Last week we reviewed a few basics of the Workers’ Compensation claims process. This week we take a deeper dive into some of the processes surrounding hearings and appeals after a claim has been filed.
Once filed, claims enter what is known as a 15-day conciliation period. This is a period of time where a person known as a conciliator is appointed to encourage the parties to settle the dispute through informal negotiations. If an agreement cannot be reached, the unresolved claim will be referred to a formal review process, unless:
- The party who brought the claim fails to appear before the conciliator or fails to provide any information requested
- The conciliator authorizes an extension of the conciliation period
- The parties agree to submit their claim to arbitration proceedings
As long as liability is not an issue, the conciliator will wait for written notice from each party and then refer the claim for additional compensation, discontinuing or modifying compensation to the Department of Insurance Adjusters (DIA). After a claim is referred to the DIA, the parties will be required to participate in a pre-hearing conference (an informal proceeding held before an administrative judge). During the pre-hearing conference, the parties may be required to present reports of injury, signed employee and witness statements, medical hospital and rehabilitation records and any other evidence that supports their case.
Insurers (including self-insured employers) will be required to pay a fee equal to 65 percent of the state average weekly wage (SAWW) for each claim that is referred to the DIA. The fee increases to 130 percent of the SAWW if the insurer fails to appear at a scheduled conciliation session
Conciliators may impose a time limit for the parties to submit their offers and may assign a default offer for any party that fails to comply within the time limit.
- The default offer for an employee is the last best offer he or she made or the maximum compensation rate allowed by the state.
- The default offer for an employer is its last best offer made or zero.
The DIA will issue a written order within seven days of the conference, requiring or denying the payment, modification or termination of benefits. Any party adversely affected by the DIA’s order may appeal the order within 14 days of when the order is issued and must take place within 28 days of when the appeal is filed. The DIA’s order becomes final if no appeal is filed within 14 days.