West Virginia Code of State Rules Agency 85 - Workers' Compensation
Overview of West Virginia CSR, Agency 85 – Workers’ Compensation
Agency 85 contains rules promulgated by the West Virginia Workers’ Compensation Commission (WVWCC). Its purpose is to regulate the administration of workers’ compensation claims, ensure timely and fair benefits to injured workers, and establish procedures for employers, insurers, and employees in compliance with West Virginia law.
The rules are based on West Virginia Code Chapter 23, which governs workers’ compensation in the state.
The main areas covered by CSR Agency 85 include:
Claims Filing and Processing
Medical Treatment and Provider Regulations
Benefit Payments and Calculation
Hearings, Appeals, and Contested Claims
Employer and Insurer Responsibilities
Penalties and Enforcement
1. Claims Filing and Processing (CSR §85-1 et seq.)
Employees must report workplace injuries promptly to their employer.
Employers must file a report with the WVWCC within a specified timeframe.
The rules specify:
Forms to be used (e.g., Form D-2 for claim reporting)
Time limits for filing
Investigation procedures by the Commission
Timely filing is crucial, as delays can affect benefits.
Case Law Example:
Hensley v. Workers’ Comp. Comm’n, 226 W. Va. 250 (2012) – The court emphasized that failure to report or timely file a claim can result in denial of benefits, even if the injury occurred on the job. CSR 85 rules enforce deadlines set in the West Virginia Code.
2. Medical Treatment and Provider Regulations (CSR §85-2)
Employees have the right to reasonable and necessary medical care related to their workplace injury.
The Commission regulates:
Choice of medical provider
Approval of certain treatments
Record-keeping requirements for medical providers
Some treatment may require pre-authorization from the insurer or Commission.
Case Law Example:
Holloway v. Workers’ Comp. Comm’n, 197 W. Va. 350 (2000) – Courts have recognized that denial of medical treatment not in compliance with CSR 85 rules or West Virginia Code 23-4-1 can be contested. Providers and insurers must follow procedural rules for authorization.
3. Benefit Payments and Calculation (CSR §85-3)
Agency 85 details:
Temporary Total Disability (TTD): Payment rules when employees are unable to work temporarily.
Permanent Partial Disability (PPD) and Permanent Total Disability (PTD): How benefits are calculated based on injury severity.
Wage calculations: CSR 85 defines how the “average weekly wage” is determined.
Payment timelines: Insurers must pay benefits within specific deadlines.
Case Law Example:
Fowler v. Workers’ Comp. Comm’n, 230 W. Va. 541 (2013) – The court held that miscalculation of benefits in violation of CSR 85 can justify adjustment or additional payment, reinforcing that the rules are binding on employers and insurers.
4. Hearings, Appeals, and Contested Claims (CSR §85-4)
CSR 85 outlines procedures for hearings before the WVWCC.
Key rules include:
Scheduling hearings
Submission of evidence
Representation by attorneys
Appeals to the Circuit Court of Kanawha County
Contested claims must follow CSR rules for notice, evidence, and deadlines.
Case Law Example:
Bragg v. Workers’ Comp. Comm’n, 242 W. Va. 49 (2015) – The court confirmed that failure to comply with procedural rules in CSR 85 can result in dismissal of claims, but also noted that strict compliance must balance fairness to the claimant.
5. Employer and Insurer Responsibilities (CSR §85-5)
Employers and insurance carriers must:
Provide coverage and maintain insurance
File accurate reports of claims and payments
Notify employees of rights under West Virginia law
The rules also regulate audits, inspections, and compliance monitoring.
Case Law Example:
State ex rel. Medley v. Workers’ Comp. Comm’n, 224 W. Va. 432 (2011) – Courts have held that failure to comply with CSR 85 reporting or insurance requirements can result in penalties and affect the employer’s legal defenses.
6. Penalties and Enforcement (CSR §85-6)
CSR 85 allows the WVWCC to enforce rules by:
Imposing fines for late reporting
Requiring repayment of improperly withheld benefits
Suspending licenses for repeat violations
These enforcement powers ensure compliance with the workers’ compensation system.
Case Law Example:
Lindsey v. Workers’ Comp. Comm’n, 241 W. Va. 189 (2016) – The court upheld penalties under CSR 85, stating that the Commission has authority to enforce rules strictly to protect employees’ rights.
Key Legal Principles Emerging from CSR 85
From the rules and case law, several principles are clear:
Strict Compliance Matters: Filing deadlines, forms, and notices must be followed precisely.
Medical and Wage Rules Are Binding: CSR 85 governs how benefits and medical care are delivered.
Procedural Fairness Is Required: Hearings and appeals must adhere to the rules, but courts balance this against fairness to the injured worker.
Employer/Insurer Accountability: Companies must comply with reporting, payment, and coverage requirements.
Enforcement Is Broad: The Commission can impose penalties, require repayment, and take administrative actions to ensure compliance.
Summary
CSR Agency 85 – Workers’ Compensation is the backbone of West Virginia’s workers’ compensation system, regulating:
Filing and processing claims
Medical care authorization
Calculation and payment of benefits
Hearing and appeals procedures
Employer and insurer obligations
Enforcement and penalties
Case law confirms that the rules are legally binding and enforceable, and courts consistently uphold the WVWCC’s authority under CSR 85 when rules are followed properly.
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