Fla. Admin. Code R. 69L-56.4012

Current through Reg. 50, No. 222; November 13, 2024

Section 69L-56.4012 - Notice of Denial

(1) If the claim administrator denies entitlement to any benefit, or subsequently rescinds that denial, it shall send a copy of Form DFS-F2-DWC-12, as adopted in Rule 69L-3.025, F.A.C., to the employee, employer and any additional party requesting payment or authorization. The Form DFS-F2-DWC-12 shall be mailed within 14 days of the date the claim administrator decided to deny or rescind the denial of benefits.

(2) If the claim administrator initially denies the compensability of or coverage for a case, it shall send Form DFS-F2-DWC-12 to the Division within 14 days after the claim administrator receives notification of the injury, illness or death. The claim administrator shall also mark the "Denied Case" box on Form DFS-F2-DWC-1 pursuant to sub-subparagraph 69L-56.4011(1)(d) 5.a., F.A.C.

(3) If the claim administrator initially denies only the indemnity benefits of a claim, it shall send Form DFS-F2-DWC-12 to the Division within 14 days after the claim administrator's notification of the injury, illness or death. The claim administrator shall also mark the "Indemnity Only Denied Case" box on Form DFS-F2-DWC-1, as adopted in Rule 69L-3.025, F.A.C., pursuant to sub-subparagraph 69L-56.4011(1)(d) 5.b., F.A.C.

(4) When the claim administrator denies any subsequent indemnity benefit on a lost time case, it shall send Form DFS-F2-DWC-12. The Form DFS-F2-DWC-12 shall be sent to the Division within 14 days of the claim administrator's knowledge of the requested benefit being denied.

(5) If a Petition for Benefits is the claim administrator's first notification of an injury and the claim administrator denies the case in its entirety, it shall send Forms DFS-F2-DWC-12 and DFS-F2-DWC-1 to the Division within 14 days of the claim administrator's receipt of the Petition for Benefits.

(6) When the claim administrator has previously denied any indemnity benefits for a lost time case and has sent Form DFS-F2-DWC-12 to the Division, and then commences the payment of indemnity benefits, the claim administrator shall send Form DFS-F2-DWC-12 with the denial rescinded section completed. The "Date Denial Rescinded" is the date the claim administrator decided to rescind the denial. The Form DFS-F2-DWC-12 shall be sent to the Division within 14 days of the date that the denial was rescinded.

(7) When an employee requests wage loss benefits for dates of accident August 1, 1979 through December 31, 1993, by sending Form DFS-F2-DWC-3, as adopted in Rule 69L-3.025, F.A.C., to the claim administrator, and the wage loss calculation yields an amount of benefits payable, but the claim administrator denies or disputes the employee's eligibility for those benefits, the claim administrator shall, within 14 days of receipt of the Form DFS-F2-DWC-3:

(a) Send to the Division the following:

1. Form DFS-F2-DWC-3, completed by the employee and the claim administrator;

2. Form DFS-F2-DWC-12; and,

3. A copy of any information or document relating to the employee's job search.

(b) Send to the employee the following:

1. Copies of the Forms DFS-F2-DWC-3; and,

2. DFS-F2-DWC-12.

(8) When an employee files a Statement of Quarterly Earnings for Supplemental Income Benefits for Dates of Accident January 1, 1994 through September 30, 2003, Form DFS-F2-DWC-40, as adopted in rule 69L-3.025, F.A.C., and the supplemental income benefit calculation yields an amount of benefits payable, but the claim administrator denies or disputes the employee's eligibility for those benefits, the claim administrator shall, within 14 days of receipt of the form:

(a) Send to the Division the following:

1. Form DFS-F2-DWC-40, completed by the employee and the claim administrator; and,

2. Form DFS-F2-DWC-12.

(b) Send to the employee the following:

1. Copies of the Forms DFS-F2-DWC-40; and,

2. DFS-F2-DWC-12.

(9) This rule does not supersede Division filing requirements found in Rule 69L-56.3012, F.A.C., and the filing requirements found herein only apply to circumstances under which a Petition for Variance or Waiver has been granted pursuant to Section 120.542, F.S.

Fla. Admin. Code Ann. R. 69L-56.4012

Rulemaking Authority 440.185(5), 440.20(3), 440.591 FS. Law Implemented 440.12(2), 440.14, 440.192(8), 440.20(2), (4), (9), (15)(f), 440.207(2) FS.

New 10-30-79, Amended 11-5-81, 5-30-82, 6-12-84, Formerly 38F-3.12, Amended 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.012, 4L-3.012, Amended 1-10-05, 6-30-14, Formerly 69L-3.012.