West Virginia Code of State Rules Agency 197 - Traumatic Brain And Spinal Cord Injury Rehabilitation Fund
1. Overview of Agency 197
Agency 197 is the West Virginia legislative rule that governs the Traumatic Brain and Spinal Cord Injury Rehabilitation Fund (“the Fund”). Its main purpose is to provide financial support and rehabilitation services to West Virginians who have suffered a traumatic brain injury (TBI) or spinal cord injury (SCI). The goal is to help these individuals achieve greater independence and improve quality of life.
The Fund is administered by the Secretary of the Department of Human Services (formerly the Department of Health and Human Resources).
2. Statutory Foundation
The Fund is authorized under Chapter 9, Article 10 of the West Virginia Code. Key provisions include:
a. Definitions (W.Va. Code §9‑10‑1)
Traumatic Brain Injury (TBI): An acquired injury to the brain caused by external force, excluding congenital or degenerative disorders.
Spinal Cord Injury (SCI): A traumatic injury resulting in partial or total loss of sensation or voluntary movement below the site of injury.
Secretary: The Secretary of the Department of Human Services, responsible for administering the Fund.
b. Fund Administration (W.Va. Code §9‑10‑3)
The Fund is supported by legislative appropriations and may accept gifts, grants, and contributions.
Funds are used only for rehabilitation services consistent with statutory priorities.
Services include case management, therapy, home modifications, assistive equipment, and family support.
The Fund operates as a payer of last resort, meaning it only covers costs not paid by insurance or other sources.
c. Rulemaking Authority (W.Va. Code §9‑10‑5)
The Secretary is authorized to promulgate rules necessary to carry out the Fund’s purpose, including eligibility criteria, funding priorities, and appeal procedures. These rules are codified as Agency 197.
3. Structure of Agency 197
Agency 197 is divided into two main parts:
Series 197‑01: Fund Rules
Purpose: Explains the Fund’s objectives and the types of services covered.
Eligibility: Individuals must demonstrate TBI or SCI and meet other program criteria.
Payer of Last Resort: The applicant must show that other funding sources (like insurance or other programs) have been exhausted.
Appeals: If an application is denied, the applicant may appeal in writing within 30 days. An appeals panel reviews the case and issues a written decision. This decision can then be appealed to the circuit court.
Series 197‑02: Procedural Rules (Fund Board)
Status: The Fund Board was abolished, and responsibilities transferred to the Secretary.
Procedures: Formerly, the rules governed meetings, conflict of interest avoidance, and public accessibility of meetings. Some procedural elements remain relevant for administrative hearings.
4. Administrative Process
If a person is denied benefits:
Initial Appeal: File a written appeal with the Fund within 30 days of the denial.
Appeals Panel Hearing: The panel considers evidence, may hold a hearing, and issues a written decision.
Judicial Review: If the applicant disagrees with the panel’s decision, they can appeal to the West Virginia Circuit Court, which reviews whether the administrative decision was lawful, supported by substantial evidence, and not arbitrary or capricious.
This process follows West Virginia’s Administrative Procedure Act standards.
5. Case Law Context
While no published appellate decisions directly interpret Agency 197, related case law helps understand how disputes with state agencies are handled:
a. Buckhannon Board & Care Home, Inc. v. West Virginia Department of Health and Human Resources, 532 U.S. 598 (2001)
Not specific to Agency 197, but relevant to agency litigation.
The Supreme Court held that a “prevailing party” must receive a judgment on the merits or court-ordered consent decree to recover attorney’s fees.
In practice, if someone challenges a Fund decision in court, this principle limits when attorneys’ fees may be awarded.
b. Administrative Review Standard
West Virginia courts generally review administrative decisions to ensure they are supported by substantial evidence, in accordance with law, and not arbitrary or capricious.
Any appeal of an Agency 197 decision would follow this standard.
6. Key Takeaways
Agency 197 provides structured rules for administering the Traumatic Brain and Spinal Cord Injury Rehabilitation Fund.
It ensures the Fund is a payer of last resort and defines eligibility, services, and appeals procedures.
Applicants have rights to administrative hearings and judicial review if denied benefits.
Case law mainly supports procedural protections and judicial standards for reviewing agency decisions, even though no court has specifically interpreted Agency 197.
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