(a) Section 11 of the Reform Act directs the Secretary of Health,
Education and Welfare to notify each miner receiving benefits under
part B of title IV of the Act that he or she may file a claim for
medical treatment benefits described in this subpart. Section
725.308(b) provides that a claim for medical treatment benefits shall
be filed on or before December 31, 1980, unless the period is enlarged
for good cause shown. This section sets forth the rules governing the
processing, adjudication, and payment of claims filed under section 11.
(b)(1) A claim filed pursuant to the notice described in paragraph
(a) of this section shall be considered a claim for medical benefits
only, and shall be filed, processed, and adjudicated in accordance with
the provisions of this part, except as provided in this section. While
a claim for medical benefits must be treated as any other claim filed
under part C of title IV of the Act, the Department shall accept the
Social Security Administration's finding of entitlement as its initial
determination.
(2) In the case of a part B beneficiary whose coal mine employment
terminated before January 1, 1970, the Secretary shall make an
immediate award of medical benefits. Where the part B beneficiary's
coal mine employment terminated on or after January 1, 1970, the
Secretary shall immediately authorize the payment of medical benefits
and thereafter inform the responsible operator, if any, of the
operator's right to contest the claimant's entitlement for medical
benefits.
(c) A miner on whose behalf a claim is filed under this section
(see Sec. 725.301) must have been alive on March 1, 1978, in order for
the claim to be considered.
(d) The criteria contained in subpart C of part 727 of this
subchapter (see Sec. 725.4(d)) are applicable to claims for medical
benefits filed under this section.
(e) No determination made with respect to a claim filed under this
section shall affect any determination previously made by the Social
Security Administration. The Social Security Administration may,
however, reopen a previously approved claim if the conditions set forth
in Sec. 410.672(c) of this chapter are present. These conditions are
generally limited to fraud or concealment.
(f) If medical benefits are awarded under this section, such
benefits shall be payable by a responsible coal mine operator (see
subpart G of this part), if the miner's last employment occurred on or
after January 1, 1970, and in all other cases by the fund. An operator
which may be required to provide medical treatment benefits to a miner
under this section shall have the right to participate in the
adjudication of the claim as is otherwise provided in this part.
(g) Any miner whose coal mine employment terminated after January
1, 1970, may be required to submit to a medical examination requested
by an identified operator. The unreasonable refusal to submit to such
an examination shall have the same consequences as are provided under
Sec. 725.414.
(h) If a miner is determined eligible for medical benefits in
accordance with this section, such benefits shall be provided from the
date of filing, except that such benefits may also include payments for
any unreimbursed medical treatment costs incurred personally by such
miner during the period from January 1, 1974, to the date of filing
which are attributable to medical care required as a result of the
miner's total disability due to pneumoconiosis. No reimbursement for
health insurance premiums, taxes attributable to any public health
insurance coverage, or other deduction or payments made for the purpose
of securing third party liability for medical care costs is authorized
by this section. If a miner seeks reimbursement for medical care costs
personally incurred before the filing of a claim under this section,
the district director shall require documented proof of the nature of
the medical service provided, the identity of the medical provider, the
cost of the service, and the fact that the cost was paid by the miner,
before reimbursement for such cost may be awarded.
