(1) 
Notice of Injury or Occupational Disease. Any employee who has sustained an injury or developed a disease in the course of employment shall immediately report the accident or diagnosis of disease to the supervisor in charge of the employee and to the designated employer representative. An injury may be reported by another on behalf of the employee. An occupational disease must be reported immediately after the employee learns of, or reasonably should have been aware of, the connection between their employment and the occupational disease.
(2) 
Form of Notice. Such notice shall be submitted in writing on a form provided by the employer.
(3) 
Failure to Provide Notice. If the employee fails to report the injury immediately, any award of compensation under this chapter may be reduced proportionately to any prejudice that the employer has sustained by reason of the employee’s failure to immediately report the injury. The burden of proof with respect to such prejudice shall rest on the employer.
(Ord. 108 § 108.4.1, 10-6-2006 (Res. 2006-312))
(1) 
Application for Compensation. Where an employee is entitled to compensation under this chapter, the employee shall file an application for compensation with the designated employer representative and shall identify their treating physician. No medical services covered in this plan shall be paid for at rates exceeding those promulgated by the Workers’ Compensation Committee.
(2) 
Failure to Submit Application for Compensation. An employee shall not be entitled to recover any amount expended by the employee for medical or other treatment or services unless they shall have filed an application for compensation.
(3) 
Physician’s Duty to Aid. It shall be the duty of the treating physician to lend all necessary assistance in making the application for compensation and such proof of other matters required by the rules of the Workers’ Compensation Committee without charge to the employee.
(Ord. 108 § 108.4.2, 10-6-2006 (Res. 2006-312))
Where a claim has been filed and benefits are being provided, it shall be the obligation of the employee to contact the designated employer representative at least once every 30 days.
(Ord. 108 § 108.4.3, 10-6-2006 (Res. 2006-312))
(1) 
One-Year Statute of Limitations. Except as otherwise provided herein, the right to compensation for disability or death under this chapter shall be barred unless a claim is filed within one year after the injury or death. The time for filing a claim shall not begin to run until the employee or beneficiary is aware, or by the exercise of reasonable diligence should have been aware, of the relationship between the injury or death and the employment.
(2) 
Incompetents and Minors. If an employee who is entitled to compensation under this chapter is mentally incompetent or a minor, the provisions herein shall not be applicable so long as such person has no guardian or other authorized representative, but shall be applicable from the date of appointment of such guardian or other representative. In the case of a minor, if no guardian is appointed before the minor becomes of age, then these provisions shall be applicable from the date such minor becomes of age.
(3) 
Occupational Disease. Claims for occupational disease or infection must be filed within one year following the date the employee or beneficiary had notice from a physician of the existence of the employee’s occupational disease without reference to its date of origin, or within one year after the employee or beneficiary is aware, or by the exercise of reasonable diligence should have been aware, of the relationship between the disease or death and the employment, but in no event longer than three years from the date the employee terminates their employment with the Tribes or one of its enterprises.
(Ord. 108 § 108.4.4, 10-6-2006 (Res. 2006-312))
The burden of proof to establish entitlement benefits under this chapter, except as set forth in TTC § 9.15.380, shall rest on the covered employee, or their dependents in the case of death.
(Ord. 108 § 108.4.5, 10-6-2006 (Res. 2006-312))
When a covered employee is found dead by accident under circumstances indicating that the accident took place within time and place limits of employment and no conclusive evidence is present to exclude coverage as provided herein, it shall be the presumption that death arose out of employment, and benefits shall be paid.
(Ord. 108 § 108.4.6, 10-6-2006 (Res. 2006-312))
Upon request at any time, a dependent shall furnish the Claims Administrator with proof satisfactory to the Claims Administrator of the nature, amount, and extent of the contribution by the employee for such dependent’s support.
(Ord. 108 § 108.4.7, 10-6-2006 (Res. 2006-312))
Nothing in this chapter shall impair the rights of the parties to compromise, subject to the provisions herein, any liability which is claimed to exist under this chapter on account of injury, disease, or death. After reaching a compromise, a copy of the release or compromise agreement signed by both the claimant and the Claims Administrator shall be presented to the Workers’ Compensation Committee for approval. If approved, the Claims Administrator shall enter an award based on the release or compromise agreement.
(Ord. 108 § 108.4.8, 10-6-2006 (Res. 2006-312))
(1) 
Closure Determination. An employee’s claim shall be closed when the Claims Administrator determines that the injured employee has reached the point where maximum medical improvement has been reached. Where a claim has been filed and where benefits have been provided by the employer, the Claims Administrator shall close an employee’s claim if there has been no claim activity for the previous 180 days. Such closure shall be deemed to occur by operation of law. The Claims Administrator shall serve written notice of the closure of the claim after expiration of the 180-day period.
(2) 
Reopening of Claims. Where any significant change in disability occurs within seven years of the closing of the claim, the employee may petition for a readjustment of the compensation rate. The Claims Administrator may, at any time, upon his or her own motion, readjust the rate of compensation, or in a proper case, terminate the payment. If an order denying an application to reopen is not issued within 90 days of receipt by the Claims Administrator, such application shall be deemed granted. However, for good cause, the Claims Administrator may extend the time for making the final determination on the application for an additional 60 days.
(Ord. 108 § 108.4.9, 10-6-2006 (Res. 2006-312))
(1) 
Payments Due to Error and Mistake. Whenever any payment of benefits under this chapter is made because of clerical error, mistaken identity, innocent misrepresentation by or on behalf of the recipient thereof mistakenly acted upon, or any other circumstances of a similar nature not induced by fraud, the recipient shall repay it. Recoupment may be made from any future payments due the recipient on any claim against the Tribes. The Claims Administrator must make a claim for such repayment or recoupment within one year of the making of any such payment or it will be deemed that any claim therefor has been waived. The Claims Administrator may exercise their discretion to waive, in whole or in part, the amount of any such timely claim where the recovery would be against equity and good conscience.
(2) 
Payments Due to Erroneous Adjudication. Whenever any payment of benefits under this chapter has been made pursuant to a determination by the Claims Administrator and timely protest or appeal has been made, where the final decision is that any such payment was made pursuant to an erroneous adjudication or pursuant to the exhaustion of administrative appeals, the recipient shall repay it, and recoupment may be made from any future payments due the recipient on any claim being paid by the Tribes. The Claims Administrator may exercise their discretion to waive, in whole or in part, the amount of any such payments where the recovery would be against equity and good conscience.
(3) 
Payments Due to Fraud. Whenever any payment of benefits under this chapter has been induced by fraud, the recipient shall repay any such payments together with a penalty of 50 percent of the total of any such payments, and the amount of such total sum may be recouped from any future payments due the recipient on any claim against the Tribes. Such repayment or recoupment must be demanded within one year of the discovery of the fraud. In addition to the penalties provided under this chapter, the recipient may also be charged with a Class D offense under TTC § 3.35.140, False claims to Tribal agencies.
(Ord. 108 § 108.4.10, 10-6-2006 (Res. 2006-312))
(1) 
Medical Examination May Be Required. When medical questions arise, an employee entitled to or claiming compensation under this chapter shall, if requested by the Claims Administrator, submit to medical examination at a time, and from time to time, and at a place reasonably convenient for the employee by a physician selected by the Claims Administrator.
(2) 
Medical Evaluations. Medical evaluations for purposes of determining permanent disability, claim reopening, and claim closure shall not be made by the employee’s treating physician. Such evaluations shall be made by an evaluating physician selected by the Claims Administrator.
(3) 
Refusal to Submit. If the employee refuses to submit to a medical examination or obstructs the same, or if any injured employee shall persist in unsanitary or injurious practices which tend to imperil or retard such worker’s recovery, or shall refuse to submit to such medical or surgical treatment as is reasonably essential to the employee’s recovery, the Claims Administrator, with notice to the employee, may reduce or suspend the employee’s compensation as long as such refusal or practice continues.
(4) 
Travel Expenses. If the employee necessarily incurs traveling expenses in attending a medical examination pursuant to the request of the Claims Administrator, such traveling expenses shall be repaid to the employee by the Tribes.
(Ord. 108 § 108.4.11, 10-6-2006 (Res. 2006-312))
Information obtained by the attending physician or surgeon while treating the injured employee shall not be a privileged communication if such information is required by the Claims Administrator for a proper understanding of the case and a determination of the rights involved. The Claims Administrator shall have the right to request a full and complete report from the physician or surgeon at times and in the form and detail deemed necessary to evaluate the claim.
(Ord. 108 § 108.4.12, 10-6-2006 (Res. 2006-312))
Information contained in the claims files and records of injured employees under the provisions of this plan shall be deemed confidential and shall not be open to public inspection. Representatives of the claimant, be it an individual or an organization, may review a claim file or receive specific information therefrom upon the presentation of the signed authorization of the claimant. The employer or its duly authorized representatives may review any files of their own injured employees in connection with any pending claims. Physicians treating or examining employees claiming benefits under this chapter, or physicians giving medical advice to the Claims Administrator regarding any claim, may, at the discretion of the Claims Administrator, inspect the claims files and records of the injured employee. Other persons may make such inspection, at the Claims Administrator’s discretion, when such persons are rendering assistance to the Claims Administrator at any stage of the proceedings on any matter pertaining to the administration of this chapter.
(Ord. 108 § 108.4.13, 10-6-2006 (Res. 2006-312))
(1) 
Election to Bring Third Party Action. If a third person, not in the employ of the Tribes, is or may become liable to pay damages on account of an employee’s injury for which benefits and compensation are being provided under this chapter, the injured employee or their beneficiary may elect to seek damages from that third person. The injured employee will be entitled to the full compensation and benefits provided under this chapter regardless of any such third party action.
(2) 
Assignment of Action to Tribes. An election not to proceed against the third party operates as an assignment of the cause of action to the Workers’ Compensation Committee, which may prosecute or compromise the action, at its discretion, in the name of the injured employee, beneficiary or legal representative. If such an election is made, the injured employee or their beneficiary shall be entitled to any remaining balance of the award or settlement recovered after deduction of the expenses incurred in making the recovery, including reasonable legal services, and the compensation and benefits paid on behalf of the employee or their beneficiary by the Workers’ Compensation Committee.
(3) 
Notice to Parties. If either the employee or the Workers’ Compensation Committee brings an action against a third party for the injury, they shall give to the other a copy of the complaint either by personal service or certified mail. If either the employee or the Committee brings the action, the other may, at any time before trial on the facts, join as a party plaintiff or consolidate actions if they were brought independently.
(4) 
Distribution of Award or Settlement.
(a) 
In an action by an injured employee or their beneficiary against a third party, any award or settlement shall be distributed as follows:
(i) 
The costs and reasonable attorneys fees shall be paid;
(ii) 
The injured employee or their beneficiary shall be paid 25 percent of the balance of the award; provided, that in the event of a compromise and settlement by the parties, the injured employee or their beneficiary may agree to a sum less than 25 percent;
(iii) 
The balance of the award will be deposited with the Tribal fund, but only to the extent necessary to reimburse the fund for compensation benefits paid;
(iv) 
Any remaining balance shall be paid to the injured employee or their beneficiary.
(b) 
After the award or settlement has been distributed, no payment will be made to or on behalf of the employee or beneficiary from the Tribal fund for such injury until the amount of any further compensation or benefits that would have been due equals any such remaining balance under subsection (4)(a)(iv) of this section. Thereafter such benefits shall be paid from the fund to or on behalf of the employee or their beneficiary as though no third party action had been made.
(c) 
Any compromise or settlement of a third party cause of action that results in less than the entitlement in subsections (4)(a)(i) through (iii) of this section is void unless made with the written approval of the Workers’ Compensation Committee and the employee or their beneficiary.
(5) 
Award Subject to Lien. The award or settlement shall be subject to a lien in favor of the Tribal fund for its share under this section.
(6) 
Required Election. The Workers’ Compensation Committee may require the injured employee or their beneficiary to exercise the right to election herein by serving a written demand, either by mail or personal service, on the employee or their beneficiary. Unless an election is made within 60 days of receipt of the demand, the employee or beneficiary is deemed to have assigned the action to the Tribes.
(Ord. 108 § 108.4.14, 10-6-2006 (Res. 2006-312))