Black Lung Benefits Claims Process
The Black Lung benefits claims process can be confusing. There are many steps involved and each of them takes time, so it can be years before a miner or his widow receives benefits. There are state claims and federal claims. Stone Mountain assists miners with federal claims and refers miners and their families to attorneys for the state process. Below is a brief description of the federal claims process. Stone Mountain Benefits Counselors assist people through the process of submitting claims and then, if the miner chooses, our Layperson Legal Representatives can help with the hearing process. Miners’ widows also are eligible to file claims but the process is different for them so we suggest that widows contact our office directly.
1. Miner calls for an appointment
2. We mail paperwork, which the miner completes and brings in or we help to complete the paperwork
3. When the miner comes in for the appointment, the paperwork is reviewed and insurance information is recorded – if the miner does not have insurance then our sliding scale option is explained
4. After paperwork is done, the miner sees one of the Respiratory Therapists
a. Vital signs are taken
b. Medical history is reviewed
c. Pulmonary Function Test (PFT) is completed
i. If the PFT indicates that the miner may have some breathing problems that may be because of their work as a miner, the miner is referred for a chest x-ray
ii. If the PFT does not show breathing problems, the Respiratory Therapist explains the progressive nature of Black Lung Disease and schedules the miner to come back in one year for a check-up to see if the person’s breathing is worse
iii. Test results are sent to the miner’s primary care provider
5. As noted above, if the PFT shows breathing problems, the miner is referred for a chest x-ray, and the miner sends a disk of the x-ray image to us along with a check or money order so that an expert can review the x-ray to determine if the miner may have Black Lung Disease.
6. We send the disk and check or money order to the “B-reader” who may take 4-6 weeks to review the x-ray and send us a report.
7. If the B-reader’s report says that the miner may have Black Lung Disease, the miner is sent an application packet and is scheduled to meet with a Benefits Counselor.
8. The Benefits Counselor reviews the paperwork and explains the process to the miner. The miner selects a physician to perform a Department of Labor examination.
9. The miner is examined by a DOL physician and completes related testing. The physician has 120 days to complete the report.
10. The Benefits Counselor works with the miner to complete the Schedule for Submission of Additional Evidence (SSAE).
a. If the SSAE review determines that the miner would not be eligible for benefits, the Benefits Counselor and miner will review the reports and test results to determine whether to move forward or withdraw the claim and refile within the next year when more medical evidence is available.
b. If the SSAE review indicates that the miner would be entitled to benefits, the miner and Benefits Counselor begin collecting more information and submitting evidence.
11. The Department of Labor issues a Proposed Decision Order (PDO)
a. If the PDO is a denial, the miner and Benefits Counselor will discuss options and determine if a request for modification is possible. If a modification is filed, it can be granted or denied
i. If the modification is denied, the miner can refile within a year
ii. If the modification is granted, new medical evidence must be submitted and then a hearing with the Administrative Law Judge is scheduled
b. If the PDO is for an award, the miner and Benefits Counselor will collect evidence and schedule a hearing before an Administrative Law Judge (ALJ)
i. The ALJ may decide on an award, which may either be accepted or appealed by the coal company’s insurance carrier.
1. If it is accepted, then the miner will begin receiving benefits in the future as well as back benefits from when the claim was filed.
2. If it is appealed, the insurance company must show that an error was made.
ii. The ALJ may deny the claim, in which case the miner can accept the denial or appeal to the Benefits Review Board (BRB).
1. The BRB can either “vacate” (overturn) or “affirm” (approve) the ALJ decision.