725.2(c)). The criteria contained in subpart C of part 727 of this subchapter are applicable in determining claims filed prior to April 1, 1980, under this part, and such criteria shall be applicable at all times with respect to claims filed under this part and under section 11 of the Black Lung Benefits Reform Act of 1977. (b) Parts 715, 717, and 720. Pertinent and significant provisions of Parts 715, 717, and 720 of this subchapter (formerly contained in 20 CFR, parts 500 to end, edition revised as of April 1, 1978), which established the procedures for the filing, processing, and payment of claims filed under section 415 of the Act, are included within this part as appropriate. (c) Part 726. Part 726 of this subchapter, which sets forth the obligations imposed upon a coal operator to insure or self-insure its liability for the payment of benefits to certain eligible claimants, is applicable to this part as appropriate. (d) Part 727. Part 727 of this subchapter, which governs the review, adjudication and payment of pending and denied claims under section 435 of the Act, is applicable with respect to such claims. The criteria contained in subpart C of part 727 for determining a claimant's eligibility for benefits are applicable under this part with respect to all claims filed before April 1, 1980, and to all claims filed under this part and under section 11 of the Black Lung Benefits Reform Act of 1977. Because the part 727 regulations affect an increasingly smaller number of claims, however, the Department has discontinued publication of the criteri… | ||||
| 20:20:4.0.2.2.8.1.83.5 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | A | Subpart A—General | § 725.101 Definition and use of terms. | DOL | [65 FR 80054, Dec. 20, 2000, as amended at 77 FR 37286, June 21, 2012; 78 FR 59117, Sept. 25, 2013] | (a) Definitions. For purposes of this subchapter, except where the content clearly indicates otherwise, the following definitions apply: (1) The Act means the Black Lung Benefits Act, 30 U.S.C. 901-44, as amended. (2) The Longshore Act or LHWCA means the Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 901-950, as amended from time to time. (3) The Social Security Act means the Social Security Act, Act of August 14, 1935, c. 531, 49 Stat. 620, 42 U.S.C. 301-431, as amended from time to time. (4) Administrative law judge means a person qualified under 5 U.S.C. 3105 to conduct hearings and adjudicate claims for benefits filed pursuant to section 415 and part C of the Act. Until March 1, 1979, it also means an individual appointed to conduct such hearings and adjudicate such claims under Public Law 94-504. (5) Beneficiary means a miner or any surviving spouse, divorced spouse, child, parent, brother or sister, who is entitled to benefits under either section 415 or part C of title IV of the Act. (6) Benefits means all money or other benefits paid or payable under section 415 or part C of title IV of the Act on account of disability or death due to pneumoconiosis, including augmented benefits (see § 725.520(c)). The term also includes any expenses related to the medical examination and testing authorized by the district director pursuant to § 725.406. (7) Benefits Review Board or Board means the Benefits Review Board, U.S. Department of Labor, an appellate tribunal appointed by the Secretary of Labor pursuant to the provisions of section 21(b)(1) of the LHWCA. See parts 801 and 802 of this title. (8) Black Lung Disability Trust Fund or the fund means the Black Lung Disability Trust Fund established by the Black Lung Benefits Revenue Act of 1977, as amended by the Black Lung Benefits Revenue Act of 1981, for the payment of certain claims adjudicated under this part (see subpart G of this part). (9) Chief Administrative Law Judge means the Chief Administrative Law Judge o… | |||
| 20:20:4.0.2.2.8.1.83.6 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | A | Subpart A—General | § 725.102 Disclosure of program information. | DOL | (a) All reports, records, or other documents filed with the OWCP with respect to claims are the records of the OWCP. The Director or his or her designee shall be the official custodian of those records maintained by the OWCP at its national office. The District Director shall be the official custodian of those records maintained at a district office. (b) The official custodian of any record sought to be inspected shall permit or deny inspection in accordance with the Department of Labor's regulations pertaining thereto (see 29 CFR Part 70). The original record in any such case shall not be removed from the Office of the custodian for such inspection. The custodian may, in his or her discretion, deny inspection of any record or part thereof which is of a character specified in 5 U.S.C. 552(b) if in his or her opinion such inspection may result in damage, harm, or harassment to the beneficiary or to any other person. For special provisions concerning release of information regarding injured employees undergoing vocational rehabilitation, see § 702.508 of this chapter. (c) Any person may request copies of records he or she has been permitted to inspect. Such requests shall be addressed to the official custodian of the records sought to be copied. The official custodian shall provide the requested copies under the terms and conditions specified in the Department of Labor's regulations relating thereto (see 29 CFR Part 70). (d) Any party to a claim (§ 725.360) or his or her duly authorized representative shall be permitted upon request to inspect the file which has been compiled in connection with such claim. Any party to a claim or representative of such party shall upon request be provided with a copy of any or all material contained in such claim file. A request for information by a party or representative made under this paragraph shall be answered within a reasonable time after receipt by the Office. Internal documents prepared by the district director which do not constitute evidence of a fact which must be e… | ||||
| 20:20:4.0.2.2.8.1.83.7 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | A | Subpart A—General | § 725.103 Burden of proof. | DOL | Except as otherwise provided in this part and part 718, the burden of proving a fact alleged in connection with any provision shall rest with the party making such allegation. | ||||
| 20:20:4.0.2.2.8.10.90.1 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.701 What medical benefits are available? | DOL | (a) A miner who is determined to be eligible for benefits under this part or part 727 of this subchapter ( see § 725.4(d)) is entitled to medical benefits as set forth in this subpart as of the date of his or her claim, but in no event before January 1, 1974. Medical benefits may not be provided to the survivor or dependent of a miner under this part. (b) A responsible operator, or where there is none, the fund, must furnish a miner entitled to benefits under this part with such medical services and treatments (including professional medical services and medical equipment, prescription drugs, outpatient medical services, inpatient medical services, and any other medical service, treatment or supply) for such periods as the nature of the miner's pneumoconiosis and disability requires. (c) The medical benefits referred to in paragraphs (a) and (b) of this section include palliative measures useful only to prevent pain or discomfort associated with the miner's pneumoconiosis or attendant disability. (d) An operator or the fund must also pay the miner's reasonable cost of travel necessary for medical treatment (to be determined in accordance with prevailing United States government mileage rates) and the reasonable documented cost to the miner or medical provider incurred in communicating with the operator, carrier, or OWCP on matters connected with medical benefits. (e)(1) If a miner receives a medical service or treatment, as described in this section, for any pulmonary disorder, there will be a rebuttable presumption that the disorder is caused or aggravated by the miner's pneumoconiosis. (2) The party liable for the payment of benefits may rebut the presumption by producing credible evidence that the medical service or treatment provided was for a pulmonary disorder apart from those previously associated with the miner's disability, or was beyond that necessary to effectively treat a covered disorder, or was not for a pulmonary disorder at all. (3) An operator or the fund, however, cannot rely on evidence … | ||||
| 20:20:4.0.2.2.8.10.90.10 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.710 How are payments for outpatient medical services determined? | DOL | [83 FR 27695, June 14, 2018, as amended at 84 FR 64198, Nov. 21, 2019] | (a)(1) Except as provided in paragraphs (b) and (c) of this section, OWCP pays for outpatient medical services according to Ambulatory Payment Classifications (APCs) derived from the Outpatient Prospective Payment System (OPPS) devised by the Centers for Medicare & Medicaid Services (CMS) for the Medicare program (42 CFR part 419). (2) For outpatient medical services paid under the OPPS, such services are assigned according to the APC prescribed by CMS for that service. Each payment is derived by multiplying the prospectively established scaled relative weight for the service's clinical APC by a conversion factor to arrive at a national unadjusted payment rate for the APC. The labor portion of the national unadjusted payment rate is further adjusted by the hospital wage index for the area where payment is being made. Additional adjustments are also made as required or needed. (b) If a compensable service cannot be assigned or paid at the prevailing community rate under the OPPS or occurs at a facility excluded from the Medicare OPPS, OWCP may pay for the service based on fee schedules or other pricing formulas utilized by OWCP for outpatient services. (c) This section does not apply to services provided by ambulatory surgical centers. (d) This section applies to outpatient medical services rendered after April 26, 2020. | |||
| 20:20:4.0.2.2.8.10.90.11 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.711 How are payments for inpatient medical services determined? | DOL | (a)(1) OWCP pays for inpatient medical services according to predetermined rates derived from the Medicare Inpatient Prospective Payment System (IPPS) used by the Centers for Medicare & Medicaid Services (CMS) for the Medicare program (42 CFR part 412). (2) Inpatient hospital discharges are classified into diagnosis-related groups (DRGs). Each DRG groups together clinically similar conditions that require comparable amounts of inpatient resources. For each DRG, an appropriate weighting factor is assigned that reflects the estimated relative cost of hospital resources used with respect to discharges classified within that group compared to discharges classified within other groups. (3) For each hospital discharge classified within a DRG, a payment amount for that discharge is determined by using the national weighting factor determined for that DRG, national standardized adjustments, and other factors which may vary by hospital, such as an adjustment for area wage levels. OWCP may also use other price adjustment factors as appropriate based on its processing experience and internal data. (b) If an inpatient service cannot be classified by DRG, occurs at a facility excluded from the Medicare IPPS, or otherwise cannot be paid at the prevailing community rate under the pricing formula described in paragraph (a) of this section, OWCP may pay for the service based on fee schedules or other pricing formulas utilized by OWCP for inpatient services. | ||||
| 20:20:4.0.2.2.8.10.90.12 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.712 When and how are fees reduced? | DOL | (a) A provider's designation of the code used to identify a billed service or treatment will be accepted if the code is consistent with the medical and other evidence, and the provider will be paid no more than the maximum allowable fee for that service or treatment. If the code is not consistent with the medical evidence or where no code is supplied, the bill will be returned to the provider for correction and resubmission or denied. (b) If the charge submitted for a service or treatment supplied to a miner exceeds the maximum amount determined to be reasonable under this subpart, OWCP must pay the amount allowed by §§ 725.707-725.711 for that service and notify the provider in writing that payment was reduced for that service in accordance with those provisions. (c) A provider or other party who disagrees with a fee determination may seek review of that determination as provided in this subpart ( see § 725.718). | ||||
| 20:20:4.0.2.2.8.10.90.13 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.713 If a fee is reduced, may a provider bill the claimant for the balance? | DOL | Where a provider submits a bill to OWCP and OWCP has reduced the provider's fee, the miner is not responsible for any additional payment for services or treatments covered under this subpart. Thus, a provider whose fee for service is partially paid by OWCP as a result of the application of the provisions of §§ 725.707-725.711 or otherwise in accordance with this subpart may not request reimbursement from the miner for additional amounts. | ||||
| 20:20:4.0.2.2.8.10.90.14 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.714 How do providers enroll with OWCP for authorizations and billing? | DOL | (a) All non-pharmacy providers seeking payment from the fund must enroll with OWCP or its designated bill processing agent to have access to the automated authorization system and to submit medical bills to OWCP. (b) To enroll, the non-pharmacy provider must complete and submit a Form OWCP-1168 to the appropriate location noted on that form. By completing and submitting this form, providers certify that they satisfy all applicable Federal and State licensure and regulatory requirements that apply to their specific provider or supplier type. (c) The non-pharmacy provider must maintain documentary evidence indicating that it satisfies those requirements. (d) The non-pharmacy provider must also notify OWCP immediately if any information provided to OWCP in the enrollment process changes. (e) All pharmacy providers must obtain a National Council for Prescription Drug Programs number. Upon obtaining such number, they are automatically enrolled in OWCP's pharmacy billing system. (f) After enrollment, a provider must submit all medical bills to OWCP through its bill processing portal or to the OWCP address specified for such purpose and must include the Provider Number/ID obtained through enrollment, or its National Provider Number (NPI) or any other identifying numbers required by OWCP. | ||||
| 20:20:4.0.2.2.8.10.90.15 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.715 How do providers submit medical bills? | DOL | (a) A provider must itemize charges on Form OWCP-1500 or CMS-1500 (for professional services, equipment or drugs dispensed in the office), Form OWCP-04 or UB-04 (for hospitals), an electronic or paper-based bill that includes required data elements (for pharmacies) or other form as designated by OWCP, and submit the form promptly to OWCP. (b) The provider must identify each medical service performed using the Current Procedural Terminology (CPT) code, the Healthcare Common Procedure Coding System (HCPCS) code, the National Drug Code (NDC) number, or the Revenue Center Code (RCC), as appropriate to the type of service. OWCP has discretion to determine which of these codes may be utilized in the billing process. OWCP also has the authority to create and supply codes for specific services or treatments. These OWCP-created codes will be issued to providers by OWCP as appropriate and may only be used as authorized by OWCP. A provider may not use an OWCP-created code for other types of medical examinations, services or treatments. (1) For professional medical services, the provider must list each diagnosed condition in order of priority and furnish the corresponding diagnostic code using the “International Classification of Disease, 10th Edition, Clinical Modification” (ICD-10-CM), or as revised. (2) For prescription drugs or supplies, the provider must include the NDC assigned to the product, and such other information as OWCP may require. (3) For outpatient medical services, the provider must use HCPCS codes and other coding schemes in accordance with the Outpatient Prospective Payment System. (4) For inpatient medical services, the provider must include admission and discharge summaries and an itemized statement of the charges. (c)(1) By submitting a bill or accepting payment, the provider signifies that the service for which reimbursement is sought was performed as described, necessary, appropriate, and properly billed in accordance with accepted industry standards. For example, accepted industry standards pr… | ||||
| 20:20:4.0.2.2.8.10.90.16 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.716 How should a miner prepare and submit requests for reimbursement for covered medical expenses and transportation costs? | DOL | (a) If a miner has paid bills for a medical service or treatment covered under § 725.701 and seeks reimbursement for those expenses, he or she may submit a request for reimbursement on Form OWCP-915, together with an itemized bill. The reimbursement request must be accompanied by evidence that the provider received payment for the service from the miner and a statement of the amount paid. Acceptable evidence that payment was received includes, but is not limited to, a copy of the miner's canceled check (both front and back) or a copy of the miner's credit card receipt. (b) OWCP may waive the requirements of paragraph (a) of this section if extensive delays in the filing or the adjudication of a claim make it unusually difficult for the miner to obtain the required information. (c) Reimbursements for covered medical services paid by a miner generally will be no greater than the maximum allowable charge for such service as determined under §§ 725.707-725.711. (d) A miner will be only partially reimbursed for a covered medical service if the amount he or she paid to a provider for the service exceeds the maximum charge allowable. If this happens, OWCP will advise the miner of the maximum allowable charge for the service in question and of his or her responsibility to ask the provider to refund to the miner, or credit to the miner's account, the amount he or she paid which exceeds the maximum allowable charge. (e) If the provider does not refund to the miner or credit to his or her account the amount of money paid in excess of the charge allowed by OWCP, the miner should submit documentation to OWCP of the attempt to obtain such refund or credit. OWCP may make reasonable reimbursement to the miner after reviewing the facts and circumstances of the case. (f) If a miner has paid transportation costs or other incidental expenses related to covered medical services under this part, the miner may submit a request for reimbursement on Form OWCP-957 or OWCP-915, together with proof of payment. | ||||
| 20:20:4.0.2.2.8.10.90.17 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.717 What are the time limitations for requesting payment or reimbursement for covered medical services or treatments? | DOL | OWCP will pay providers and reimburse miners promptly for all bills received on an approved form and in a timely manner. However, absent good cause, no bill will be paid for expenses incurred if the bill is submitted more than one year beyond the end of the calendar year in which the expense was incurred or the service or supply was provided, or more than one year beyond the end of the calendar year in which the miner's eligibility for benefits is finally adjudicated, whichever is later. A provider may not request reimbursement from a miner for a bill denied by OWCP due to late submission of the bill by the provider. | ||||
| 20:20:4.0.2.2.8.10.90.18 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.718 How are disputes concerning medical benefits resolved? | DOL | (a) If a dispute develops concerning medical services or treatments or their payment under this part, OWCP must attempt to informally resolve the dispute. OWCP may, on its own initiative or at the request of the responsible operator or its insurance carrier, order the claimant to submit to an examination by a physician selected by OWCP. (b) If a dispute cannot be resolved informally, OWCP will refer the case to the Office of Administrative Law Judges for a hearing in accordance with this part. Any such hearing concerning authorization of medical services or treatments must be scheduled at the earliest possible time and must take precedence over all other hearing requests except for other requests under this section and as provided by § 727.405 of this subchapter ( see § 725.4(d)). During the pendency of such adjudication, OWCP may order the payment of medical benefits prior to final adjudication under the same conditions applicable to benefits awarded under § 725.522. (c) In the development or adjudication of a dispute over medical benefits, the adjudication officer is authorized to take whatever action may be necessary to protect the health of a totally disabled miner. (d) Any interested medical provider may, if appropriate, be made a party to a dispute under this subpart. | ||||
| 20:20:4.0.2.2.8.10.90.19 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.719 What is the objective of vocational rehabilitation? | DOL | The objective of vocational rehabilitation is the return of a miner who is totally disabled by pneumoconiosis to gainful employment commensurate with such miner's physical impairment. This objective may be achieved through a program of re-evaluation and redirection of the miner's abilities, or retraining in another occupation, and selective job placement assistance. | ||||
| 20:20:4.0.2.2.8.10.90.2 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.702 Who is considered a physician? | DOL | The term “physician” includes only doctors of medicine (MD) and doctors of osteopathy (DO) within the scope of their practices as defined by State law. No treatment or medical services performed by any other practitioner of the healing arts is authorized by this part, unless such treatment or service is authorized and supervised both by a physician as defined in this section and by OWCP. | ||||
| 20:20:4.0.2.2.8.10.90.20 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.720 How does a miner request vocational rehabilitation assistance? | DOL | Each miner who has been determined entitled to receive benefits under part C of title IV of the Act must be informed by OWCP of the availability and advisability of vocational rehabilitation services. If such miner chooses to avail himself or herself of vocational rehabilitation, his or her request will be processed and referred by OWCP vocational rehabilitation advisors pursuant to the provisions of §§ 702.501 through 702.508 of this chapter as is appropriate. | ||||
| 20:20:4.0.2.2.8.10.90.3 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.703 How is treatment authorized? | DOL | (a) Upon notification to a miner of such miner's entitlement to benefits, OWCP must provide the miner with a list of authorized treating physicians and medical facilities in the area of the miner's residence. The miner may select a physician from this list or may select another physician with approval of OWCP. Where emergency services are necessary and appropriate, authorization by OWCP is not required. (b) OWCP may, on its own initiative, or at the request of a responsible operator, order a change of physicians or facilities, but only where it has been determined that the change is desirable or necessary in the best interest of the miner. The miner may change physicians or facilities subject to the approval of OWCP. (c) If adequate treatment cannot be obtained in the area of the claimant's residence, OWCP may authorize the use of physicians or medical facilities outside such area as well as reimbursement for travel expenses and overnight accommodations. | ||||
| 20:20:4.0.2.2.8.10.90.4 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.704 How are arrangements for medical care made? | DOL | (a) Operator liability. If an operator has been determined liable for the payment of benefits to a miner, OWCP will notify the operator or its insurance carrier of the names, addresses, and telephone numbers of the authorized providers of medical benefits chosen by an entitled miner, and require the operator or carrier to: (1) Notify the miner and the providers chosen that the operator or carrier will be responsible for the cost of medical services provided to the miner on account of the miner's total disability due to pneumoconiosis; (2) Designate a person or persons with decision-making authority with whom OWCP, the miner and authorized providers may communicate on matters involving medical benefits provided under this subpart and notify OWCP, the miner and providers of this designation; (3) Make arrangements for the direct reimbursement of providers for their services. (b) Fund liability. If there is no operator found liable for the payment of benefits, OWCP will make necessary arrangements to provide medical care to the miner, notify the miner and providers selected of the liability of the fund, designate a person or persons with whom the miner or provider may communicate on matters relating to medical care, and make arrangements for the direct reimbursement of the medical provider. | ||||
| 20:20:4.0.2.2.8.10.90.5 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.705 Is prior authorization for medical services required? | DOL | (a) Except as provided in paragraph (b) of this section, medical services from an authorized provider which are payable under § 725.701 do not require prior approval of OWCP or the responsible operator. (b) Except where emergency treatment is required, prior approval of OWCP or the responsible operator must be obtained before any hospitalization or surgery, or before ordering medical equipment where the purchase price exceeds $300. A request for approval of non-emergency hospitalization or surgery must be acted upon expeditiously, and approval or disapproval will be given by telephone if a written response cannot be given within 7 days following the request. No employee of the Department of Labor, other than a district director or the Chief, Medical Audit and Operations Section, DCMWC, is authorized to approve a request for hospitalization or surgery by telephone. | ||||
| 20:20:4.0.2.2.8.10.90.6 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.706 What reports must a medical provider give to OWCP? | DOL | (a) Within 30 days following the first medical or surgical treatment provided under § 725.701, the provider must furnish to OWCP and the responsible operator or its insurance carrier, if any, a report of such treatment. (b) In order to permit continuing supervision of the medical care provided to the miner with respect to the necessity, character and sufficiency of any medical care furnished or to be furnished, the provider, operator or carrier must submit such reports in addition to those required by paragraph (a) of this section as OWCP may from time to time require. Within the discretion of OWCP, payment may be refused to any medical provider who fails to submit any report required by this section. | ||||
| 20:20:4.0.2.2.8.10.90.7 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.707 At what rate will fees for medical services and treatments be paid? | DOL | (a) All fees charged by providers for any medical service, treatment, drug or equipment authorized under this subpart will be paid at no more than the rate prevailing for the service, treatment, drug or equipment in the community in which the provider is located. (b) When medical benefits are paid by the fund at OWCP's direction, either on an interim basis or because there is no liable operator, the prevailing community rate for various types of service will be determined as provided in §§ 725.708-725.711. (c) The provisions of §§ 725.708-725.711 do not apply to charges for medical services or treatments furnished by medical facilities of the U.S. Public Health Service or the Departments of the Army, Navy, Air Force and Veterans Affairs. (d) If the provisions of §§ 725.708-725.711 cannot be used to determine the prevailing community rate for a particular service or treatment or for a particular provider, OWCP may determine the prevailing community rate by reliance on other federal or state payment formulas or on other evidence, as appropriate. (e) OWCP must review the payment formulas described in §§ 725.708-725.711 at least once a year, and may adjust, revise or replace any payment formula or its components when necessary or appropriate to ensure miners' access to care or for other reasons. (f) Except as otherwise provided in this subpart, the provisions of §§ 725.707-725.711 apply to all medical services and treatments rendered after August 31, 2018. | ||||
| 20:20:4.0.2.2.8.10.90.8 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.708 How are payments for professional medical services and medical equipment determined? | DOL | [83 FR 27695, June 14, 2018, as amended at 84 FR 64198, Nov. 21, 2019] | (a)(1) OWCP pays for professional medical services based on a fee schedule derived from the schedule maintained by the Centers for Medicare & Medicaid Services (CMS) for the payment of such services under the Medicare program (42 CFR part 414). The schedule OWCP utilizes consists of: An assignment of Relative Value Units (RVU) to procedures identified by Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code, which represents the work (relative time and intensity of the service), the practice expense and the malpractice expense, as compared to other procedures of the same general class; an assignment of Geographic Practice Cost Index (GPCI) values, which represent the relative work, practice expense and malpractice expense relative to other localities throughout the country; and a monetary value assignment (conversion factor) for one unit of value for each coded service. (2) The maximum payment for professional medical services identified by a HCPCS/CPT code is calculated by multiplying the RVU values for the service by the GPCI values for such service in that area and multiplying the sum of these values by the conversion factor to arrive at a dollar amount assigned to one unit in that category of service. (3) OWCP utilizes the RVUs published, and updated or revised from time to time, by CMS for all services for which CMS has made assignments. Where there are no RVUs assigned, OWCP may develop and assign any RVUs that OWCP considers appropriate. OWCP utilizes the GPCI for the locality as defined by CMS and as updated or revised by CMS from time to time. OWCP will devise conversion factors for professional medical services using OWCP's processing experience and internal data. (b) Where a professional medical service is not covered by the fee schedule described in paragraph (a) of this section, OWCP may pay for the service based on other fee schedules or pricing formulas utilized by OWCP for professional medical services. (c) Paragraphs (a) and (b) of this section apply to pro… | |||
| 20:20:4.0.2.2.8.10.90.9 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | J | Subpart J—Medical Benefits and Vocational Rehabilitation | § 725.709 How are payments for prescription drugs determined? | DOL | (a)(1) OWCP pays for drugs prescribed by physicians by multiplying a percentage of the average wholesale price, or other baseline price as specified by OWCP, of the medication by the quantity or amount provided, plus a dispensing fee. (2) All prescription medications identified by National Drug Code are assigned an average wholesale price representing the product's nationally recognized wholesale price as determined by surveys of manufacturers and wholesalers, or another baseline price designated by OWCP. (3) OWCP may establish the dispensing fee. (b) If the pricing formula described in paragraph (a) of this section is inapplicable, OWCP may make payment based on other pricing formulas utilized by OWCP for prescription medications. (c) OWCP may, in its discretion, contract for or require the use of specific providers for certain medications. OWCP also may require the use of generic equivalents of prescribed medications where they are available. | ||||
| 20:20:4.0.2.2.8.2.83.1 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.201 Who is entitled to benefits; contents of this subpart. | DOL | [65 FR 80054, Dec. 20, 2000, as amended at 78 FR 59117, Sept. 25, 2013] | (a) Part C of the Act provides for the payment of periodic benefits in accordance with this part to: (1) A miner who meets the conditions of entitlement set forth in § 725.202(d); or (2) The surviving spouse or surviving divorced spouse of a deceased miner who meets the conditions of entitlement set forth in § 725.212; or, (3) Where neither exists, the child of a deceased miner who meets the conditions of entitlement set forth in § 725.218; or (4) The surviving dependent parents, where there is no surviving spouse or child, or the surviving dependent brothers or sisters, where there is no surviving spouse, child, or parent, of a miner, who meet the conditions of entitlement set forth in § 725.222; or (5) The child of a miner's surviving spouse who was receiving benefits under Part C of the Act at the time of such spouse's death. (b) The provisions contained in this subpart describe the conditions of entitlement to benefits applicable to a miner, or a surviving spouse, child, parent, brother, or sister, and the events which establish or terminate entitlement to benefits. (c) In order for an entitled miner or surviving spouse to qualify for augmented benefits because of one or more dependents, such dependents must meet relationship and dependency requirements with respect to such beneficiary prescribed by or pursuant to the Act. Such requirements are also set forth in this subpart. | |||
| 20:20:4.0.2.2.8.2.83.2 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.202 Miner defined; condition of entitlement, miner. | DOL | (a) Miner defined. A “miner” for the purposes of this part is any person who works or has worked in or around a coal mine or coal preparation facility in the extraction, preparation, or transportation of coal, and any person who works or has worked in coal mine construction or maintenance in or around a coal mine or coal preparation facility. There shall be a rebuttable presumption that any person working in or around a coal mine or coal preparation facility is a miner. This presumption may be rebutted by proof that: (1) The person was not engaged in the extraction, preparation or transportation of coal while working at the mine site, or in maintenance or construction of the mine site; or (2) The individual was not regularly employed in or around a coal mine or coal preparation facility. (b) Coal mine construction and transportation workers; special provisions. A coal mine construction or transportation worker shall be considered a miner to the extent such individual is or was exposed to coal mine dust as a result of employment in or around a coal mine or coal preparation facility. A transportation worker shall be considered a miner to the extent that his or her work is integral to the extraction or preparation of coal. A construction worker shall be considered a miner to the extent that his or her work is integral to the building of a coal or underground mine (see § 725.101(a)(12), (30)). (1) There shall be a rebuttable presumption that such individual was exposed to coal mine dust during all periods of such employment occurring in or around a coal mine or coal preparation facility for purposes of: (i) Determining whether such individual is or was a miner; (ii) Establishing the applicability of any of the presumptions described in section 411(c) of the Act and part 718 of this subchapter; and (iii) Determining the identity of a coal mine operator liable for the payment of benefits in accordance with § 725.495. (2) The presumption may be rebutted by evidence which demonstrates that: (i) The individua… | ||||
| 20:20:4.0.2.2.8.2.83.3 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.203 Duration and cessation of entitlement; miner. | DOL | (a) An individual is entitled to benefits as a miner for each month beginning with the first month on or after January 1, 1974, in which the miner is totally disabled due to pneumoconiosis arising out of coal mine employment. (b) The last month for which such individual is entitled to benefits is the month before the month during which either of the following events first occurs: (1) The miner dies; or (2) The miner's total disability ceases (see § 725.504). (c) An individual who has been finally adjudged to be totally disabled due to pneumoconiosis and is receiving benefits under the Act shall promptly notify the Office and the responsible coal mine operator, if any, if he or she engages in his or her usual coal mine work or comparable and gainful work. (d) Upon reasonable notice, an individual who has been finally adjudged entitled to benefits shall submit to any additional tests or examinations the Office deems appropriate, and shall submit medical reports and other relevant evidence the Office deems necessary, if an issue arises pertaining to the validity of the original award. | ||||
| 20:20:4.0.2.2.8.2.84.10 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.210 Duration of augmented benefits. | DOL | Augmented benefits payable on behalf of a spouse or divorced spouse, or a child, shall begin with the first month in which the dependent satisfies the conditions of relationship and dependency set forth in this subpart. Augmentation of benefits on account of a dependent continues through the month before the month in which the dependent ceases to satisfy these conditions, except in the case of a child who qualifies as a dependent because such child is a student. In the latter case, benefits continue to be augmented through the month before the first month during no part of which such child qualifies as a student. | ||||
| 20:20:4.0.2.2.8.2.84.11 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.211 Time of determination of relationship and dependency of spouse or child for purposes of augmentation of benefits. | DOL | With respect to the spouse or child of a miner entitled to benefits, and with respect to the child of a surviving spouse entitled to benefits, the determination as to whether an individual purporting to be a spouse or child is related to or dependent upon such miner or surviving spouse shall be based on the facts and circumstances present in each case, at the appropriate time. | ||||
| 20:20:4.0.2.2.8.2.84.12 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.212 Conditions of entitlement; surviving spouse or surviving divorced spouse. | DOL | [65 FR 80054, Dec. 20, 2000, as amended at 78 FR 59117, Sept. 25, 2013] | (a) An individual who is the surviving spouse or surviving divorced spouse of a miner is eligible for benefits if such individual: (1) Is not married; (2) Was dependent on the miner at the pertinent time; and (3) The deceased miner either: (i) Is determined to have died due to pneumoconiosis; or (ii) Filed a claim for benefits on or after January 1, 1982, which results or resulted in a final award of benefits, and the surviving spouse or surviving divorced spouse filed a claim for benefits after January 1, 2005 which was pending on or after March 23, 2010. (b) If more than one spouse meets the conditions of entitlement prescribed in paragraph (a), then each spouse will be considered a beneficiary for purposes of section 412(a)(2) of the Act without regard to the existence of any other entitled spouse or spouses. | |||
| 20:20:4.0.2.2.8.2.84.13 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.213 Duration of entitlement; surviving spouse or surviving divorced spouse. | DOL | (a) An individual is entitled to benefits as a surviving spouse, or as a surviving divorced spouse, for each month beginning with the first month in which all of the conditions of entitlement prescribed in § 725.212 are satisfied. (b) The last month for which such individual is entitled to such benefits is the month before the month in which either of the following events first occurs: (1) The surviving spouse or surviving divorced spouse marries; or (2) The surviving spouse or surviving divorced spouse dies. (c) A surviving spouse or surviving divorced spouse whose entitlement to benefits has been terminated pursuant to § 725.213(b)(1) may thereafter again become entitled to such benefits upon filing application for such reentitlement, beginning with the first month after the marriage ends and such individual meets the requirements of § 725.212. The individual shall not be required to reestablish the miner's entitlement to benefits (§ 725.212(a)(3)(i)) or the miner's death due to pneumoconiosis (§ 725.212(a)(3)(ii)). | ||||
| 20:20:4.0.2.2.8.2.84.14 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.214 Determination of relationship; surviving spouse. | DOL | An individual shall be considered to be the surviving spouse of a miner if: (a) The courts of the State in which the miner was domiciled (see § 725.231) at the time of his or her death would find that the individual and the miner were validly married; or (b) The courts of the State in which the miner was domiciled (see § 725.231) at the time of the miner's death would find that the individual was the miner's surviving spouse; or (c) Under State law, such individual would have the right of the spouse to share in the miner's intestate personal property; or (d) Such individual went through a marriage ceremony with the miner, resulting in a purported marriage between them which, but for a legal impediment (see § 725.230), would have been a valid marriage, unless such individual entered into the purported marriage with knowledge that it was not a valid marriage, or if such individual and the miner were not living in the same household at the time of the miner's death. | ||||
| 20:20:4.0.2.2.8.2.84.15 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.215 Determination of dependency; surviving spouse. | DOL | An individual who is the miner's surviving spouse (see § 725.214) shall be determined to have been dependent on the miner if, at the time of the miner's death: (a) The individual was living with the miner (see § 725.232); or (b) The individual was dependent upon the miner for support or the miner has been ordered by a court to contribute to such individual's support (see § 725.233); or (c) The individual was living apart from the miner because of the miner's desertion or other reasonable cause; or (d) The individual is the natural parent of the miner's son or daughter; or (e) The individual had legally adopted the miner's son or daughter while the individual was married to the miner and while such son or daughter was under the age of 18; or (f) The individual was married to the miner at the time both of them legally adopted a child under the age of 18; or (g)(1) The individual was married to the miner for a period of not less than 9 months immediately before the day on which the miner died, unless the miner's death: (i) Is accidental (as defined in paragraph (g)(2) of this section), or (ii) Occurs in line of duty while the miner is a member of a uniformed service serving on active duty (as defined in § 404.1019 of this title), and the surviving spouse was married to the miner for a period of not less than 3 months immediately prior to the day on which such miner died. (2) For purposes of paragraph (g)(1)(i) of this section, the death of a miner is accidental if such individual received bodily injuries solely through violent, external, and accidental means, and as a direct result of the bodily injuries and independently of all other causes, dies not later than 3 months after the day on which such miner receives such bodily injuries. The term “accident” means an event that was unpremeditated and unforeseen from the standpoint of the deceased individual. To determine whether the death of an individual did, in fact, result from an accident the adjudication officer will consider all the circumstances surroun… | ||||
| 20:20:4.0.2.2.8.2.84.16 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.216 Determination of relationship; surviving divorced spouse. | DOL | An individual will be considered to be the surviving divorced spouse of a deceased miner in a claim considered under this part or reviewed under part 727 of this subchapter (see § 725.4(d)), if such individual's marriage to the miner had been terminated by a final divorce on or after the 10th anniversary of the marriage unless, if such individual was married to and divorced from the miner more than once, such individual was married to such miner in each calendar year of the period beginning 10 years immediately before the date on which any divorce became final and ending with the year in which the divorce became final. | ||||
| 20:20:4.0.2.2.8.2.84.17 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.217 Determination of dependency; surviving divorced spouse. | DOL | An individual who is the miner's surviving divorced spouse (see § 725.216) shall be determined to have been dependent on the miner if, for the month before the month in which the miner died: (a) The individual was receiving at least one-half of his or her support from the miner (see § 725.233(g)); or (b) The individual was receiving substantial contributions from the miner pursuant to a written agreement (see § 725.233(c) and (f)); or (c) A court order required the miner to furnish substantial contributions to the individual's support (see § 725.233(c) and (e)). | ||||
| 20:20:4.0.2.2.8.2.84.18 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.218 Conditions of entitlement; child. | DOL | [65 FR 80054, Dec. 20, 2000, as amended at 78 FR 59117, Sept. 25, 2013] | (a) An individual is entitled to benefits where he or she meets the required standards of relationship and dependency under this subpart (see § 725.220 and § 725.221) and is the child of a deceased miner who: (1) Is determined to have died due to pneumoconiosis; or (2) Filed a claim for benefits on or after January 1, 1982, which results or resulted in a final award of benefits, and the surviving child filed a claim for benefits after January 1, 2005 which was pending on or after March 23, 2010. (b) A child is not entitled to benefits for any month for which a miner, or the surviving spouse or surviving divorced spouse of a miner, establishes entitlement to benefits. | |||
| 20:20:4.0.2.2.8.2.84.19 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.219 Duration of entitlement; child. | DOL | (a) An individual is entitled to benefits as a child for each month beginning with the first month in which all of the conditions of entitlement prescribed in § 725.218 are satisfied. (b) The last month for which such individual is entitled to such benefits is the month before the month in which any one of the following events first occurs: (1) The child dies; (2) The child marries; (3) The child attains age 18; and (i) Is not a student (as defined in § 725.209(b)) during any part of the month in which the child attains age 18; and (ii) Is not under a disability (as defined in § 725.209(a)(2)(ii)) at that time; (4) If the child's entitlement beyond age 18 is based on his or her status as a student, the earlier of: (i) The first month during no part of which the child is a student; or (ii) The month in which the child attains age 23 and is not under a disability (as defined in § 725.209(a)(2)(ii)) at that time; (5) If the child's entitlement beyond age 18 is based on disability, the first month in no part of which such individual is under a disability. (c) A child whose entitlement to benefits terminated with the month before the month in which the child attained age 18, or later, may thereafter (provided such individual is not married) again become entitled to such benefits upon filing application for such reentitlement, beginning with the first month after termination of benefits in which such individual is a student and has not attained the age of 23. (d) A child whose entitlement to benefits has been terminated pursuant to § 725.219(b)(2) may thereafter again become entitled to such benefits upon filing application for such reentitlement, beginning with the first month after the marriage ends and such individual meets the requirements of § 725.218. The individual shall not be required to reestablish the miner's entitlement to benefits (§ 725.218(a)(1)) or the miner's death due to pneumoconiosis (§ 725.212(a)(2)). | ||||
| 20:20:4.0.2.2.8.2.84.20 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.220 Determination of relationship; child. | DOL | For purposes of determining whether an individual may qualify for benefits as the child of a deceased miner, the provisions of § 725.208 shall be applicable. As used in this section, the term “beneficiary” means only a surviving spouse entitled to benefits at the time of such surviving spouse's death (see § 725.212), or a miner. For purposes of a survivor's claim, an individual will be considered to be a child of a beneficiary if: (a) The courts of the State in which such beneficiary is domiciled (see § 725.231) would find, under the law they would apply in determining the devolution of the beneficiary's intestate personal property, that the individual is the beneficiary's child; or (b) Such individual is the legally adopted child of such beneficiary; or (c) Such individual is the stepchild of such beneficiary by reason of a valid marriage of such individual's parent or adopting parent to such beneficiary; or (d) Such individual does not bear the relationship of child to such beneficiary under paragraph (a), (b), or (c) of this section, but would, under State law, have the same right as a child to share in the beneficiary's intestate personal property; or (e) Such individual is the natural son or daughter of a beneficiary but does not bear the relationship of child to such beneficiary under paragraph (a), (b), or (c) of this section, and is not considered to be the child of the beneficiary under paragraph (d) of this section, such individual shall nevertheless be considered to be the child of such beneficiary if the beneficiary and the mother or father, as the case may be, of such individual went through a marriage ceremony resulting in a purported marriage between them which but for a legal impediment (see § 725.230) would have been a valid marriage; or (f) Such individual is the natural son or daughter of a beneficiary but does not have the relationship of child to such beneficiary under paragraph (a), (b), or (c) of this section, and is not considered to be the child of the beneficiary under paragraph (d… | ||||
| 20:20:4.0.2.2.8.2.84.21 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.221 Determination of dependency; child. | DOL | For the purposes of determining whether a child was dependent upon a deceased miner, the provisions of § 725.209 shall be applicable, except that for purposes of determining the eligibility of a child who is under a disability as defined in section 223(d) of the Social Security Act, such disability must have begun before the child attained age 22, or in the case of a student, before the child ceased to be a student. | ||||
| 20:20:4.0.2.2.8.2.84.22 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.222 Conditions of entitlement; parent, brother, or sister. | DOL | [65 FR 80054, Dec. 20, 2000, as amended at 78 FR 59117, Sept. 25, 2013] | (a) An individual is eligible for benefits as a surviving parent, brother or sister if all of the following requirements are met: (1) The individual is the parent, brother, or sister of a deceased miner; (2) The individual was dependent on the miner at the pertinent time; (3) Proof of support is filed within 2 years after the miner's death, unless the time is extended for good cause (§ 725.226); (4) In the case of a brother or sister, such individual also: (i) Is under 18 years of age; or (ii) Is under a disability as defined in section 223(d) of the Social Security Act, 42 U.S.C. 423(d), which began before such individual attained age 22, or in the case of a student, before the student ceased to be a student; or (iii) Is a student (see § 725.209(b)); or (iv) Is under a disability as defined in section 223(d) of the Social Security Act, 42 U.S.C. 423(d), at the time of the miner's death; (5) The deceased miner: (i) Is determined to have died due to pneumoconiosis; or (ii) Filed a claim for benefits on or after January 1, 1982, which results or resulted in a final award of benefits, and the surviving parent, brother or sister filed a claim for benefits after January 1, 2005 which was pending on or after March 23, 2010. (b)(1) A parent is not entitled to benefits if the deceased miner was survived by a spouse or child at the time of such miner's death. (2) A brother or sister is not entitled to benefits if the deceased miner was survived by a spouse, child, or parent at the time of such miner's death. | |||
| 20:20:4.0.2.2.8.2.84.23 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.223 Duration of entitlement; parent, brother, or sister. | DOL | (a) A parent, sister, or brother is entitled to benefits beginning with the month all the conditions of entitlement described in § 725.222 are met. (b) The last month for which such parent is entitled to benefits is the month in which the parent dies. (c) The last month for which such brother or sister is entitled to benefits is the month before the month in which any of the following events first occurs: (1) The individual dies; (2)(i) The individual marries or remarries; or (ii) If already married, the individual received support in any amount from his or her spouse; (3) The individual attains age 18; and (i) Is not a student (as defined in § 725.209(b)) during any part of the month in which the individual attains age 18; and (ii) Is not under a disability (as defined in § 725.209(a)(2)(ii)) at that time; (4) If the individual's entitlement beyond age 18 is based on his or her status as a student, the earlier of: (i) The first month during no part of which the individual is a student; or (ii) The month in which the individual attains age 23 and is not under a disability (as defined in § 725.209(a)(2)(ii)) at that time; (5) If the individual's entitlement beyond age 18 is based on disability, the first month in no part of which such individual is under a disability. | ||||
| 20:20:4.0.2.2.8.2.84.24 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.224 Determination of relationship; parent, brother, or sister. | DOL | (a) An individual will be considered to be the parent, brother, or sister of a miner if the courts of the State in which the miner was domiciled (see § 225.231) at the time of death would find, under the law they would apply, that the individual is the miner's parent, brother, or sister. (b) Where, under State law, the individual is not the miner's parent, brother, or sister, but would, under State law, have the same status ( i.e., right to share in the miner's intestate personal property) as a parent, brother, or sister, the individual will be considered to be the parent, brother, or sister as appropriate. | ||||
| 20:20:4.0.2.2.8.2.84.25 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.225 Determination of dependency; parent, brother, or sister. | DOL | An individual who is the miner's parent, brother, or sister will be determined to have been dependent on the miner if, during the 1-year period immediately prior to the miner's death: (a) The individual and the miner were living in the same household (see § 725.232); and (b) The individual was totally dependent on the miner for support (see § 725.233(h)). | ||||
| 20:20:4.0.2.2.8.2.84.26 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.226 “Good cause” for delayed filing of proof of support. | DOL | (a) What constitutes “good cause.” “Good cause” may be found for failure to file timely proof of support where the parent, brother, or sister establishes to the satisfaction of the Office that such failure to file was due to: (1) Circumstances beyond the individual's control, such as extended illness, mental, or physical incapacity, or communication difficulties; or (2) Incorrect or incomplete information furnished the individual by the Office; or (3) Efforts by the individual to secure supporting evidence without a realization that such evidence could be submitted after filing proof of support. (b) What does not constitute “good cause.” “Good cause” for failure to file timely proof of support (see § 725.222(a)(3)) does not exist when there is evidence of record in the Office that the individual was informed that he or she should file within the prescribed period and he or she failed to do so deliberately or through negligence. | ||||
| 20:20:4.0.2.2.8.2.84.27 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.227 Time of determination of relationship and dependency of survivors. | DOL | The determination as to whether an individual purporting to be an entitled survivor of a miner or beneficiary was related to, or dependent upon, the miner is made after such individual files a claim for benefits as a survivor. Such determination is based on the facts and circumstances with respect to a reasonable period of time ending with the miner's death. A prior determination that such individual was, or was not, a dependent for the purposes of augmenting the miner's benefits for a certain period, is not determinative of the issue of whether the individual is a dependent survivor of such miner. | ||||
| 20:20:4.0.2.2.8.2.84.28 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.228 Effect of conviction of felonious and intentional homicide on entitlement to benefits. | DOL | An individual who has been convicted of the felonious and intentional homicide of a miner or other beneficiary shall not be entitled to receive any benefits payable because of the death of such miner or other beneficiary, and such person shall be considered nonexistent in determining the entitlement to benefits of other individuals. | ||||
| 20:20:4.0.2.2.8.2.84.29 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.229 Intestate personal property. | DOL | References in this subpart to the “same right to share in the intestate personal property” of a deceased miner (or surviving spouse) refer to the right of an individual to share in such distribution in the individual's own right and not the right of representation. | ||||
| 20:20:4.0.2.2.8.2.84.30 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.230 Legal impediment. | DOL | For purposes of this subpart, “legal impediment” means an impediment resulting from the lack of dissolution of a previous marriage or otherwise arising out of such previous marriage or its dissolution or resulting from a defect in the procedure followed in connection with the purported marriage ceremony—for example, the solemnization of a marriage only through a religious ceremony in a country which requires a civil ceremony for a valid marriage. | ||||
| 20:20:4.0.2.2.8.2.84.31 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.231 Domicile. | DOL | (a) For purposes of this subpart, the term “domicile” means the place of an individual's true, fixed, and permanent home. (b) The domicile of a deceased miner or surviving spouse is determined as of the time of death. (c) If an individual was not domiciled in any State at the pertinent time, the law of the District of Columbia is applied. | ||||
| 20:20:4.0.2.2.8.2.84.32 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.232 Member of the same household—“living with,” “living in the same household,” and “living in the miner's household,” defined. | DOL | (a) Defined. (1) The term “member of the same household” as used in section 402(a)(2) of the Act (with respect to a spouse); the term “living with” as used in section 402(e) of the Act (with respect to a surviving spouse); and the term “living in the same household” as used in this subpart, means that a husband and wife were customarily living together as husband and wife in the same place. (2) The term “living in the miner's household” as used in section 412(a)(5) of the Act (with respect to a parent, brother, or sister) means that the miner and such parent, brother, or sister were sharing the same residence. (b) Temporary absence. The temporary absence from the same residence of either the miner, or the miner's spouse, parent, brother, or sister (as the case may be), does not preclude a finding that one was “living with” the other, or that they were “members of the same household.” The absence of one such individual from the residence in which both had customarily lived shall, in the absence of evidence to the contrary, be considered temporary: (1) If such absence was due to service in the Armed Forces of the United States; or (2) If the period of absence from his or her residence did not exceed 6 months and the absence was due to business or employment reasons, or because of confinement in a penal institution or in a hospital, nursing home, or other curative institution; or (3) In any other case, if the evidence establishes that despite such absence they nevertheless reasonably expected to resume physically living together. (c) Relevant period of time. (1) The determination as to whether a surviving spouse had been “living with” the miner shall be based upon the facts and circumstances as of the time of the death of the miner. (2) The determination as to whether a spouse is a “member of the same household” as the miner shall be based upon the facts and circumstances with respect to the period or periods of time as to which the issue of membership in the same household is material. (3) The determi… | ||||
| 20:20:4.0.2.2.8.2.84.33 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.233 Support and contributions. | DOL | (a) Support defined. The term “support” includes food, shelter, clothing, ordinary medical expenses, and other ordinary and customary items for the maintenance of the person supported. (b) Contributions defined. The term “contributions” refers to contributions actually provided by the contributor from such individual's property, or the use thereof, or by the use of such individual's own credit. (c) Regular contributions and substantial contributions defined. The terms “regular contributions” and “substantial contributions” mean contributions that are customary and sufficient to constitute a material factor in the cost of the individual's support. (d) Contributions and community property. When a spouse receives and uses for his or her support income from services or property, and such income, under applicable State law, is the community property of the wife and her husband, no part of such income is a “contribution” by one spouse to the other's support regardless of the legal interest of the donor. However, when a spouse receives and uses for support, income from the services and the property of the other spouse and, under applicable State law, such income is community property, all of such income is considered to be a contribution by the donor to the spouse's support. (e) Court order for support defined. References to a support order in this subpart means any court order, judgment, or decree of a court of competent jurisdiction which requires regular contributions that are a material factor in the cost of the individual's support and which is in effect at the applicable time. If such contributions are required by a court order, this condition is met whether or not the contributions were actually made. (f) Written agreement defined. The term “written agreement” in the phrase “substantial contributions pursuant to a written agreement”, as used in this subpart means an agreement signed by the miner providing for substantial contributions by the miner for the individual's support. It must be in eff… | ||||
| 20:20:4.0.2.2.8.2.84.4 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.204 Determination of relationship; spouse. | DOL | (a) For the purpose of augmenting benefits, an individual will be considered to be the spouse of a miner if: (1) The courts of the State in which the miner is domiciled would find that such individual and the miner validly married; or (2) The courts of the State in which the miner is domiciled would find, under the law they would apply in determining the devolution of the miner's intestate personal property, that the individual is the miner's spouse; or (3) Under State law, such individual would have the right of a spouse to share in the miner's intestate personal property; or (4) Such individual went through a marriage ceremony with the miner resulting in a purported marriage between them and which, but for a legal impediment, would have been a valid marriage, unless the individual entered into the purported marriage with knowledge that it was not a valid marriage, or if such individual and the miner were not living in the same household in the month in which a request is filed that the miner's benefits be augmented because such individual qualifies as the miner's spouse. (b) The qualification of an individual for augmentation purposes under this section shall end with the month before the month in which: (1) The individual dies, or (2) The individual who previously qualified as a spouse for purposes of § 725.520(c), entered into a valid marriage without regard to this section, with a person other than the miner. | ||||
| 20:20:4.0.2.2.8.2.84.5 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.205 Determination of dependency; spouse. | DOL | For the purposes of augmenting benefits, an individual who is the miner's spouse (see § 725.204) will be determined to be dependent upon the miner if: (a) The individual is a member of the same household as the miner (see § 725.232); or (b) The individual is receiving regular contributions from the miner for support (see § 725.233(c)); or (c) The miner has been ordered by a court to contribute to such individual's support (see § 725.233(e)); or (d) The individual is the natural parent of the son or daughter of the miner; or (e) The individual was married to the miner (see § 725.204) for a period of not less than 1 year. | ||||
| 20:20:4.0.2.2.8.2.84.6 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.206 Determination of relationship; divorced spouse. | DOL | For the purposes of augmenting benefits with respect to any claim considered or reviewed under this part or part 727 of this subchapter (see § 725.4(d)), an individual will be considered to be the divorced spouse of a miner if the individual's marriage to the miner has been terminated by a final divorce on or after the 10th anniversary of the marriage unless, if such individual was married to and divorced from the miner more than once, such individual was married to the miner in each calendar year of the period beginning 10 years immediately before the date on which any divorce became final. | ||||
| 20:20:4.0.2.2.8.2.84.7 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.207 Determination of dependency; divorced spouse. | DOL | For the purpose of augmenting benefits, an individual who is the miner's divorced spouse (§ 725.206) will be determined to be dependent upon the miner if: (a) The individual is receiving at least one-half of his or her support from the miner (see § 725.233(g)); or (b) The individual is receiving substantial contributions from the miner pursuant to a written agreement (see § 725.233(c) and (f)); or (c) A court order requires the miner to furnish substantial contributions to the individual's support (see § 725.233(c) and (e)). | ||||
| 20:20:4.0.2.2.8.2.84.8 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.208 Determination of relationship; child. | DOL | As used in this section, the term “beneficiary” means only a surviving spouse entitled to benefits at the time of death (see § 725.212), or a miner. An individual will be considered to be the child of a beneficiary if: (a) The courts of the State in which the beneficiary is domiciled (see § 725.231) would find, under the law they would apply, that the individual is the beneficiary's child; or (b) The individual is the legally adopted child of such beneficiary; or (c) The individual is the stepchild of such beneficiary by reason of a valid marriage of the individual's parent or adopting parent to such beneficiary; or (d) The individual does not bear the relationship of child to such beneficiary under paragraph (a), (b), or (c) of this section, but would, under State law, have the same right as a child to share in the beneficiary's intestate personal property; or (e) The individual is the natural son or daughter of a beneficiary but is not a child under paragraph (a), (b), or (c) of this section, and is not considered to be the child of the beneficiary under paragraph (d) of this section if the beneficiary and the mother or the father, as the case may be, of the individual went through a marriage ceremony resulting in a purported marriage between them which but for a legal impediment (see § 725.230) would have been a valid marriage; or (f) The individual is the natural son or daughter of a beneficiary but is not a child under paragraph (a), (b), or (c) of this section, and is not considered to be the child of the beneficiary under paragraph (d) or (e) of this section, such individual shall nevertheless be considered to be the child of the beneficiary if: (1) The beneficiary, prior to his or her entitlement to benefits, has acknowledged in writing that the individual is his or her son or daughter, or has been decreed by a court to be the parent of the individual, or has been ordered by a court to contribute to the support of the individual (see § 725.233(e)) because the individual is his or her son or daughte… | ||||
| 20:20:4.0.2.2.8.2.84.9 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | B | Subpart B—Persons Entitled to Benefits, Conditions, and Duration of Entitlement | § 725.209 Determination of dependency; child. | DOL | (a) For purposes of augmenting the benefits of a miner or surviving spouse, the term “beneficiary” as used in this section means only a miner or surviving spouse entitled to benefits (see § 725.202 and § 725.212). An individual who is the beneficiary's child (§ 725.208) will be determined to be, or to have been, dependent on the beneficiary, if the child: (1) Is unmarried; and (2)(i) Is under 18 years of age; or (ii) Is under a disability as defined in section 223(d) of the Social Security Act, 42 U.S.C. 423(d); or (iii) Is 18 years of age or older and is a student. (b)(1) The term “student” means a “full-time student” as defined in section 202(d)(7) of the Social Security Act, 42 U.S.C. 402(d)(7) (see §§ 404.367-404.369 of this title), or an individual under 23 years of age who has not completed 4 years of education beyond the high school level and who is regularly pursuing a full-time course of study or training at an institution which is: (i) A school, college, or university operated or directly supported by the United States, or by a State or local government or political subdivision thereof; or (ii) A school, college, or university which has been accredited by a State or by a State-recognized or nationally-recognized accrediting agency or body; or (iii) A school, college, or university not so accredited but whose credits are accepted, on transfer, by at least three institutions which are so accredited; or (iv) A technical, trade, vocational, business, or professional school accredited or licensed by the Federal or a State government or any political subdivision thereof, providing courses of not less than 3 months' duration that prepare the student for a livelihood in a trade, industry, vocation, or profession. (2) A student will be considered to be “pursuing a full-time course of study or training at an institution” if the student is enrolled in a noncorrespondence course of at least 13 weeks duration and is carrying a subject load which is considered full-time for day students under the institutio… | ||||
| 20:20:4.0.2.2.8.3.85.1 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.301 Who may file a claim. | DOL | (a) Any person who believes he or she may be entitled to benefits under the Act may file a claim in accordance with this subpart. (b) A claimant who has attained the age of 18, is mentally competent and physically able, may file a claim on his or her own behalf. (c) If a claimant is unable to file a claim on his or her behalf because of a legal or physical impairment, the following rules shall apply: (1) A claimant between the ages of 16 and 18 years who is mentally competent and not under the legal custody or care of another person, or a committee or institution, may upon filing a statement to the effect, file a claim on his or her own behalf. In any other case where the claimant is under 18 years of age, only a person, or the manager or principal officer of an institution having legal custody or care of the claimant may file a claim on his or her behalf. (2) If a claimant over 18 years of age has a legally appointed guardian or committee, only the guardian or committee may file a claim on his or her behalf. (3) If a claimant over 18 years of age is mentally incompetent or physically unable to file a claim and is under the care of another person, or an institution, only the person, or the manager or principal officer of the institution responsible for the care of the claimant, may file a claim on his or her behalf. (4) For good cause shown, the Office may accept a claim executed by a person other than one described in paragraphs (c)(2) or (3) of this section. (d) Except as provided in § 725.305, in order for a claim to be considered, the claimant must be alive at the time the claim is filed. | ||||
| 20:20:4.0.2.2.8.3.85.10 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.310 Modification of awards and denials. | DOL | [65 FR 80054, Dec. 20, 2000, as amended at 81 FR 24479, Apr. 26, 2016] | (a) Upon his or her own initiative, or upon the request of any party on grounds of a change in conditions or because of a mistake in a determination of fact, the district director may, at any time before one year from the date of the last payment of benefits, or at any time before one year after the denial of a claim, reconsider the terms of an award or denial of benefits. (b) Modification proceedings must be conducted in accordance with the provisions of this part as appropriate, except that the claimant and the operator, or group of operators or the fund, as appropriate, are each entitled to submit no more than one additional chest X-ray interpretation, one additional pulmonary function test, one additional arterial blood gas study, and one additional medical report in support of its affirmative case along with such rebuttal evidence and additional statements as are authorized by paragraphs (a)(2)(ii) and (a)(3)(ii) of § 725.414. Modification proceedings may not be initiated before an administrative law judge or the Benefits Review Board. (c) At the conclusion of modification proceedings before the district director, the district director may issue a proposed decision and order (§ 725.418) or, if appropriate, deny the claim by reason of abandonment (§ 725.409). In any case in which the district director has initiated modification proceedings on his own initiative to alter the terms of an award or denial of benefits issued by an administrative law judge, the district director must, at the conclusion of modification proceedings, forward the claim for a hearing (§ 725.421). In any case forwarded for a hearing, the administrative law judge assigned to hear such case must consider whether any additional evidence submitted by the parties demonstrates a change in condition and, regardless of whether the parties have submitted new evidence, whether the evidence of record demonstrates a mistake in a determination of fact. (d) An order issued following the conclusion of modification proceedings may terminate, continue… | |||
| 20:20:4.0.2.2.8.3.85.11 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.311 Communications with respect to claims; time computations. | DOL | (a) Unless otherwise specified by this part, all requests, responses, notices, decisions, orders, or other communications required or permitted by this part shall be in writing. (b) If required by this part, any document, brief, or other statement submitted in connection with the adjudication of a claim under this part shall be sent to each party to the claim by the submitting party. If proof of service is required with respect to any communication, such proof of service shall be submitted to the appropriate adjudication officer and filed as part of the claim record. (c) In computing any period of time described in this part, by any applicable statute, or by the order of any adjudication officer, the day of the act or event from which the designated period of time begins to run shall not be included. The last day of the period shall be included unless it is a Saturday, Sunday, or legal holiday, in which event the period extends until the next day which is not a Saturday, Sunday, or legal holiday. “Legal holiday” includes New Year's Day, Birthday of Martin Luther King, Jr., Washington's Birthday, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day, Christmas Day and any other day appointed as a holiday by the President or the Congress of the United States. (d) In computing any period of time described in this part in which the period within which to file a response commences upon receipt of a document, it shall be presumed, in the absence of evidence to the contrary, that the document was received on the seventh day after it was mailed. In any case in which a provision of this part requires a document to be sent to a person or party by certified mail, and the document is not sent by certified mail, but the person or party actually received the document, the document shall be deemed to have been sent in compliance with the provisions of this part. In such a case, any time period which commences upon the service of the document shall commence on the date the document was receiv… | ||||
| 20:20:4.0.2.2.8.3.85.2 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.302 Evidence of authority to file a claim on behalf of another. | DOL | A person filing a claim on behalf of a claimant shall submit evidence of his or her authority to so act at the time of filing or at a reasonable time thereafter in accordance with the following: (a) A legally appointed guardian or committee shall provide the Office with certification of appointment by a proper official of the court. (b) Any other person shall provide a statement describing his or her relationship to the claimant, the extent to which he or she has care of the claimant, or his or her position as an officer of the institution of which the claimant is an inmate. The Office may, at any time, require additional evidence to establish the authority of any such person. | ||||
| 20:20:4.0.2.2.8.3.85.3 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.303 Date and place of filing of claims. | DOL | (a)(1) Claims for benefits shall be delivered, mailed to, or presented at, any of the various district offices of the Social Security Administration, or any of the various offices of the Department of Labor authorized to accept claims, or, in the case of a claim filed by or on behalf of a claimant residing outside the United States, mailed or presented to any office maintained by the Foreign Service of the United States. A claim shall be considered filed on the day it is received by the office in which it is first filed. (2) A claim submitted to a Foreign Service Office or any other agency or subdivision of the U.S. Government shall be forwarded to the Office and considered filed as of the date it was received at the Foreign Service Office or other governmental agency or unit. (b) A claim submitted by mail shall be considered filed as of the date of delivery unless a loss or impairment of benefit rights would result, in which case a claim shall be considered filed as of the date of its postmark. In the absence of a legible postmark, other evidence may be used to establish the mailing date. | ||||
| 20:20:4.0.2.2.8.3.85.4 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.304 Forms and initial processing. | DOL | (a) Claims shall be filed on forms prescribed and approved by the Office. The district office at which the claim is filed will assist claimants in completing their forms. (b) If the place at which a claim is filed is an office of the Social Security Administration, such office shall forward the completed claim form to an office of the DCMWC, which is authorized to process the claim. | ||||
| 20:20:4.0.2.2.8.3.85.5 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.305 When a written statement is considered a claim. | DOL | (a) The filing of a statement signed by an individual indicating an intention to claim benefits shall be considered to be the filing of a claim for the purposes of this part under the following circumstances: (1) The claimant or a proper person on his or her behalf (see § 725.301) executes and files a prescribed claim form with the Office during the claimant's lifetime within the period specified in paragraph (b) of this section. (2) Where the claimant dies within the period specified in paragraph (b) of this section without filing a prescribed claim form, and a person acting on behalf of the deceased claimant's estate executes and files a prescribed claim form within the period specified in paragraph (c) of this section. (b) Upon receipt of a written statement indicating an intention to claim benefits, the Office shall notify the signer in writing that to be considered the claim must be executed by the claimant or a proper party on his or her behalf on the prescribed form and filed with the Office within six months from the date of mailing of the notice. (c) If before the notice specified in paragraph (b) of this section is sent, or within six months after such notice is sent, the claimant dies without having executed and filed a prescribed form, or without having had one executed and filed in his or her behalf, the Office shall upon receipt of notice of the claimant's death advise his or her estate, or those living at his or her last known address, in writing that for the claim to be considered, a prescribed claim form must be executed and filed by a person authorized to do so on behalf of the claimant's estate within six months of the date of the later notice. (d) Claims based upon written statements indicating an intention to claim benefits not perfected in accordance with this section shall not be processed. | ||||
| 20:20:4.0.2.2.8.3.85.6 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.306 Withdrawal of a claim. | DOL | (a) A claimant or an individual authorized to execute a claim on a claimant's behalf or on behalf of claimant's estate under § 725.305, may withdraw a previously filed claim provided that: (1) He or she files a written request with the appropriate adjudication officer indicating the reasons for seeking withdrawal of the claim; (2) The appropriate adjudication officer approves the request for withdrawal on the grounds that it is in the best interests of the claimant or his or her estate, and; (3) Any payments made to the claimant in accordance with § 725.522 are reimbursed. (b) When a claim has been withdrawn under paragraph (a) of this section, the claim will be considered not to have been filed. | ||||
| 20:20:4.0.2.2.8.3.85.7 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.307 Cancellation of a request for withdrawal. | DOL | At any time prior to approval, a request for withdrawal may be canceled by a written request of the claimant or a person authorized to act on the claimant's behalf or on behalf of the claimant's estate. | ||||
| 20:20:4.0.2.2.8.3.85.8 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.308 Time limits for filing claims. | DOL | [65 FR 80054, Dec. 20, 2000, as amended at 83 FR 27695, June 14, 2018] | (a) A claim for benefits filed under this part by, or on behalf of, a miner shall be filed within three years after a medical determination of total disability due to pneumoconiosis which has been communicated to the miner or a person responsible for the care of the miner, or within three years after the date of enactment of the Black Lung Benefits Reform Act of 1977, whichever is later. There is no time limit on the filing of a claim by the survivor of a miner. (b) There shall be a rebuttable presumption that every claim for benefits is timely filed. The time limits in this section are mandatory and may not be waived or tolled except upon a showing of extraordinary circumstances. | |||
| 20:20:4.0.2.2.8.3.85.9 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | C | Subpart C—Filing of Claims | § 725.309 Additional claims; effect of prior denial of benefits. | DOL | [78 FR 59118, Sept. 25, 2013] | (a) If a claimant files a claim under this part while another claim filed by the claimant under this part is still pending, the later claim must be merged with the earlier claim for all purposes. For purposes of this section, a claim must be considered pending if it has not yet been finally denied. (b) If a claimant files a claim under this part within one year after the effective date of a final order denying a claim previously filed by the claimant under this part (see § 725.502(a)(2)), the later claim must be considered a request for modification of the prior denial and will be processed and adjudicated under § 725.310. (c) If a claimant files a claim under this part more than one year after the effective date of a final order denying a claim previously filed by the claimant under this part (see § 725.502(a)(2)), the later claim must be considered a subsequent claim for benefits. A subsequent claim will be processed and adjudicated in accordance with the provisions of subparts E and F of this part. Except as provided in paragraph (1) below, a subsequent claim must be denied unless the claimant demonstrates that one of the applicable conditions of entitlement (see §§ 725.202(d) (miner), 725.212 (spouse), 725.218 (child), and 725.222 (parent, brother, or sister)) has changed since the date upon which the order denying the prior claim became final. The applicability of this paragraph may be waived by the operator or fund, as appropriate. The following additional rules apply to the adjudication of a subsequent claim: (1) The requirement to establish a change in an applicable condition of entitlement does not apply to a survivor's claim if the requirements of §§ 725.212(a)(3)(ii), 725.218(a)(2), or 725.222(a)(5)(ii) are met, and the survivor's prior claim was filed— (i) On or before January 1, 2005, or (ii) After January 1, 2005 and was finally denied prior to March 23, 2010. (2) Any evidence submitted in connection with any prior claim must be made a part of the record in the subsequent claim, provided that … | |||
| 20:20:4.0.2.2.8.4.85.1 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.350 Who are the adjudication officers? | DOL | (a) General. The persons authorized by the Secretary of Labor to accept evidence and decide claims on the basis of such evidence are called “adjudication officers.” This section describes the status of black lung claims adjudication officers. (b) District Director. The district director is that official of the DCMWC or his designee who is authorized to perform functions with respect to the development, processing, and adjudication of claims in accordance with this part. (c) Administrative law judge. An administrative law judge is that official appointed pursuant to 5 U.S.C. 3105 (or Public Law 94-504) who is qualified to preside at hearings under 5 U.S.C. 557 and is empowered by the Secretary to conduct formal hearings with respect to, and adjudicate, claims in accordance with this part. A person appointed under Public Law 94-504 shall not be considered an administrative law judge for purposes of this part for any period after March 1, 1979. | ||||
| 20:20:4.0.2.2.8.4.85.10 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.366 Fees for representatives. | DOL | (a) A representative seeking a fee for services performed on behalf of a claimant shall make application therefor to the district director, administrative law judge, or appropriate appellate tribunal, as the case may be, before whom the services were performed. The application shall be filed and served upon the claimant and all other parties within the time limits allowed by the district director, administrative law judge, or appropriate appellate tribunal. The application shall be supported by a complete statement of the extent and character of the necessary work done, and shall indicate the professional status (e.g., attorney, paralegal, law clerk, lay representative or clerical) of the person performing such work, and the customary billing rate for each such person. The application shall also include a listing of reasonable unreimbursed expenses, including those for travel, incurred by the representative or an employee of a representative in establishing the claimant's case. Any fee requested under this paragraph shall also contain a description of any fee requested, charged, or received for services rendered to the claimant before any State or Federal court or agency in connection with a related matter. (b) Any fee approved under paragraph (a) of this section shall be reasonably commensurate with the necessary work done and shall take into account the quality of the representation, the qualifications of the representative, the complexity of the legal issues involved, the level of proceedings to which the claim was raised, the level at which the representative entered the proceedings, and any other information which may be relevant to the amount of fee requested. No fee approved shall include payment for time spent in preparation of a fee application. No fee shall be approved for work done on claims filed between December 30, 1969, and June 30, 1973, under part B of title IV of the Act, except for services rendered on behalf of the claimant in regard to the review of the claim under section 435 of the Act and… | ||||
| 20:20:4.0.2.2.8.4.85.11 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.367 Payment of a claimant's attorney's fee by responsible operator or fund. | DOL | (a) An attorney who represents a claimant in the successful prosecution of a claim for benefits may be entitled to collect a reasonable attorney's fee from the responsible operator that is ultimately found liable for the payment of benefits, or, in a case in which there is no operator who is liable for the payment of benefits, from the fund. Generally, the operator or fund liable for the payment of benefits shall be liable for the payment of the claimant's attorney's fees where the operator or fund, as appropriate, took action, or acquiesced in action, that created an adversarial relationship between itself and the claimant. The fees payable under this section shall include reasonable fees for necessary services performed prior to the creation of the adversarial relationship. Circumstances in which a successful attorney's fees shall be payable by the responsible operator or the fund include, but are not limited to, the following: (1) The responsible operator designated by the district director (see § 725.410(a)(3)) fails to accept the claimant's entitlement to benefits within the 30-day period provided by § 725.412(b) and is ultimately determined to be liable for benefits. The operator shall be liable for an attorney's fee with respect to all necessary services performed by the claimant's attorney; (2) There is no operator that may be held liable for the payment of benefits, and the district director issues a schedule for the submission of additional evidence under § 725.410. The fund shall be liable for an attorney's fee with respect to all necessary services performed by the claimant's attorney; (3) The claimant submits a bill for medical treatment, and the party liable for the payment of benefits declines to pay the bill on the grounds that the treatment is unreasonable, or is for a condition that is not compensable. The responsible operator or fund, as appropriate, shall be liable for an attorney's fee with respect to all necessary services performed by the claimant's attorney; (4) A beneficiary seeks an … | ||||
| 20:20:4.0.2.2.8.4.85.2 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.351 Powers of adjudication officers. | DOL | (a) District Director. The district director is authorized to: (1) Make determinations with respect to claims as is provided in this part; (2) Conduct conferences and informal discovery proceedings as provided in this part; (3) Compel the production of documents by the issuance of a subpoena; (4) Prepare documents for the signature of parties; (5) Issue appropriate orders as provided in this part; and (6) Do all other things necessary to enable him or her to discharge the duties of the office. (b) Administrative Law Judge. An administrative law judge is authorized to: (1) Conduct formal hearings in accordance with the provisions of this part; (2) Administer oaths and examine witnesses; (3) Compel the production of documents and appearance of witnesses by the issuance of subpoenas; (4) Issue decisions and orders with respect to claims as provided in this part; and (5) Do all other things necessary to enable him or her to discharge the duties of the office. (c) If any person in proceedings before an adjudication officer disobeys or resists any lawful order or process, or misbehaves during a hearing or so near the place thereof as to obstruct the same, or neglects to produce, after having been ordered to do so, any pertinent book, paper or document, or refuses to appear after having been subpoenaed, or upon appearing refuses to take the oath as a witness, or after having taken the oath refuses to be examined according to law, the district director, or the administrative law judge responsible for the adjudication of the claim, shall certify the facts to the Federal district court having jurisdiction in the place in which he or she is sitting (or to the U.S. District Court for the District of Columbia if he or she is sitting in the District) which shall thereupon in a summary manner hear the evidence as to the acts complained of, and, if the evidence so warrants, punish such person in the same manner and to the same extent as for a contempt committed before the court, or commit such person upon the same… | ||||
| 20:20:4.0.2.2.8.4.85.3 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.352 Disqualification of adjudication officer. | DOL | (a) No adjudication officer shall conduct any proceedings in a claim in which he or she is prejudiced or partial, or where he or she has any interest in the matter pending for decision. A decision to withdraw from the consideration of a claim shall be within the discretion of the adjudication officer. If that adjudication officer withdraws, another officer shall be designated by the Director or the Chief Administrative Law Judge, as the case may be, to complete the adjudication of the claim. (b) No adjudication officer shall be permitted to appear or act as a representative of a party under this part while such individual is employed as an adjudication officer. No adjudication officer shall be permitted at any time to appear or act as a representative in connection with any case or claim in which he or she was personally involved. No fee or reimbursement shall be awarded under this part to an individual who acts in violation of this paragraph. (c) No adjudication officer shall act in any claim involving a party which employed such adjudication officer within one year before the adjudication of such claim. (d) Notwithstanding paragraph (a) of this section, no adjudication officer shall be permitted to act in any claim involving a party who is related to the adjudication officer by consanguinity or affinity within the third degree as determined by the law of the place where such party is domiciled. Any action taken by an adjudication officer in knowing violation of this paragraph shall be void. | ||||
| 20:20:4.0.2.2.8.4.85.4 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.360 Parties to proceedings. | DOL | (a) Except as provided in § 725.361, no person other than the Secretary of Labor and authorized personnel of the Department of Labor shall participate at any stage in the adjudication of a claim for benefits under this part, unless such person is determined by the appropriate adjudication officer to qualify under the provisions of this section as a party to the claim. The following persons shall be parties: (1) The claimant; (2) A person other than a claimant, authorized to execute a claim on such claimant's behalf under § 725.301; (3) Any coal mine operator notified under § 725.407 of its possible liability for the claim; (4) Any insurance carrier of such operator; and (5) The Director in all proceedings relating to a claim for benefits under this part. (b) A widow, child, parent, brother, or sister, or the representative of a decedent's estate, who makes a showing in writing that his or her rights with respect to benefits may be prejudiced by a decision of an adjudication officer, may be made a party. (c) Any coal mine operator or prior operator or insurance carrier which has not been notified under § 725.407 and which makes a showing in writing that its rights may be prejudiced by a decision of an adjudication officer may be made a party. (d) Any other individual may be made a party if that individual's rights with respect to benefits may be prejudiced by a decision to be made. | ||||
| 20:20:4.0.2.2.8.4.85.5 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.361 Party amicus curiae. | DOL | At the discretion of the Chief Administrative Law Judge or the administrative law judge assigned to the case, a person or entity which is not a party may be allowed to participate amicus curiae in a formal hearing only as to an issue of law. A person may participate amicus curiae in a formal hearing upon written request submitted with supporting arguments prior to the hearing. If the request is granted, the administrative law judge hearing the case will inform the party of the extent to which participation will be permitted. The request may, however, be denied summarily and without explanation. | ||||
| 20:20:4.0.2.2.8.4.85.6 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.362 Representation of parties. | DOL | (a) Except for the Secretary of Labor, whose interests shall be represented by the Solicitor of Labor or his or her designee, each of the parties may appoint an individual to represent his or her interest in any proceeding for determination of a claim under this part. Such appointment shall be made in writing or on the record at the hearing. An attorney qualified in accordance with § 725.363(a) shall file a written declaration that he or she is authorized to represent a party, or declare his or her representation on the record at a formal hearing. Any other person (see § 725.363(b)) shall file a written notice of appointment signed by the party or his or her legal guardian, or enter his or her appearance on the record at a formal hearing if the party he or she seeks to represent is present and consents to the representation. Any written declaration or notice required by this section shall include the OWCP number assigned by the Office and shall be sent to the Office or, for representation at a formal hearing, to the Chief Administrative Law Judge. In any case, such representative must be qualified under § 725.363. No authorization for representation or agreement between a claimant and representative as to the amount of a fee, filed with the Social Security Administration in connection with a claim under part B of title IV of the Act, shall be valid under this part. A claimant who has previously authorized a person to represent him or her in connection with a claim originally filed under part B of title IV may renew such authorization by filing a statement to such effect with the Office or appropriate adjudication officer. (b) Any party may waive his or her right to be represented in the adjudication of a claim. If an adjudication officer determines, after an appropriate inquiry has been made, that a claimant who has been informed of his or her right to representation does not wish to obtain the services of a representative, such adjudication officer shall proceed to consider the claim in accordance with this par… | ||||
| 20:20:4.0.2.2.8.4.85.7 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.363 Qualification of representative. | DOL | (a) Attorney. Any attorney in good standing who is admitted to practice before a court of a State, territory, district, or insular possession, or before the Supreme Court of the United States or other Federal court and is not, pursuant to any provision of law, prohibited from acting as a representative, may be appointed as a representative. (b) Other person. With the approval of the adjudication officer, any other person may be appointed as a representative so long as that person is not, pursuant to any provision of law, prohibited from acting as a representative. | ||||
| 20:20:4.0.2.2.8.4.85.8 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.364 Authority of representative. | DOL | A representative, appointed and qualified as provided in §§ 725.362 and 725.363, may make or give on behalf of the party he or she represents, any request or notice relative to any proceeding before an adjudication officer, including formal hearing and review, except that such representative may not execute a claim for benefits, unless he or she is a person designated in § 725.301 as authorized to execute a claim. A representative shall be entitled to present or elicit evidence and make allegations as to facts and law in any proceeding affecting the party represented and to obtain information with respect to the claim of such party to the same extent as such party. Notice given to any party of any administrative action, determination, or decision, or request to any party for the production of evidence shall be sent to the representative of such party and such notice or request shall have the same force and effect as if it had been sent to the party represented. | ||||
| 20:20:4.0.2.2.8.4.85.9 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | D | Subpart D—Adjudication Officers; Parties and Representatives | § 725.365 Approval of representative's fees; lien against benefits. | DOL | No fee charged for representation services rendered to a claimant with respect to any claim under this part shall be valid unless approved under this subpart. No contract or prior agreement for a fee shall be valid. In cases where the obligation to pay the attorney's fee is upon the claimant, the amount of the fee awarded may be made a lien upon the benefits due under an award and the adjudication officer shall fix, in the award approving the fee, such lien and the manner of payment of the fee. Any representative who is not an attorney may be awarded a fee for services under this subpart, except that no lien may be imposed with respect to such representative's fee. | ||||
| 20:20:4.0.2.2.8.5.85.1 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.401 Claims development—general. | DOL | After a claim has been received by the district director, the district director shall take such action as is necessary to develop, process, and make determinations with respect to the claim as provided in this subpart. | ||||
| 20:20:4.0.2.2.8.5.85.10 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.410 Submission of additional evidence. | DOL | (a) After the district director completes the development of medical evidence under § 725.405 of this part, including the complete pulmonary evaluation authorized by § 725.406, and receives the responses and evidence submitted pursuant to § 725.408, he shall issue a schedule for the submission of additional evidence. The schedule shall contain the following information: (1) If the claim was filed by, or on behalf of, a miner, the schedule shall contain a summary of the complete pulmonary evaluation administered pursuant to § 725.406. If the claim was filed by, or on behalf of, a survivor, the schedule shall contain a summary of any medical evidence developed by the district director pursuant to § 725.405(c). (2) The schedule shall contain the district director's preliminary analysis of the medical evidence. If the district director believes that the evidence fails to establish any necessary element of entitlement, he shall inform the claimant of the element of entitlement not established and the reasons for his conclusions and advise the claimant that, unless he submits additional evidence, the district director will issue a proposed decision and order denying the claim. (3) The schedule shall contain the district director's designation of a responsible operator liable for the payment of benefits. In the event that the district director has designated as the responsible operator an employer other than the employer who last employed the claimant as a miner, the district director shall include, with the schedule, a copy of the statements required by § 725.495(d) of this part. The district director may, in his discretion, dismiss as parties any of the operators notified of their potential liability pursuant to § 725.407. If the district director thereafter determines that the participation of a party dismissed pursuant to this section is required, he may once again notify the operator in accordance with § 725.407(d). (4) The schedule shall notify the claimant and the designated responsible operator that they hav… | ||||
| 20:20:4.0.2.2.8.5.85.11 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.411 Initial adjudication in Trust Fund cases. | DOL | Notwithstanding the requirements of § 725.410 of this part, if the district director concludes that the results of the complete pulmonary evaluation support a finding of eligibility, and that there is no operator responsible for the payment of benefits, the district director shall issue a proposed decision and order in accordance with § 725.418 of this part. | ||||
| 20:20:4.0.2.2.8.5.85.12 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.412 Operator's response. | DOL | (a)(1) Within 30 days after the district director issues a schedule pursuant to § 725.410 of this part containing a designation of the responsible operator liable for the payment of benefits, that operator shall file a response with regard to its liability. The response shall specifically indicate whether the operator agrees or disagrees with the district director's designation. (2) If the responsible operator designated by the district director does not file a timely response, it shall be deemed to have accepted the district director's designation with respect to its liability, and to have waived its right to contest its liability in any further proceeding conducted with respect to the claim. (b) The responsible operator designated by the district director may also file a statement accepting claimant's entitlement to benefits. If that operator fails to file a timely response to the district director's designation, the district director shall, upon receipt of such a statement, issue a proposed decision and order in accordance with § 725.418 of this part. If the operator fails to file a statement accepting the claimant's entitlement to benefits within 30 days after the district director issues a schedule pursuant to § 725.410 of this part, the operator shall be deemed to have contested the claimant's entitlement. | ||||
| 20:20:4.0.2.2.8.5.85.13 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.413 Disclosure of medical information. | DOL | [81 FR 24480, Apr. 26, 2016, as amended at 81 FR 31854, May 20, 2016] | (a) For purposes of this section, medical information is any written medical data, including data in electronic format, about the miner that a party develops in connection with a claim for benefits, including medical data developed with any prior claim that has not been disclosed previously to the other parties. Medical information includes, but is not limited to— (1) Any examining physician's written or testimonial assessment of the miner, including the examiner's findings, diagnoses, conclusions, and the results of any tests; (2) Any other physician's written or testimonial assessment of the miner's respiratory or pulmonary condition; (3) The results of any test or procedure related to the miner's respiratory or pulmonary condition, including any information relevant to the test or procedure's administration; and (4) Any physician's or other medical professional's interpretation of the results of any test or procedure related to the miner's respiratory or pulmonary condition. (b) For purposes of this section, medical information does not include— (1) Any record of a miner's hospitalization or other medical treatment; or (2) Communications from a party's representative to a medical expert. (c) Each party must disclose medical information the party or the party's agent receives by sending a complete copy of the information to all other parties in the claim within 30 days after receipt. If the information is received after the claim is already scheduled for hearing before an administrative law judge, the disclosure must be made at least 20 days before the scheduled hearing is held ( see § 725.456(b)). (d) Medical information disclosed under this section must not be considered in adjudicating any claim unless a party designates the information as evidence in the claim. (e) At the request of any party or on his or her own motion, an adjudication officer may impose sanctions on any party or his or her representative who fails to timely disclose medical information in compliance with this section. (1) Sanc… | |||
| 20:20:4.0.2.2.8.5.85.14 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.414 Development of evidence. | DOL | [65 FR 80054, Dec. 20, 2000, as amended at 81 FR 24480, Apr. 26, 2016] | (a) Medical evidence. (1) For purposes of this section, a medical report is a physician's written assessment of the miner's respiratory or pulmonary condition. A medical report may be prepared by a physician who examined the miner and/or reviewed the available admissible evidence. Supplemental medical reports prepared by the same physician must be considered part of the physician's original medical report. A physician's written assessment of a single objective test, such as a chest X-ray or a pulmonary function test, is not a medical report for purposes of this section. (2)(i) The claimant is entitled to submit, in support of his affirmative case, no more than two chest X-ray interpretations, the results of no more than two pulmonary function tests, the results of no more than two arterial blood gas studies, no more than one report of an autopsy, no more than one report of each biopsy, and no more than two medical reports. Any chest X-ray interpretations, pulmonary function test results, blood gas studies, autopsy report, biopsy report, and physicians' opinions that appear in a medical report must each be admissible under this paragraph or paragraph (a)(4) of this section. (ii) The claimant is entitled to submit, in rebuttal of the case presented by the party opposing entitlement, no more than one physician's interpretation of each chest X-ray, pulmonary function test, arterial blood gas study, autopsy or biopsy submitted by the designated responsible operator or the fund, as appropriate, under paragraph (a)(3)(i) or (a)(3)(iii) of this section and by the Director pursuant to § 725.406. In any case in which the party opposing entitlement has submitted the results of other testing pursuant to § 718.107, the claimant is entitled to submit one physician's assessment of each piece of such evidence in rebuttal. In addition, where the responsible operator or fund has submitted rebuttal evidence under paragraph (a)(3)(ii) or (a)(3)(iii) of this section with respect to medical testing submitted by the claimant, the c… | |||
| 20:20:4.0.2.2.8.5.85.15 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.415 Action by the district director after development of evidence. | DOL | (a) At the end of the period permitted under § 725.410(b) for the submission of evidence, the district director shall review the claim on the basis of all evidence submitted in accordance with § 725.414. (b) After review of all evidence submitted, the district director may issue another schedule for the submission of additional evidence pursuant to § 725.410, identifying another potentially liable operator as the responsible operator liable for the payment of benefits. In such a case, the district director shall not permit the development or submission of any additional medical evidence until after he has made a final determination of the identity of the responsible operator liable for the payment of benefits. If the operator who is finally determined to be the responsible operator has not had the opportunity to submit medical evidence pursuant to § 725.410, the district director shall allow the designated responsible operator and the claimant not less than 60 days within which to submit evidence relevant to the claimant's eligibility for benefits. The designated responsible operator may elect to adopt any medical evidence previously submitted by another operator as its own evidence, subject to the limitations of § 725.414. The district director may also schedule a conference in accordance with § 725.416, issue a proposed decision and order in accordance with § 725.418, or take such other action as the district director considers appropriate. | ||||
| 20:20:4.0.2.2.8.5.85.16 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.416 Conferences. | DOL | (a) At the conclusion of the period permitted by § 725.410(b) of this part for the submission of evidence, the district director may conduct an informal conference in any claim where it appears that such conference will assist in the voluntary resolution of any issue raised with respect to the claim. The conference proceedings shall not be stenographically reported and sworn testimony shall not be taken. Any conference conducted pursuant to this paragraph shall be held no later than 90 days after the conclusion of the period permitted by § 725.410(b) of this part for the submission of evidence, unless one of the parties requests that the time period be extended for good cause shown. If the district director is unable to hold the conference within the time period permitted by this paragraph, he shall proceed to issue a proposed decision and order under § 725.418 of this part. (b) The district director shall notify the parties of a definite time and place for the conference. The district director shall advise the parties that they have a right to representation at the conference, by an attorney or a lay representative, and that no conference shall take place unless the parties are represented. A coal mine operator which is self-insured, or which is covered by a policy of insurance for the claim for which a conference is scheduled, shall be deemed to be represented. The notification shall set forth the specific reasons why the district director believes that a conference will assist in the voluntary resolution of any issue raised with respect to the claim. No sanction may be imposed under paragraph (c) of this section unless the record contains a notification that meets the requirements of this section. The district director may in his or her discretion, or on the motion of any party, cancel a conference or allow any or all of the parties to participate by telephone. (c) The unexcused failure of any party to appear at an informal conference shall be grounds for the imposition of sanctions. If the claimant fails to… | ||||
| 20:20:4.0.2.2.8.5.85.17 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.417 Action at the conclusion of conference. | DOL | (a) At the conclusion of a conference, the district director shall prepare a stipulation of contested and uncontested issues which shall be signed by the parties and the district director. If a hearing is conducted with respect to the claim, this stipulation shall be submitted to the Office of Administrative Law Judges and placed in the claim record. (b) In appropriate cases, the district director may permit a reasonable time for the submission of additional evidence following a conference, provided that such evidence does not exceed the limits set forth in § 725.414. The district director may also notify additional operators of their potential liability pursuant to § 725.407, or issue another schedule for the submission of additional evidence pursuant to § 725.410, designating another potentially liable operator as the responsible operator liable for the payment of benefits, in order to allow that operator an opportunity to submit evidence relevant to its liability for benefits as well as the claimant's eligibility for benefits. (c) Within 20 days after the termination of all conference proceedings, the district director shall prepare and send to the parties a proposed decision and order pursuant to § 725.418 of this part. | ||||
| 20:20:4.0.2.2.8.5.85.18 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.418 Proposed decision and order. | DOL | [78 FR 59118, Sept. 25, 2013] | (a) Within 20 days after the termination of all informal conference proceedings, or, if no informal conference is held, at the conclusion of the period permitted by § 725.410(b) for the submission of evidence, the district director will issue a proposed decision and order. A proposed decision and order is a document, issued by the district director after the evidentiary development of the claim is completed and all contested issues, if any, are joined, which purports to resolve a claim on the basis of the evidence submitted to or obtained by the district director. A proposed decision and order will be considered a final adjudication of a claim only as provided in § 725.419. A proposed decision and order may be issued by the district director at any time during the adjudication of any claim if: (1) Issuance is authorized or required by this part; (2) The district director determines that its issuance will expedite the adjudication of the claim; or (3) The district director determines that the claimant is a survivor who is entitled to benefits under 30 U.S.C. 932(l). In such cases, the district director may designate the responsible operator in the proposed decision and order regardless of whether the requirements of paragraph (d) of this section have been met. Any operator identified as liable for benefits under this paragraph may challenge the finding of liability by timely requesting revision of the proposed decision and order and specifically indicating disagreement with that finding. See 20 CFR 725.419(a) and (b). In such cases, the district director must allow all parties 30 days within which to submit liability evidence. At the end of this period, the district director must issue a new proposed decision and order. (b) A proposed decision and order must contain findings of fact and conclusions of law. It must be served on all parties to the claim by certified mail. (c) The proposed decision and order must contain a notice of the right of any interested party to request a formal hearing before the Offic… | |||
| 20:20:4.0.2.2.8.5.85.19 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.419 Response to proposed decision and order. | DOL | (a) Within 30 days after the date of issuance of a proposed decision and order, any party may, in writing, request a revision of the proposed decision and order or a hearing. If a hearing is requested, the district director shall refer the claim to the Office of Administrative Law Judges (see § 725.421). (b) Any response made by a party to a proposed decision and order shall specify the findings and conclusions with which the responding party disagrees, and shall be served on the district director and all other parties to the claim. (c) If a timely request for revision of a proposed decision and order is made, the district director may amend the proposed decision and order, as circumstances require, and serve the revised proposed decision and order on all parties or take such other action as is appropriate. If a revised proposed decision and order is issued, each party to the claim shall have 30 days from the date of issuance of that revised proposed decision and order within which to request a hearing. (d) If no response to a proposed decision and order is sent to the district director within the period described in paragraph (a) of this section, or if no response to a revised proposed decision and order is sent to the district director within the period described in paragraph (c) of this section, the proposed decision and order shall become a final decision and order, which is effective upon the expiration of the applicable 30-day period. Once a proposed decision and order or revised proposed decision and order becomes final and effective, all rights to further proceedings with respect to the claim shall be considered waived, except as provided in § 725.310. | ||||
| 20:20:4.0.2.2.8.5.85.2 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.402 Approved State workers' compensation law. | DOL | If a district director determines that any claim filed under this part is one subject to adjudication under a workers' compensation law approved under part 722 of this subchapter, he or she shall advise the claimant of this determination and of the Act's requirement that the claim must be filed under the applicable State workers' compensation law. The district director shall then prepare a proposed decision and order dismissing the claim for lack of jurisdiction pursuant to § 725.418 and proceed as appropriate. | ||||
| 20:20:4.0.2.2.8.5.85.20 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.420 Initial determinations. | DOL | (a) Section 9501(d)(1)(A)(1) of the Internal Revenue Code (26 U.S.C.) provides that the Black Lung Disability Trust Fund shall begin the payment of benefits on behalf of an operator in any case in which the operator liable for such payments has not commenced payment of such benefits within 30 days after the date of an initial determination of eligibility by the Secretary. For claims filed on or after January 1, 1982, the payment of such interim benefits from the fund is limited to benefits accruing after the date of such initial determination. (b) Except as provided in § 725.415, after the district director has determined that a claimant is eligible for benefits, on the basis of all evidence submitted by a claimant and operator, and has determined that a hearing will be necessary to resolve the claim, the district director shall in writing so inform the parties and direct the operator to begin the payment of benefits to the claimant in accordance with § 725.522. The date on which this writing is sent to the parties shall be considered the date of initial determination of the claim. (c) If a notified operator refuses to commence payment of a claim within 30 days from the date on which an initial determination is made under this section, benefits shall be paid by the fund to the claimant in accordance with § 725.522, and the operator shall be liable to the fund, if such operator is determined liable for the claim, for all benefits paid by the fund on behalf of such operator, and, in addition, such penalties and interest as are appropriate. | ||||
| 20:20:4.0.2.2.8.5.85.21 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.421 Referral of a claim to the Office of Administrative Law Judges. | DOL | (a) In any claim for which a formal hearing is requested or ordered, and with respect to which the district director has completed evidentiary development and adjudication without having resolved all contested issues, the district director shall refer the claim to the Office of Administrative Law Judges for a hearing. (b) In any case referred to the Office of Administrative Law Judges under this section, the district director shall transmit to that office the following documents, which shall be placed in the record at the hearing subject to the objection of any party: (1) Copies of the claim form or forms; (2) Any statement, document, or pleading submitted by a party to the claim; (3) A copy of the notification to an operator of its possible liability for the claim, and any schedule for the submission of additional evidence issued pursuant to § 725.410 designating a potentially liable operator as the responsible operator; (4) All medical evidence submitted to the district director under this part by the claimant and the potentially liable operator designated as the responsible operator in the proposed decision and order issued pursuant to § 725.418, or the fund, as appropriate, subject to the limitations of § 725.414 of this part; this evidence shall include the results of any medical examination or test conducted pursuant to § 725.406, and all evidence relevant to the liability of the responsible operator submitted to the district director under this part; (5) Any written stipulation of law or fact or stipulation of contested and uncontested issues entered into by the parties; (6) Any pertinent forms submitted to the district director; (7) The statement by the district director of contested and uncontested issues in the claim; and (8) The district director's initial determination of eligibility or other documents necessary to establish the right of the fund to reimbursement, if appropriate. Copies of the transmittal notice shall also be sent to all parties to the claim by regular mail. (c) A party may … | ||||
| 20:20:4.0.2.2.8.5.85.22 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.422 Legal assistance. | DOL | The Secretary or his or her designee may, upon request, provide a claimant with legal assistance in processing a claim under the Act. Such assistance may be made available to a claimant in the discretion of the Solicitor of Labor or his or her designee at any time prior to or during the time in which the claim is being adjudicated and shall be furnished without charge to the claimant. Representation of a claimant in adjudicatory proceedings shall not be provided by the Department of Labor unless it is determined by the Solicitor of Labor that such representation is in the best interests of the black lung benefits program. In no event shall representation be provided to a claimant in a claim with respect to which the claimant's interests are adverse to those of the Secretary of Labor or the fund. | ||||
| 20:20:4.0.2.2.8.5.85.23 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.423 Extensions of time. | DOL | Except for the 30-day time limit set forth in § 725.419, any of the time periods set forth in this subpart may be extended, for good cause shown, by filing a request for an extension with the district director prior to the expiration of the time period. | ||||
| 20:20:4.0.2.2.8.5.85.3 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.403 [Reserved] | DOL | |||||
| 20:20:4.0.2.2.8.5.85.4 | 20 | Employees' Benefits | VI | B | 725 | PART 725—CLAIMS FOR BENEFITS UNDER PART C OF TITLE IV OF THE FEDERAL MINE SAFETY AND HEALTH ACT, AS AMENDED | E | Subpart E—Adjudication of Claims by the District Director | § 725.404 Development of evidence—general. | DOL | (a) Employment history. Each claimant shall furnish the district director with a complete and detailed history of the coal miner's employment and, upon request, supporting documentation. (b) Matters of record. Where it is necessary to obtain proof of age, marriage or termination of marriage, death, family relationship, dependency (see subpart B of this part), or any other fact which may be proven as a matter of public record, the claimant shall furnish such proof to the district director upon request. (c) Documentary evidence. If a claimant is required to submit documents to the district director, the claimant shall submit either the original, a certified copy or a clear readable copy thereof. The district director or administrative law judge may require the submission of an original document or certified copy thereof, if necessary. (d) Submission of insufficient evidence. In the event a claimant submits insufficient evidence regarding any matter, the district director shall inform the claimant of what further evidence is necessary and request that such evidence be submitted within a specified reasonable time which may, upon request, be extended for good cause. |
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CREATE TABLE cfr_sections (
section_id TEXT PRIMARY KEY,
title_number INTEGER,
title_name TEXT,
chapter TEXT,
subchapter TEXT,
part_number TEXT,
part_name TEXT,
subpart TEXT,
subpart_name TEXT,
section_number TEXT,
section_heading TEXT,
agency TEXT,
authority TEXT,
source_citation TEXT,
amendment_citations TEXT,
full_text TEXT
);
CREATE INDEX idx_cfr_title ON cfr_sections(title_number);
CREATE INDEX idx_cfr_part ON cfr_sections(part_number);
CREATE INDEX idx_cfr_agency ON cfr_sections(agency);