Procedures for Non-contested and Contested Workers’ Compensation Cases

PURPOSE: This rule sets forth the procedures relating to workers’ compensation injuries in noncontested and contested cases. (1) Any injury which requires medical aid, other than immediate first aid with no lost time from the employment, shall be fully reported to the division, by the insurer or third-party administrator, as a Report of Injury (in accordance with section 287.380.1, RSMo). The employer, if selfadministered and self-insured, shall submit the Report of Injury. The Report of Injury may also be filed electronically with the approval of the division. (A) Employers shall report injuries, other than immediate first aid with no lost time from the employment, to their insurance carrier, or third-party administrator, if applicable, within five (5) days of the date of the injury or within five (5) days of the date on which the injury was reported to the employer by the employee, whichever is later. (B) Where the division has not received a Report of Injury and receives other notice of a work-related injury, the case may be referred for a dispute management meeting under section (4) of this rule. When a Claim for Compensation is filed, a party may not request a dispute management meeting. (2) A report of medical costs and temporary benefits paid pursuant to sections 287.170 and 287.180, RSMo, shall be filed within thirty (30) days of the date of original notification of the injury. If medical treatment or temporary benefits will continue past thirty (30) days, a status report including estimated dates of completion of medical treatment and temporary benefits, shall be provided to the division at that time. A final report shall be filed on conclusion or termination of medical treatment and temporary benefits. A final medical report shall be filed with the final report. (3) The employer/insurer shall notify the employee of the termination of benefits pursuant to section 287.203, RSMo, within ten (10) days of when such benefits were due, and shall provide the division with a copy of the notice. (4) Any party may request a dispute management meeting with a mediator on issues of medical or temporary benefits. Any such meeting is voluntary and will be conducted according to section 435.104, RSMo 1994. Any agreement regarding medical or temporary benefits shall be reduced to writing and signed by the parties. Any such agreement is to memorialize the understanding of the parties and is not binding as settlement of the benefits or rights of the employee. Venue for a dispute management meeting shall be in Jefferson City, or as may be determined by the division. When a Claim for Compensation is filed, a party may not request a dispute management meeting. (5) Unless the parties otherwise agree, all hearings shall be held in the county, or in a city not part of any county, where the accident occurred, or in any county, or such city adjacent thereto, or if the accident occurred outside of the state, then the hearing shall be held in the county or city where the contract of employment was made. (6) Any party, subject to the written procedures of the local adjudication office, may request a conference in any case filed with the division pursuant to section (1) of this rule. The division may also set a case for a conference. The parties shall be notified of the time and place of the setting at least ten (10) days prior to the setting. (7) The employee or the employee’s dependents may file a Claim for Compensation. In order that the place of setting may be determined, the county in which the accident occurred must be stated on the claim, and if the injury occurred outside of the state of Missouri, the name of the county in which the contract of employment was made must be stated. The claim shall be filed with sufficient copies for the division and each employer and insurer named, and the attorney general in case of a Second Injury Fund claim. The claim must be filed within the time prescribed by sections 287.430 or 287.440, RSMo, for accidental injuries, or section 287.063.3, RSMo, for occupational disease. A claim against the Second Injury Fund must be asserted affirmatively by the claimant and cannot be made by any other party to the claim, on motion or otherwise. Naming the state treasurer as a party is not, in itself, sufficient to make a claim against the fund. Injuries which are claimed to create fund liability must be specifically set forth in the Claim for Compensation. (A) The filing of a claim initiates a contested case. (B) A claim against an employer/insurer and the Second Injury Fund are against two (2) separate parties and the assertion of a claim against one is not an assertion of a claim against the other. (8) Upon receipt of a Claim for Compensation, the division shall forward a copy of the claim to the employer and its insurer, or third-party administrator, if applicable, or Second Injury Fund, if applicable, and within thirty (30) days from the date of the division’s acknowledgment of the claim, the employer or its insurer, or third-party administrator, if applicable, or the Second Injury Fund, if applicable, shall file an Answer to Claim for Compensation, with sufficient copies for the division, the claimant(s) and each of his/her attorneys. (A) Extensions of time to file an Answer to Claim for Compensation will be granted only upon a showing of good cause. Applications for an extension of time to answer the claim shall be made to the chief administrative law judge of the local office with venue of the case. (B) Unless the Answer to Claim for Compensation is filed within thirty (30) days from the date the division acknowledges receipt of the claim or any extension previously granted, the statements of fact in the Claim for Compensation shall be deemed admitted for any further proceedings. (9) When an Answer to Claim for Compensation has been filed, or the time to answer, including any extensions, has run, any party may request a setting according to the written procedures of the local adjudication office. The division may also set a contested case for a prehearing. At the prehearing conference, a contested case may be reset for a prehearing conference, or set for a mediation or a hearing according to the written procedures of the local adjudication office. (A) The local adjudication offices may, by written local procedures, require a mediation setting before a hearing will be set in a contested case. This mediation shall not be construed as the dispute management meeting held pursuant to section (4) of this rule. (B) Any mediation in a contested case shall be conducted according to 8 CSR 50-2.050. (C) The parties shall be notified of the date, time and place of any setting at least ten (10) days prior to the setting. (D) Attendance at any setting is mandatory. Continuance of a case may be allowed for a prehearing conference at the discretion of the administrative law judge or legal advisor. A continuance from a mediation or hearing setting, or a dismissal docket, if established by written procedures for a local adjudication office, shall be allowed only for good cause shown. (10) When any party estimates that the hearing of a case will last longer than four (4) hours, the division shall be notified prior to setting the case for hearing and given an estimate of the length of time that will be required for the hearing. The division shall schedule the hearing according to written procedures of local adjudicative offices. (11) All parties shall be prepared to introduce all relevant evidence when the case is heard. Continuances to file additional evidence will only be granted for good cause shown, when the administrative law judge who conducted the hearing decides that the additional evidence is necessary for a full and complete hearing. (12) A Claim for Compensation may be dismissed or a default award issued, upon proper notice by the division. (A) A Claim for Compensation may be voluntarily dismissed with or without prejudice at any time prior to the introduction of evidence at a hearing. The claim for compensation may be refiled by claimant so long as the statute of limitations has not run. (B) A default award may be entered against an employer/insurer, upon proper notice, for failure to appear or defend the claim. (C) Notice to the party or parties shall be sent by certified mail according to the provisions of Chapter 287, RSMo. Notice of hearing or dismissal to a party’s attorney, at the attorney’s last known address, which shall be sent by ordinary mail and need not be certified, shall meet the requirement of this section. All other notices, unless required by this rule or determined by the division, shall be sent by ordinary mail. The records of the division shall constitute prima facie evidence of the date of mailing of any notice, determination, award or other paper mailed pursuant to Chapter 287, RSMo. (13) A party may request that a case be set for hearing on the grounds of undue hardship or pursuant to section 287.203, RSMo. The party making the request shall file a written copy of the request with the division and mail copies to all parties to the contested case. If the request for a hardship hearing is granted, it shall be set according to the written procedures of the local adjudication office which has venue over the contested case. The division will not set a hearing under this section unless a request is filed by a party. (14) Hearings before the division shall be simple, informal proceedings. The rules of evidence for civil cases in the state of Missouri shall apply. Prior to hearing, the parties shall stipulate uncontested facts and present evidence only on contested issues. (A) The administrative law judge shall have the power to exclude witnesses from the hearing room or close a hearing in the interest of a fair and impartial hearing. (B) When the final award is rendered by the administrative law judge, the division will retain all exhibits offered or placed in evidence for three (3) months, except as required for review of the decision pursuant to section (16) of this rule. The parties shall be notified at the time of the award. After that time, or three (3) months after final review, exhibits not claimed by the parties and that are otherwise preserved by the division will be destroyed. This provision shall not apply to cases in which permanent total, future medical, or dependent death benefits are awarded. (C) On the request of any party and on order of the administrative law judge, a brief may be submitted, which must be filed within the time set by the administrative law judge, which in no event shall be later than thirty (30) days after the submission of the case. The parties shall have equal time to prepare briefs, unless otherwise agreed by the judge and the parties. (D) Within sixty (60) days after the submission of the case or the filing of briefs, whichever is later, the administrative law judge shall issue the award, together with a statement of findings of fact, but in no event longer than ninety (90) days from the last date of the hearing rulings of law and any other matters pertinent to the questions at issue. Signed copies of the award shall be sent to all parties by certified mail. (15) If the services of an attorney are found to be necessary in proceedings for compensation, the administrative law judge shall set a reasonable fee considering relevant factors which may include, but are not limited to, the nature, character and amount of services rendered, the amount in dispute, and the complexity of the case and may allow a lien on the compensation due to the claimant. (16) A request for review of an award must be postmarked within twenty (20) days of the date of the award. The form of application for review and filing for review and practice before the Labor and Industrial Relations Commission is governed by the provisions of (17) When request for a lump sum payment is made on behalf of a minor, commutation of compensation will not be ordered until there is filed with the division a certified copy of the order of the probate division of the circuit court for the county where the dependent resides, naming a legal guardian or conservator of the minor dependent, unless payment can be made to the parent or other person as natural guardian or conservator of the dependent. (18) Statutory prerequisites for approval of a compromise settlement are set forth in sections 287.390 and 287.616, RSMo. (A) The compromise settlement agreement shall set forth the workers’ compensation issues compromised, the total amount of medical costs incurred and previously paid, the total amount of medical costs paid under the agreement, the total amount of temporary benefits previously paid, the total amount of temporary benefits paid under the agreement, the total amount of any permanency benefits previously paid, the total amount of permanency benefits paid under the agreement, the total amount of all benefits paid under the agreement, the total amount or the percentage of the employee’s attorney’s fees and expenses, and the total compensation paid in the case. A provision which prorates the amount of settlement over the life expectancy of the injured employee may be included. (B) Before a compromise settlement will be approved, the employee must appear before the division and be advised of his or her rights under Chapter 287, RSMo, except as provided in subsection (D) of this section. (C) A compromise settlement will be approved pursuant to sections 287.390 and 287.616, RSMo, unless in the opinion of the administrative law judge or legal advisor the settlement is not in accordance with the rights of the parties. (D) If the employee does not live in the state of Missouri, has been inducted into the armed forces of the United States, has previously appeared before the division and been advised of his or her rights under Chapter 287, RSMo, is represented by an attorney, or shows other extenuating circumstances, the compromise settlement may be submitted without the appearance of the employee or dependent. Upon agreement of the parties, the conference may be held by telephone. A representative of the employer/insurer is responsible for scheduling a telephone conference subject to the availability of an administrative law judge or legal advisor. Where the employee is not represented by counsel and does not appear at the time of approval of settlement, his or her signature shall be acknowledged by a notary public. Any compromise settlement submitted pursuant to this subsection shall be approved according to the provision of this section of the rule and sections 287.390 and 287.616, RSMo. (E) The employer/insurer shall submit any required forms that have not previously been submitted with the compromise settlement before the close of the case. (19) As the basis for arriving at the amount of compensation due for loss of teeth and resultant disfigurement provided for in section 287.190, RSMo, 8 CSR 50-5.010 Compensation for Loss of Teeth shall be used. (20) As the basis for arriving at the amount of compensation due for visual loss provided for in section 287.190, RSMo, 8 CSR 50-5.020 Evaluation of Visual Disabilities shall be used. (21) As the basis for arriving at the amount of compensation due for hearing impairment provided for in sections 287.190 and 287.197, RSMo, 8 CSR 50-5.060 Evaluation of Hearing Loss shall be used. (22) As the basis for arriving at commutation amounts authorized by section 287.530.1, RSMo, 8 CSR 50-5.030 Present Worth Table shall be used for permanent partial and death benefits payable to those employees or dependents, except where death benefits are payable only to the surviving spouse. (23) As the basis for arriving at commutation amounts authorized by section 287.530.1, 8 CSR 50-5.030 Present Value Table for Widows, which contains remarriage and widowdeath experience factors, shall be used in cases of death benefits payable only to the surviving spouse. AUTHORITY: section 287.650, RSMo Supp. 1997.* Original rule filed Dec. 23, 1953, effective Jan. 3, 1954. Amended: Filed Jan. 15, 1960, effective Jan. 26, 1960. Amended: Filed Sept. 4, 1963, effective Sept. 15, 1963. Amended: Filed Aug. 26, 1975, effective Sept. 5, 1975. Amended: Filed Jan. 26, 1977, effective June 11, 1977. Amended: Filed Dec. 14, 1977, effective April 13, 1978. Emergency amendment filed Jan. 16, 1996, effective Jan. 26, 1996, expired July 23, 1996. Amended: Filed Feb. 15, 1996, effective Aug. 30, 1996. Rescinded and readopted: Filed May 29, 1998, effective Feb. 28, 1999. *Original authority: 287.650, RSMo 1939, amended 1949, 1961, 1980, 1993, 1995. State ex rel River Cement Co. v. Pepple 585 SW2d 122 (Mo. App. 1979). In workers’ compensation case, the right to inspect inheres in the powers authorized by section 287.560, RSMo, since without this right claimant’s ability to prove his/her case would be greatly diminished. Hendricks v. Motor Freight Corp. 570 SW2d 702 (Mo. App. 1978). Injured truck driver filed a claim for compensation incorrectly giving the date of accident as June 12, 1972. Since appellant’s employer and insurer failed to file an answer to the claim in the time permitted under 8 CSR 50-2.010(13), the fact of the accident was taken as admitted. Liechty v. Kansas City Bridge Company 155 SW2d 297, affirmed 162 SW2d 275 (1942). The Missouri Workers’ Compensation Commission is a ministerial and administrative body, with incidental quasi-judicial powers, exercised by the consent of those elected to be governed by the act, and is not vested with powers or duties in violation of constitutional limitations. The commission cannot usurp judicial functions contrary to the constitutional inhibition; however it has those powers which are incidental and necessary to the proper discharge of its duties in administering the Workers’ Compensation Act.