Rev: 3.41.

0
CASE NUMBER

T2202400318
DATE RECEIVED

STATE OF HAWAII 01/05/2024

DEPARTMENT OF LABOR & INDUSTRIAL RELATIONS EMPLOYER
DISABILITY COMPENSATION DIVISION
Hanh Nguyen
 NEW TDI-46 DENIAL OF CLAIM FOR DISABILITY BENEFITS FIRST DATE OF

 AMEND DISABILITY CLAIMED

11/07/2023
This decision may be appealed by completing this Section and filling with the Director of Labor and Industrial Relations (DLIR) WITHIN 20 days

after the denial decision has been sent.

Instructions to Claimant

1. Give SPECIFIC reasons for appealing for each item of the denial.

2. Attach any medical evidence and/or employment records that will support your appeal.

3. File the Claimant’s Appeal WITHIN 20 DAYS of the date the denial was sent via the DLIR case portal of Mail to:

Disability Compensation Division

PO Box 3769

Honolulu, Hawaii 96812-3769

It is the policy of the DLIR that no person shall on the basis of race, color, sex, marital status, religion, creed, ethnic origin, national

origin, age, disability, ancestry, arrest/court record, sexual orientation and National Guard participation be subjected to discrimination,

excluded from participation, or denied the benefits of the department's services, programs, activities, or employment.

NOTICE TO CLAIMANT - SECTION 1

**If you do not agree with this denial of your claim, you must file an appeal WITHIN 20 DAYS from the date of the receipt of
this notice by you. Use Claimant’s Appeal section of this form to file your appeal.

CLAIMANT - SECTION 2
CLAIMANT LAST NAME CLAIMANT FIRST NAME CLAIMANT M.I. CLAIMANT SUFFIX IDENTIFICATION TYPE

Maildsa Gwyhneth DSD suf  SSN PASSPORT

IDENTIFICATION NUMBER

*****1412
ADDRESS PHONE NUMBER CITY STATE ZIP CODE

445 Paster (077) 270-7468 Honolulu CA 90004

EMAIL ADDRESS FIRST DATE OF DISABILITY CLAIMED DATE CLAIM FILED

cong_dang@datahouse.com 11/07/2023 11/15/2023

DATE NOTICE SENT TO DLIR DATE NOTICE SENT TO CLAIMANT CLAIM OR FILE NUMBER

11/20/2023 11/29/2023 Claim or File Number

DENIAL REASONS - SECTION 3
You are hereby notified that your claim for Disability Benefits is denied under the provision of the Hawaii Temporary

Disability Insurance Law for reason(s) checked below. (Please check EACH item on which claim is being denied below.)

1. You do not meet the eligibility requirements. You must work at least 20 hours each week for 14 weeks during the 52

weeks immediately preceding the first day of disability; and have earnings of at least $400. Employment must have

been with covered Hawaii employers.

2. You did not perform regular service for the employer within the two weeks before the start of your disability

period.

3. You were not disabled beyond the 7 consecutive-day waiting period. (Statutory benefits commence on the 8th day of

disability.)

4. You have received 26 weeks of benefits, the maximum payable during a benefit year

from 11/07/2023 to 11/07/2023.
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 Case Number: T2202400318
Rev: 3.41.0
 5. Your claim was filed on 11/07/2023 which was more than 90 days after the start of your disability. No

benefits shall be paid unless proof of disability is furnished within 26 weeks after the start of the disability. If

good cause can be shown for filing after 90 days but within 26 weeks of the start of the disability, some benefits

may be payable.

○ No benefits are payable.

◉ Payments will start 14 days before the date the claim was filed.

6. You have indicated that you are claiming benefits under the Workers’ Compensation Law of this State or any other

state.

 7. Medical records indicate you were able to perform regular work on 11/07/2023. Payment of benefits is denied

after 11/07/2023

8. The medical certification does not establish that you were unable to perform your regular work due to a

disability.

9. You were not under the care of a physician, dentist, chiropractor, osteopath, naturopath, APRN, physician

assistant, or equivalent during the period from 11/07/2023 to 11/07/2023

○ No benefits are payable.

◉ Payments will start on 11/07/2023

10. You are entitled to benefits under your union contract.


11. We are not the insurance carrier for the employer listed on Section 4.

◉ Your claim has been forwarded to 654654
○ Your claim is returned. For correct Insurance carrier, call (808) 586-9188.
12. Other reasons for denial

automation testing

EMPLOYER - SECTION 4
DEPARTMENT OF LABOR NUMBER EMPLOYER NAME

534-543-5435 Hanh Nguyen

ADDRESS CITY STATE ZIP CODE

554 Frankfurt LA CA 90004

INSURANCE CARRIER - SECTION 5
INSURANCE CARRIER NAME CLAIMS ADJUSTING SERVICE NAME, IF APPLICABLE CARRIER ID

Insurance Hanh Adjuster SIT check 1334

ADJUSTING SERVICE ADDRESS (OR INSURANCE CARRIER ADDRESS IF NO ADJUSTING SERVICE) CITY
STATE MA ZIP CODE

Hawaii Honolulu 96728

POINT OF CONTACT NAME PHONE NUMBER EMAIL ADDRESS

Diem Hanh (077) 270-7468 diemhanh_nguyen@d

atahouse.com
AUTHORIZED REPRESENTATIVE – SECTION 6

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 Case Number: T2202400318
Rev: 3.41.0
NAME OF REPRESENTATIVE AUTHORIZED TO ISSUE DENIAL OF CLAIM TITLE

Mautye Carrier testing

SIGNATURE - SECTION 7
I declare under penalty of law that all the information provided herein is true and correct to the best of my knowledge and belief.

SIGNATURE EMAIL ADDRESS DATE

NGUYEN FAKE TEST ANGELA PHUONG TRINH lien_nguyen+2adjuster@datah 01/05/2024
TEST ouse.com
CLAIMANT’S APPEAL – SECTION 8
MY CLAIM FOR DISABILITY BENEFITS HAS BEEN DENIED AND I HEREBY APPEAL SUCH DENIAL, FOR THE FOLLOWING REASON(S): (ANSWER ONLY WITH RESPECT TO
ITEMS OF DENIAL CHECKED ON THIS FORM)
* My claim for Disability Benefits has been denied and I hereby appeal such denial,
for the following reason(s): (Answer only with respect to items of denial checked
on this form)
CLAIMANT LAST NAME CLAIMANT FIRST NAME CLAIMANT M.I. CLAIMANT SUFFIX

DO NOT USE AUTOMATION HHH HNH

DATE NOTICE OF DENIAL OF CLAIM FOR DISABILITY BENEFITS RECEIVED BY CLAIMANT CLAIMANT’S EMAIL ADDRESS
01/22/2024
CLAIMANT’S SIGNATURE – SECTION 9
I declare under penalty of law that all the information provided herein is true and correct to the best of my knowledge and belief.

SIGNATURE DATE
LMA FIRST LMA LAST 01/05/2024

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