Fill and Sign the Partial Denial of Claim Form

Form 089 EMPLOYEE NOTIFICATION OF DENIAL OR PARTIAL DENIAL OF CLAIM PLEASE PRINT OR TYPE Employee: _________________________________ Date of Alleged Injury : _____________________ Address: ___________________________________ Phone Number: ___________________________ City, State : _________________________________ Social Security #:___________________________ Employer : __________________________________ Body Part Injured: _________________________ Insurance Carrier : __________________________ Date Carrier was Notified: __________________ Claim Number : _____________________________ Date of Denial: ____________________________ Adjustor: ____________________ Adjustor’s Address: ______________________________________ Adjustor’s Phone Number : _______________________ NOTICE TO THE CLAIMANT: If you are in disagreement with the denial and cannot resolve your differences by talking with the carrier and/or your treating physicia n, you can file for a hearing and/or a mediation. To obtain an applicati on for mediation and/or a hearing, contact the Utah Labor Commission, Division of Industrial Ac cident at (800) 530-5090. Please check appropriate reason for denial (if a partial denial is issued, please refer to the section below). □ Fatality □ Fa ilure by an employee claiming benefits to sign releases for medical information. □ Injury/Occupational Disease did not o ccur within the scope of employment. □ Medical information does not support the claim. □ Claim not filed within the statute of limitations. □ Claimant is not an employee. □ Claimant has failed to cooperate in the investigation of the claim. □ Pre-existing condition. Please be very specific. _____________________________________ _____________________________________________________________________________ Other – A specific reason must be given. ____________________________________________ _____________________________________________________________________________ Please check appropriate reason for partial denial . □ Tested positive to a drug/alcohol ch emical test - Medicals only paid. □ Disputed validity - Medicals only paid. □ Disputed validity - Compensation only paid. Please give a brief explanation of any item checked above: ___________________________________ __________________________________________________________________________________ LABOR COMMISSION RULE GOVERNING ACCEPTANCE/DENIAL OF A CLAIM R612-200-1. Reporting and Investigating Injuries. (Refer to the Utah Labor Commission Workers’ Compensation Rules for complete text.) C. Investigation of Claims; Notice to Division and Claimants; Commencement of Benefits. An insurance carrier, claim administr ator or uninsured employer shall promptly investigate the claim and either accept or deny workers’ compensation liability for the claim within 21 days after receiving initial notice of injury. a. If, with reasonable diligence, an insu rance carrier, self-insured employer, or un insured employer cannot complete its inves tigation within 21 days after initial notice, it ma y complete and submit Division Form 441, “Notice of Further Investigation of a Workers’ Compensation,” notify the Division and claimant that the matter remains under investigation. The insurance carrier, self-insured employer, or uninsured employer is then allowed 24 days in addition to the in itial 21-day period to complete its investigation and accept or deny liability of the claim. b. An insurance carrier or self-insured employer denying a claim for workers’ compensation benefits shall report such denial t hrough current EDI processes. An uninsured employer denying a claim for worker s’ compensation benefits shall complete and mail to the Division Form 089, “Employee Notification of Denial of Claim” and to the claimant. D. Consequences of Failure to Comply. 1. Pursuant to Subsection 34A-2-407(8) of the Utah Workers’ Compensation Act, the Division may impose a civil assessment of up to $500 for an insurance carrier, insured employer, self-insured employer, or uninsured employer’s failure, without good cause, to comply w ith the requirements of this rule. Official Form 089 Revised 10/14 State of Utah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P.O. Box 146610 Salt Lake City, UT 84114-6610 * Telephone: 801 530-6800 * Fax: 801 530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov