§ 12-109 Claims Administrator duties.
A. The Administrator shall act on behalf of the casino in receiving, processing, and administering claims, including the payment of benefits, under this chapter. The Administrator’s responsibility to make determinations and decisions on the casino’s behalf shall include, without limitation, the following duties:
1. Conduct a thorough investigation of each claim filed, and complete initial contacts with all relevant parties within seventy-two (72) hours of receipt of the claim.
2. Until such time as a claim is accepted or rejected, pay up to ten thousand dollars ($10,000.00) in medical treatment for claimant’s alleged injury.
3. Determine whether to accept, deny, or further investigate a claim and issue a written decision notifying the claimant of such determination within fourteen (14) days of receipt of the claim. Where the claim is accepted, the Administrator shall establish a reserve to reflect the claim’s anticipated exposure, with a detailed analysis of how the reserve was calculated, including an estimate of the benefits due and the duration and frequency of those benefits. Where the claim is denied, the Administrator shall include the specific basis for denial, and provide information about the claimant’s rights under the dispute resolution process in Section 12-113. Should the Administrator determine, within the specified period, that further investigation is required, the Administrator shall establish a detailed plan of action regarding the purpose of the investigation and what is sought to be discovered and shall make best efforts to complete the investigation expeditiously; and under such circumstances, the Administrator shall make a final written decision outlining its determination regarding the claim within ninety (90) days from the date the claim was filed. The Administrator may extend the time period for rendering a final written decision beyond ninety (90) days when warranted under the circumstances, in the Administrator’s sole discretion.
4. Determine the reasonableness and necessity of medical care and charges and shall determine whether and to what extent compensation is due under this chapter. The Administrator shall promptly approve or disapprove any referrals, procedures, surgeries, or other medical requests made by assigned medical providers. Disapproval of such requests shall be based on sufficient justification, including but not limited to medical evidence to the contrary, peer review, utilization review, surveillance video, and similar considerations.
5. Determine the eligibility and compensation rate payable for temporary total disability, temporary partial disability, permanent partial impairment, permanent total impairment, vocational rehabilitation, and/or death benefits. In the case of death benefits, the Administrator shall determine the eligibility of dependents and the terms of any benefits payable. In the event of a need to allocate dependency benefits between dependents living in different households, the Administrator shall make the necessary allocation, based on the obligations, legal or otherwise, of the deceased employee.
6. In accordance with the Administrator’s agreement with the casino, assist the casino in pursuing any cause of action for, or defending any cause of action or claim against, the casino under this chapter.
B. The failure or alleged failure of the Administrator to perform any of the duties or responsibilities outlined above will not, as a matter of law or operation, create any cause of action for any third party, nor will the right to benefits or recovery of any employee and/or claimant be expanded or presumed in such an event. The Administrator, as an official of the casino, is entitled to the Tribe’s sovereign immunity from suit in state or federal courts or administrative agencies for its actions undertaken pursuant to this chapter. (Res. 2023-04 (Exh. A); Res. 2022-44 (Exh. A))