Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 530 - PROVISIONAL MEDICAL OR DISABILITY PAYMENTS TO WORKERS' COMPENSATION CLAIMANTS
Section 031-530-4 - Provisional payments required

A. If a workers' compensation claimant is awaiting a Board determination on a claim in which the employer or workers' compensation carrier has filed a notice of controversy contesting the work-relatedness of the claimant's condition, and the claimant is covered under an insured health plan, then the health carrier must determine eligibility and provide benefits to the claimant, according to the terms of the health plan but without regard to any policy exclusion for work-related injury or disease.

B. The health carrier may require the claimant to pursue the claim through the mediation level established pursuant to 39-A M.R.S.A. §153(6) in order to preserve his or her entitlement to provisional payments. If the mediation results in an agreement that the condition is not work-related, or if there is no agreement and the claimant elects not to prosecute the workers' compensation claim further, the health carrier must either abide by that decision or file a petition with the Board pursuant to 39-AM.R.S.A. §305. The health carrier's liability for provisional benefit payments ceases if the Board determines that the claimant's condition is work-related, if the employer acknowledges for purposes of the Workers' Compensation Law that the claimant's condition is work-related, or if the employer or workers' compensation carrier makes or agrees to make any payment, to or for the benefit of the claimant, in settlement of the workers' compensation claim.

C. Unless a shorter period is provided for by law or by the terms of the health plan, any payments required by this Section shall be paid to or on behalf of the claimant within the following time limits. For periodic disability benefits, payment shall be made in full by the end of each 30-day period during which the claimant is entitled to benefits, subject to proof of loss. Other payments shall be made within 60 days after the health carrier receives proof of loss. Provided, however, that no payment is due until 10 days after the health carrier has received both:

D. Upon making any payment required by this Section, the health carrier shall notify the claimant that the payment is made on a provisional basis, pending resolution of the workers' compensation claim, and is subject to recovery or offset as provided in 39-A M.R.S.A. §222(2). In particular, the health carrier shall clearly warn that the payment may be more than the amount the claimant is ultimately entitled to under the workers' compensation law, and that the claimant would then be liable to refund the difference.