8 CSR 50-2.010 - Procedures for Non-con-tested and Contested Workers' Compensation 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 self-administered 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 8 CSR 20-3.030.
(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 widow-death experience factors, shall be used in cases
of death benefits payable only to the surviving spouse.
Notes
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