Md. Code Regs. 14.09.02.04 - Death and Funeral Benefits
A.
Election for Counties and Municipal Corporations.
(1) A county or municipal corporation may
elect for the death benefits provisions of Labor and Employment Article,
§§
9-683.1
-9-683.5, Annotated Code of Maryland, to apply to its public safety employees
subject to the statutory presumption set forth in Labor and Employment Article,
§
9-503, Annotated
Code of Maryland.
(2) A county or
municipal corporation may make this election by:
(a) Completing an online form, available at
the Commission's website; and
(b)
Attaching a copy of the county or municipal corporation's ordinance or
resolution making the election.
(3) The Commission shall issue a date-stamped
notice advising the county or municipal government of its receipt of the
election.
(4) The date stamp of the
Commission's notice will be used as the effective date of the
election.
(5) All death benefit
claims arising out of a death that occurred after the date of election are
subject to the death benefits provisions set forth in Labor and Employment
Article, §§
9-683.1
-9-683.5, Annotated Code of Maryland.
B. Dependent Claim for Death Benefits.
(1) To initiate a claim for death benefits, a
dependent of the deceased employee or an individual authorized to act on behalf
of the dependent claimant shall file a dependent death benefits claim form with
the Commission.
(2) The Commission
may reject a claim form that does not contain sufficient information to process
the claim including:
(a) The dependent
claimant's name and, if applicable, the authorized individual's name;
(b) The dependent claimant's address and, if
applicable, the authorized individual's address;
(c) The deceased employee's name;
(d) The deceased employee's
address;
(e) The deceased
employee's date of birth;
(f) The
date of the accident or occupational disease;
(g) The member of the deceased employee's
body that was injured;
(h) A
description of how the accidental injury or occupational disease
occurred;
(i) The deceased
employee's date of death; and
(j)
The deceased employee's employer's name and address.
(3) If the information set forth in
§B(2) of this regulation is unavailable or does not exist the claimant
shall:
(a) Enter all zeros (0) in the spaces
provided for the information; and
(b) Attach a signed statement certifying that
the information is unavailable or does not exist.
(4) Signature.
(a) The dependent claimant or authorized
individual shall sign the dependent death benefit claim form.
(b) An authorized individual shall submit
documentation establishing his or her authority to act on behalf of the
dependent claimant with the claim form.
(5) Submission of Supporting Documentation.
(a) When completing the dependent death
benefits claim form, the dependent claimant or authorized individual shall
submit:
(i) An authorization for disclosure
of health information signed by the dependent claimant or authorized
individual, directing the deceased employee's health care providers to disclose
to the dependent claimant's attorney, the deceased employee's attorney, the
deceased employee's employer, the employer's insurer, or any agent thereof, the
deceased employee's medical records that are relevant to:
1. The member of the body that was injured by
an accident or occupational disease, as indicated on the claim form;
and
2. The description of how the
accidental injury or occupational disease occurred, as indicated on the claim
form;
(ii) A
certification of funeral expenses, if the dependent claimant is making a claim
for funeral benefits, which shall:
1. Include
the name of the deceased employee;
2. Include an attached itemized statement of
the services performed and corresponding costs;
3. Be signed by the provider of the funeral
services or undertaker; and
4. Be
signed by the person authorizing the burial or other services.
(iii) A certified copy of the
certificate of death for the deceased employee;
(iv) A certified copy of the certificate of
marriage for the dependent claimant and deceased employee, if the dependent
claimant is the surviving spouse of the employee; and
(v) A certified copy of the certificate of
birth for the dependent claimant, if the dependent claimant is the surviving
child of the deceased employee.
(b) Prior to the scheduled hearing on the
death claim, the dependent claimant or authorized individual who filed the
claim shall submit:
(i) Proof of family
income at the date of the accidental personal injury or disablement;
(ii) An affidavit attesting to the
authenticity of the documents submitted as proof of family income;
and
(iii) If applicable, copies of
any legal documents or orders directing the deceased employee to pay child
support or alimony.
(c)
Proof of family income may include:
(i)
Payroll stubs or wage records covering the 14-week period prior to the
accidental injury or date of disablement;
(ii) W-2s;
(iii) 1099 forms or other evidence of
earnings from self-employment; and
(iv) Tax returns.
(d) If the dependent claimant or authorized
individual does not have access to proof of income records for some alleged
dependent claimants, the dependent claimant or authorized individual shall
submit evidence demonstrating the efforts made to obtain these records,
including any Commission subpoenas.
(6) Revocation of Authorization.
(a) A dependent claimant or authorized
individual may revoke an authorization for disclosure of health information in
writing.
(b) The dependent claimant
or authorized individual shall serve a copy of the written revocation on all
the parties in the case.
(7) The Commission shall reject a dependent
death benefits claim form that does not contain a signed authorization for
disclosure of health information.
(8) Date of Filing.
(a) A claim is considered filed on the date
that a completed and signed claim form, including the signed authorization for
disclosure of health information, is received by the Commission.
(b) The Commission's date of receipt is
determined by the date stamp affixed on the claim form.
(9) Electronic Submission.
(a) A dependent death benefits claim that is
submitted electronically is not considered filed until the signed claim form,
including the signed authorization for disclosure of health information, is
received by the Commission.
(b) The
Commission's date of receipt is determined by the date stamp affixed on the
claim form.
C.
Claim for Funeral Benefits Only.
(1) If the
deceased employee has no dependents, any person or entity responsible for
paying, or who has paid, the deceased employee's funeral expenses may initiate
a claim for funeral benefits by filing with the Commission a signed funeral
benefits only claim form certifying that the information submitted on the form
is accurate.
(2) The Commission may
reject a funeral benefits only claim form that does not contain sufficient
information to process the claim including:
(a) The filing party's name and
address;
(b) The deceased
employee's name and address;
(c)
The deceased employee's employer's name and address;
(d) The date of accident or occupational
disease; and
(e) The deceased
employee's date of death.
(3) When completing the funeral benefits only
claim form the filing party shall attach a certification of funeral expenses,
which shall:
(a) Include the name of the
deceased employee;
(b) Include an
attached itemized statement of the services performed and corresponding
costs;
(c) Be signed by the
provider of the funeral services or undertaker; and
(d) Be signed by the person authorizing the
burial or other services.
Notes
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