W. Va. Code R. § 115-7-7 - Application for Compensation

7.1. A claim for reimbursement of uncollectible economic damages shall be made by filing an original and two (2) copies of a verified written application for compensation. An application for compensation must be signed by the claimant or his or her legal representative.
7.2. As a condition of receiving compensation from the fund, the claimant shall execute appropriate confidentiality or privacy waivers granting the agency access to all of his or her medical records.
7.3. All applications for compensation must be received by the Board or, if mailed, postmarked on or before June 30, 2016, in order to be eligible for review or payment from the fund._
7.4. The verified application for compensation shall set forth and provide the following information:
7.4.a. The name and address of the claimant and other identifying information which the agency may require;
7.4.b. The name and address of the legal representative of the claimant and the basis for his or her representation of the claimant;
7.4.c. The date(s), time(s) and place(s) where the underlying medical injury occurred;
7.4.d. A statement of the facts and circumstances regarding the underlying medical injury leading to and ultimately giving rise to the submission of the application for compensation.
7.4.e. A detailed description of the economic damages for which the claim is made;
7.4.f. Documentation of expenses and services incurred to date, indicating whether such expenses and services have been paid for, and if so, by whom;
7.4.g. Documentation of any applicable private or government source of services or reimbursement relative to the underlying medical injury;
7.4.h. A schedule listing all liability insurance, policy limits, and amounts collected by claimant to date from responsible persons with respect to the medical injury and the underlying medial liability civil action. Copies of all applicable liability insurance policies or policy declaration pages shall be attached to the application;
7.4.i. A detailed statement of the facts and circumstances, including any declaratory judgments or rulings, demonstrating how the claimant exhausted all reasonable means to recover economic damages from all applicable liability insurance coverages;
7.4.j. If the underlying medical injury claim was the subject of a civil action, the court (federal or state) in which it was filed, the docket or civil action number, the parties to such action, and its present status, including certified copies of court documents including complaint, answer, judgment, special jury interrogatories, verdict forms, declaratory rulings and dispositive motion orders;
7.4.k. Appropriate and relevant assessments, evaluations, and prognoses and other records and documents the agency deems reasonably necessary for the determination of the amount of compensation to be paid to, or on behalf of, the claimant.
7.4.l. All available relevant medical records relating to the claimant and the underlying medical injury and an identification of any unavailable medical records known to the claimant and the reasons for the unavailability.
7.5. In addition to the application for compensation, the agency may require the claimant to submit materials substantiating the facts in the application. If the agency finds that an application does not contain the required information or that the facts stated therein have not been adequately explained or documented, it shall notify the claimant or his or her representative in writing the specific additional items of information or materials required and that he or she has thirty (30) days from receipt of the notification in which to supplement the application. Unless a claimant requests and is granted in writing an extension of time by the agency, the agency may reject the claim for failure to file additional information or materials within the specified time.
7.6. The claimant may file an amended application or additional substantiating material to correct inadvertent errors at any time before the agency has completed its consideration of the original application for compensation.
7.7. When a final award is made by the Board, the claimant shall file a petition for approval of the final award with the court in which the underlying civil action is pending or if none is pending, in a court of appropriate jurisdiction. The claimant shall be responsible for all court costs associated with, or relating to, approval of the final award by the court. No award may become final until approval by the court.
7.8. The claimant shall sign a written release which absolves the fund, the agency and the board of any liability or further obligation with respect to the claim, following approval of the final award and before payment.


W. Va. Code R. § 115-7-7

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