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A. Purpose: The purpose of this section is to provide a fair and efficient method for determining the eligibility of a full-time employee for the benefits enumerated under PSEBA through an administrative process, including if necessary, an administrative hearing.
B. Definitions: For the purpose of this section, the following terms will have the following meanings. These definitions are derived from the Federal Public Health and Welfare Act, 42 USC section 3796b, which was enacted in 1944 and amended in 1984 to define, by inclusion or reference, the following terms:
CATASTROPHIC INJURY: An injury, the direct and proximate consequences of which permanently prevent an individual from performing any gainful work.
GAINFUL WORK: Full- or part-time activity that actually is compensated or commonly is compensated.
INJURY: A traumatic physical wound (or a traumatized physical condition of the body) directly and proximately caused by external force (such as bullets, explosives, sharp instruments, blunt objects, or physical blows), chemicals, electricity, climatic conditions, infectious disease, radiation, virii, or bacteria, but does not include:
1. Any occupational disease; or
2. Any condition of the body caused or occasioned by stress or strain.
For use in this section, provisions containing the words "Mayor", "Commissioner", "Alderman" or "Village Council" also apply to the President, Trustee, Councilmember and Boards of Trustees so far as the provisions are applicable to them.
C. Application Procedure:
1. As noted by the Court in Englum, "while the [Act] contained substantive requirements for section 10 eligibility, the [Act] contained no procedural requirements for determining whether a former employee met the substantive criteria". ¶ 55. This section and the application procedure of this section establishes guidance on the proper procedural requirements for public safety officers seeking PSEBA benefits in the Village.
a. Public safety officers, or family member(s) of an injured or deceased public safety officer, (applicant) must file a full and complete PSEBA application in writing within thirty (30) days of filing a pension claim with the Village or within thirty (30) days of the date of the adoption of this section in the event that an applicant has filed for a pension or PSEBA claim prior to the date of adoption of this section, whichever is later, if the applicant is seeking an initial award of benefits under PSEBA. The Village shall notify applicant if the PSEBA application is incomplete and applicant shall have five (5) days to remedy their application. Failure to timely file the full and complete application shall result in a forfeiture of the benefits under PSEBA by failure to properly submit a complete application.
b. A complete PSEBA application includes the following:
(1) The name of the applicant, date of hire, detailed information regarding the incident, including information relating to how the injury was sustained in the line of duty (date, time, place, nature of injury and other factual circumstances surrounding the incident giving rise to said claim);
(2) The applicant's firsthand knowledge explaining, to the Village's satisfaction, how the injury/death directly resulted from:
(A) Response to fresh pursuit;
(B) Response to what is reasonably believed to be an emergency;
(C) An unlawful act perpetrated by another; or
(D) Participation during the investigation of a criminal act;
(3) A signed PSEBA medical authorization release which authorizes the collection of information related to the incident including, but not limited to, disability pension proceedings, worker's compensation records, and medical records and specifies the name and address for pertinent health care provider(s);
(4) A signed PSEBA general information release specifying the name and signature of the applicant or her/his authorized representative along with legal proof of said representation and name and signature of witness authorizing the collection of information pertinent to the incident review process;
(5) The name(s) of witnesses to the incident;
(6) The name(s) of witnesses the applicant intends to call at the PSEBA hearing;
(7) Information and supporting pension documentation filed with the appropriate Pension Board;
(8) Information supporting the PSEBA eligibility requirements; and
(9) Other sources of health insurance benefits currently enrolled in or received by the applicant and/or family members if the applicant is deceased.
c. The PSEBA application must be submitted to the Village Manager in its entirety.
d. The PSEBA application must be sworn and notarized to certify the truthfulness of the content of the information. A review of the application shall not occur until the application is complete.
e. On the date that the PSEBA application is deemed complete by the Village, the completed application shall then be submitted to the Village as the preliminary record, and a copy of the same shall be date stamped and provided to the applicant.
f. Upon receipt of a complete application for PSEBA benefits, the Village shall set the matter for an administrative hearing before a Hearing Officer to make a determination on whether to grant the applicant PSEBA benefits based on the result of the administrative hearing.
g. The applicant will be given written notice of the date for the scheduled administrative hearing to be served not less than ten (10) days prior to the commencement of the hearing. If the applicant, upon receiving written notice of the administrative hearing, cannot attend said date, the applicant must contact the Hearing Officer in writing within seven (7) days after being served. The Hearing Officer shall establish an alternative hearing date which is within thirty (30) days of the original hearing date. Failure to appear at the administrative hearing shall result in denial of PSEBA benefits.
D. Administrative Composition:
1. The administrative hearing shall be scheduled and conducted by a Hearing Officer whose authority and limitations are as follows:
a. Authority Of The Hearing Officer: The Hearing Officer shall have all of the authorities granted to her/him under common law relative to the conduct of an administrative hearing, including the authority to:
(1) Preside over Village hearings involving PSEBA;
(2) Administer oaths;
(3) Hear testimony and accept evidence that is relevant to the issue of eligibility under PSEBA;
(4) Issue subpoenas to secure attendance of witnesses and the production of relevant papers or documents upon the request of the parties or their representatives;
(5) Rule upon objections in the admissibility of evidence;
(6) Preserve and authenticate the record of the hearing and all exhibits in evidence introduced at the hearing; and
(7) Issue a determination based on the evidence presented at the hearing, the determination of which shall be in writing and shall include a written finding of fact, decision and order.
b. Hearing Officer: The Village President, with the advice and consent of the Village Board, is hereby authorized to appoint a person to hold the position of Hearing Officer for each hearing on PSEBA benefits that shall come before this Village. In making said selection, the following information should be considered, at a minimum:
(1) The individual's ability to comply with the job description as set forth herein; and
(2) The individual must be an attorney licensed to practice law in the State of Illinois and have knowledge of and experience in Employment and Labor Law, general civil procedure, the Rules of Evidence and administrative practice.
E. Administrative Hearing:
1. The system of administrative hearings for the determination of eligibility for benefits under PSEBA shall be initiated either by the Village or by the applicant after the submission of a full and complete PSEBA application. An administrative hearing shall be held to adjudicate and determine whether the applicant is eligible for benefits under PSEBA. If the applicant is found eligible, the benefits shall be consistent with the Act.
a. Record: The Village shall ensure that all hearings are attended by a certified court reporter and a transcript of all proceedings shall be made by said certified court reporter and a copy be provided to the applicant within twenty eight (28) days of the date of the administrative hearing.
b. Procedures: The Village and the applicant shall be entitled to representation by counsel at said administrative hearing and present witnesses, testimony and documents, may cross- examine opposing witnesses, and may request the issuance of subpoenas to compel the appearance of relevant witnesses or the production of relevant documents.
c. Evidence: The Illinois Rules of Evidence shall apply to the extent practicable unless, by such application, the Hearing Officer determines that application of the rule would be an injustice or preclude the introduction of evidence of the type commonly relied upon by a reasonably prudent person in the conduct of her or his affairs. Such determination shall be in the sole discretion of the Hearing Officer. The Hearing Officer must state on the record her or his reason for that determination.
d. Final Determination: A written determination by the Hearing Officer of whether the petitioning applicant is eligible for the benefits under PSEBA shall constitute a final administrative determination for the purpose of judicial review under the common law writ of certiorari.
e. Burden Of Proof: At any administrative hearing, the applicant shall have the obligation and burden of proof to establish that the applicant is eligible and qualified to receive PSEBA benefits. The standard of proof in all hearings conducted under this section shall be by the preponderance of the evidence.
f. Administrative Records: All records pertaining to the administrative process shall be held in a separate file under the applicant's name with the Village.
F. Health Insurance Benefits:
1. Upon qualification for PSEBA benefits, the applicant shall be entitled to the Village's basic group health insurance plan. Basic group health insurance plan shall mean the lowest- cost plan available to the Village. The basic group health insurance plan may change from time to time. An applicant may choose to enroll in any other health insurance plan offered by the Village different from the basic group health insurance plan, but shall pay the difference in insurance premium between the Village's basic plan and the other plan. Failure of the PSEBA beneficiary to timely pay the premium's non-basic level coverage shall result in coverage in the basic plan. PSEBA benefits do not include benefits not provided under the Village's basic group health insurance plan such as, but not limited to, disability benefits, life insurance, dental or vision benefits, etc.
a. Open Enrollment: Individuals receiving benefits under PSEBA will only be able to change from one plan to another during the Village's open enrollment period.
b. Other Benefits: Health insurance benefits payable from any other source will reduce the benefits payable from the Village. Each applicant shall sign an affidavit attesting that the applicant is not eligible for insurance benefits from any other source, unless there is another source. If there is another source, the applicant shall notify the Village of that source no later than five (5) business days from that source becoming available to the applicant or the applicant's beneficiaries. The Village reserves the right on an annual basis to have the benefit recipient provide another affidavit affirming whether other health insurance is available or payable to the applicant, his/her spouse and/or his/her qualifying dependent children. The affidavit must be completed and returned to the Village within thirty (30) calendar days of written notice from the Village. If the recipient does not complete and return the affidavit within the time required, the Village shall give the recipient an additional written notice providing an additional fifteen (15) calendar days for the recipient to complete and return the affidavit. Failure to return the affidavit within the time required shall result in the recipient incurring responsibility for reimbursing the Village for premiums paid during the period the affidavit is due and not filed.
c. Disclosure Of Health Insurance Coverage: The applicant has an ongoing obligation and shall update health insurance coverage information provided and failure to do so may result in the denial of benefits and/or reimbursement to the Village for duplicate coverage. If duplicate coverage has been received by a PSEBA beneficiary, further PSEBA benefits will be denied until the Village has been fully reimbursed by the PSEBA beneficiary for what it would have been credited if it had known about other coverage.
d. Reimbursement: Receipt of health insurance benefits from other sources without notice to the Village shall require the applicant to reimburse the Village for the value of those benefits.
e. Medicare Eligibility: The applicant shall notify the Village when the applicant becomes Medicare eligible regardless of the status of the enrollment period, so the Village may assist with the transition to Medicare coverage and/or adjust health insurance benefits or PSEBA benefits accordingly.
G. Conflict Of Laws: Where the conditions imposed by any provisions of this section are more restrictive than comparable provisions imposed elsewhere in any other local law, ordinance, resolution, rule or regulation, the regulations of this section will govern. (Ord. 2019-03-06, 3-21-2019)