Nev. Admin. Code § 616D.411

Current through October 11, 2024

Section 616D.411 - Benefit penalties: Determination of amount required to be paid

1. To determine the amount of a benefit penalty required to be paid pursuant to subsection 3 of NRS 616D.120, as amended by section 20 of Senate Bill No. 274, chapter 535, Statutes of Nevada 2023, at page 3635, the Administrator will determine that the violation caused physical or economic harm to the injured employee or his or her dependents if the Administrator finds, by a preponderance of the evidence, that:

(a) The harm would not have occurred but for the violation;

(b) The violation was a substantial factor in bringing about the harm; and

(c) There is no supervening cause that is responsible for bringing about the harm.

2. Physical harm must be established by a preponderance of objective medical evidence in the form of existing medical records or medical records furnished by the claimant.

3. The Administrator will determine the amount of a benefit penalty required to be paid pursuant to subsection 3 of NRS 616D.120, as amended by section 20 of Senate Bill No. 274, chapter 535, Statutes of Nevada 2023, at page 3635, according to the following schedule. In addition to the required minimum benefit penalty of $17,000, a claimant will be awarded $8,500 for each point assessed, but in no event will the amount of the benefit penalty be greater than $120,000.

Points assessed for physical harm:
Temporary minor harm .........................................................................................	2 points
Temporary major harm ..........................................................................................	5 points
Permanent minor harm ..........................................................................................	5 points
Permanent major harm ..........................................................................................	15 points
Death .....................................................................................................................	25 points
Points assessed for the amount of compensation found to be due the claimant: Amount of compensation
$3,001 - $5,000 ......................................................................................................	1 point
$5,001 - $7,000 ......................................................................................................	2 points
$7,001 - $9,000 ......................................................................................................	3 points
$9,001 - $11,000 ....................................................................................................	4 points
$11,001 - $13,000 ..................................................................................................	5 points
$13,001 - $15,000 .............................................................................................	6 points
$15,001 - $17,000 .............................................................................................	7 points
$17,001 - $19,000 .............................................................................................	8 points
$19,001 - $21,000 .............................................................................................	9 points
An amount that is greater than $21,000 ...........................................................	10 points
Points assessed for prior violations: Average number of claims handled in the past 3 years of 4,000 or more
Five or less prior violations ..............................................................................	0 points
Six prior violations ...........................................................................................	1 point
Seven prior violations .......................................................................................	2 points
Eight prior violations ........................................................................................	4 points
Nine or more prior violations ...........................................................................	6 points
Average number of claims handled in the past 3 years of less than 4,000 but more than 1,500	more than
Three or less prior violations ............................................................................	0 points
Four prior violations .........................................................................................	1 point
Five prior violations .........................................................................................	2 points
Six prior violations ...........................................................................................	4 points
Seven or more prior violations .........................................................................	6 points
Average number of claims handled in the past 3 years of 1,500 or less
One prior violation .....................................................................................................	0 points
Two prior violations ...................................................................................................	1 point
Three prior violations .................................................................................................	2 points
Four prior violations ...................................................................................................	4 points
Five or more prior violations .....................................................................................	6 points
Points assessed for economic harm: Amount of economic harm
$6,001 - $7,000 ...........................................................................................................	1 point
$7,001 - $8,000 ...........................................................................................................	2 points
$8,001 - $9,000 ...........................................................................................................	3 points
$9,001 - $10,000 .........................................................................................................	4 points
$10,001 - $11,000 .......................................................................................................	5 points
$11,001 - $12,000 .......................................................................................................	6 points
$12,001 - $13,000 .......................................................................................................	7 points
$13,001 - $14,000 .......................................................................................................	8 points
$14,001 - $15,000 .......................................................................................................	9 points
More than $15,000 ....................................................................................................	10 points

4. To determine the number of prior violations of an insurer, organization for managed care, health care provider, third-party administrator, employer or employee leasing company, the Administrator will:

(a) Consider only those fines and benefit penalties imposed pursuant to paragraphs (a) to (e), inclusive, (h) and (i) of subsection 1 of NRS 616D.120 using the 3 most recent complete years of available data.

(b) Not consider those benefit penalties imposed pursuant to paragraph (b) of subsection 3 of NRS 616D.120.

5. To determine the average number of claims handled in the past 3 years, the Administrator will consider the 3 most recent complete years of available data.

6. As used in this section:

(a) "Claim" means a claim for compensation for which a Form C-4, Employee's Claim for Compensation/Report of Initial Treatment, has been submitted to the employer of an injured employee and the insurer or third-party administrator of the employer pursuant to NAC 616C.080.

(b) "Dependent" means a person who:

(1) At the time of the violation, is:

(I) The spouse of the injured employee;

(II) A child of the injured employee and is under 18 years of age; or

(III) A child of the injured employee, is 18 years of age or older and is physically or mentally incapacitated and unable to earn a wage; or

(2) Is a parent of the injured employee, a child of the injured employee who is 18 years of age or older, a stepchild of the injured employee or a sibling of the injured employee if that person's dependency upon the injured employee is established by a federal income tax return of the injured employee or by any other reliable evidence.

(c) "Economic harm" includes:

(1) The loss of money or an item of monetary value; and

(2) The deprivation of a reasonable expectation of a financial or monetary advantage.

(d) "Number of claims handled" means the total number of claims accepted, denied or reopened during a 1-year period.

(e) "Permanent major harm" means physical harm that:

(1) Results in a complete or significant loss of the ability to engage in activities of daily living, including, without limitation, caring for oneself, performing manual tasks, walking, standing, sitting, seeing, hearing, speaking, breathing, learning, working, sleeping, functioning sexually, and engaging in normal recreational and social activities; and

(2) Is unlikely to be alleviated in spite of medical treatment that a reasonable person is willing to undergo.

(f) "Permanent minor harm" means physical harm that:

(1) Does not result in a complete or significant loss of the ability to engage in activities of daily living, including, without limitation, caring for oneself, performing manual tasks, walking, standing, sitting, seeing, hearing, speaking, breathing, learning, working, sleeping, functioning sexually, and engaging in normal recreational and social activities; and

(2) Is unlikely to be alleviated in spite of medical treatment that a reasonable person is willing to undergo.

(g) "Physical harm" means death or any physiological disorder or condition, cosmetic disfigurement or anatomic loss affecting one or more of the following body systems:

(1) The neurological system.

(2) The musculoskeletal system.

(3) Special sense organs.

(4) The respiratory system, including, without limitation, speech organs.

(5) The cardiovascular system.

(6) The reproductive system.

(7) The digestive system.

(8) The genitourinary system.

(9) The hemic and lymphatic system.

(10) The skin.

(11) The endocrine system.

(h) "Temporary major harm" means physical harm that:

(2) Is likely to be alleviated with or without medical treatment.

(i) "Temporary minor harm" means physical harm that:

(2) Is likely to be alleviated with or without medical treatment.

Nev. Admin. Code § 616D.411

Added to NAC by Div. of Industrial Relations by R118-02, eff. 9-7-2005; A by R007-06, 6-1-2006; R149-09, 10-23-2013; A by R076-23A, eff. 10/9/2024

NRS 616A.400, 616D.120, as amended by section 20 of Senate Bill No. 274, chapter 535, Statutes of Nevada 2023, at page 3635