Utah Admin. Code R602-2-1 - Adjudicative Process
A. Definitions.
1. "Commission" means the Labor
Commission.
2. "Division" means the
Division of Adjudication within the Labor Commission.
3. "Application for Hearing" means
Adjudication Form 001 Application for Hearing Industrial Accident Claim,
Adjudication Form 026 Application for Hearing Occupational Disease Claim,
Adjudication Form 025 Application for Dependent's Benefits and Burial Benefits
Industrial Accident, Adjudication Form 027 Application for Dependent's Benefits
Occupational Disease, of other request for agency action complying with Section
63G-4-102
et seq. filed by an employer or insurance carrier regarding a workers
compensation claim.
4. "Supporting
medical documentation" means Adjudication Form 113 Summary of Medical Record or
other medical report or treatment note completed by a physician that indicates
the presence or absence of a medical causal connection between benefits sought
and the alleged industrial injury or occupational disease.
5. "Authorization to Release Medical Records"
is Adjudication Form 308 Authorization to Disclose, Release and Use Protected
Health Information authorizing the injured workers' medical providers to
provide medical records and other medical information to the commission or a
party.
6. "Supporting documents"
means supporting medical documentation, Adjudication Form 307 Medical Treatment
Provider List, Adjudication Form 308 Authorization to Disclose, Release and Use
Protected Health Information and, when applicable, Adjudication Form 152
Appointment of Counsel.
7.
"Petitioner" means the person or entity who has filed an Application for
Hearing.
8. "Respondent" means the
person or entity against whom the Application for Hearing was filed.
9. "Discovery motion" includes a motion to
compel or a motion for protective order.
10. "Designated agent" is the agent
authorized to receive all notices and orders in workers' compensation
adjudications pursuant to Section
34A-2-113.
Designated agents shall provide the Adjudication Division an electronic address
to receive delivery of documents from the Adjudication Division.
B. Application for Hearing.
1. Whenever a claim for compensation benefits
is denied by an employer or insurance carrier, the burden rests with the
injured worker, authorized representative of a deceased worker's estate,
dependent of a deceased worker or medical provider, to initiate agency action
by filing an appropriate Application for Hearing with the Division.
Applications for hearing shall include an original, Adjudication Form 308
Authorization to Disclose, Release and Use Protected Health
Information.
2. An employer,
insurance carrier, or any other party with standing under the Workers
Compensation Act may obtain a hearing before the Adjudication Division by
filing a request for agency action with the Division complying with the Section
63G-4-102
et seq.
3. An Application for
Hearing shall include supporting medical documentation of the claim where there
is a dispute over medical issues. Applications for Hearing without supporting
documentation and a properly completed Adjudication Form 308 Authorization to
Disclose, Release and Use Protected Health Information may not be mailed to the
employer or insurance carrier for answer until the appropriate documents have
been provided. In addition to respondent's answer, a respondent may file a
motion to dismiss the Application for Hearing where there is no supporting
medical documentation filed to demonstrate medical causation when such is at
issue between the parties.
4. When
an Application for Hearing with appropriate supporting documentation is filed
with the Division, the Division shall mail to the respondents a copy of the
Application for Hearing, supporting documents and Notice of Formal Adjudication
and Order for Answer.
5. In cases
where the injured worker is represented by an attorney, a completed and signed
Adjudication Form 152 Appointment of Counsel form shall be filed with the
Application for Hearing or upon retention of the attorney.
C. Answer.
1. The respondent shall have 30 days from the
date of mailing the Order for Answer to file a written answer to the
Application for Hearing.
2. The
answer shall admit or deny liability for the claim and shall state the reasons
liability is denied. The answer shall state all affirmative defenses with
sufficient accuracy and detail that the petitioner and the Division may be
fully informed of the nature and substance of the defenses asserted.
3. An answer shall include a summary of
benefits which have been paid to date on the claim, designating such payments
by category, such as medical expenses, temporary total disability, permanent
partial disability.
4. When
liability is denied based upon medical issues, copies of reasonably available,
admissible medical reports sufficient to support the denial of liability shall
be filed with the answer.
5. If the
answer filed by the respondents fails to sufficiently explain the basis of the
denial, fails to include medical reports or records to support the denial, or
contains affirmative defenses without sufficient factual detail to support the
affirmative defense, the Division may strike the answer filed and order the
respondent to file within 20 days a new answer which conforms with the
requirements of this rule.
6. An
answer must state whether the respondent is willing to mediate the
claim.
7. Petitioners are allowed
to timely amend the Application for Hearing, and respondents are allowed to
timely amend the answer, as newly discovered information becomes available that
would warrant the amendment. The parties shall not amend their pleadings later
than 45 days prior to the scheduled hearing without leave of the Administrative
Law Judge.
8. Responses and answers
to amended pleadings shall be filed within ten days of service of the amended
pleading without further order of the Labor Commission.
D. Default.
1. If a respondent fails to file an answer as
provided in Subsection (c), the Division may enter a default against the
respondent.
2. If default is
entered against a respondent, the Division may conduct any further proceedings
necessary to take evidence and determine the issues raised by the Application
for Hearing without the participation of the party in default pursuant to
Subsection
63G-4-209(4).
3. A default of a respondent shall not be
construed to deprive the Employer's Reinsurance Fund or Uninsured Employers'
Fund of any appropriate defenses.
4. The defaulted party may file a motion to
set aside the default under the procedures in Subsection
63G-4-209(3).
The Adjudication Division shall set aside defaults upon written and signed
stipulation of parties to the action.
E. Hearing.
1. Hearings shall take place through an
electronic platform as noticed by the Division. An administrative law judge may
grant permission for an in-person hearing when good cause is shown.
2. Waiver of Hearing
a. The parties may, with the approval of the
administrative law judge, waive their right to a hearing and enter into a
stipulated set of facts, which may be submitted to the administrative law
judge. The administrative law judge may use the stipulated facts, medical
records and evidence in the record to make a final determination of liability
or refer the matter to a Medical Panel for consideration of the medical issues
pursuant to Section
R602-2-2.
b. Stipulated facts shall include sufficient
facts to address the issues raised in the Application for Hearing and
answer.
c. In cases where Medical
Panel review is required, the administrative law judge may forward the evidence
in the record, including medical records, fact stipulations, radiographs and
deposition transcripts, to a medical panel for assistance in resolving the
medical issues.
F. Discovery.
1. Upon filing the answer, the respondent and
the petitioner may commence discovery. Discovery documents may be delivered by
electronic transmittal. Discovery allowed under this rule may include
interrogatories, requests for production of documents, depositions, and medical
examinations. Discovery shall not include requests for admissions. Appropriate
discovery under this rule shall focus on matters relevant to the claims and
defenses at issue in the case. Discovery requests are deemed continuing and
shall be promptly supplemented by the responding party as information becomes
available.
2. Without leave of the
administrative law judge, or written stipulation, any party may serve upon any
other party written interrogatories, not exceeding 25 in number, including
discrete subparts, to be answered by the party served. The frequency or extent
of use of interrogatories, requests for production of documents, medical
examinations or depositions shall be limited by the administrative law judge if
it is determined that:
a. the discovery
sought is unreasonably cumulative or duplicative, or is obtainable from another
source that is more convenient, less burdensome, or less expensive;
b. the party seeking discovery has had ample
opportunity by discovery in the action to obtain the discovery sought;
or
c. the discovery is unduly
burdensome or expensive, taking into account the needs of the case, the amount
in controversy, limitations on the parties' resources, and the importance of
the issues at stake in the adjudication.
3. Upon reasonable notice, the respondent may
require the petitioner to submit to a medical examination by a physician of the
respondent's choice.
a. Petitioner may seek
relief from the medical examination detailed in Subsection (3), and the
administrative law judge may provide such relief, upon the showing by a
petitioner of an unreasonable demand by respondent related to such medical
examination.
b. Respondent shall
send any questionnaire, consent or release forms requested by the examining
physician or insurance carrier to the petitioner at least 14 days prior to the
scheduled medical examination.
c.
After a reasonable attempt between the parties to resolve any issues which may
arise due to the forms in Subsection (b), a petitioner shall file objections to
any questionnaire, consent or release forms requested by the examining
physician or insurance carrier with the administrative law judge at least seven
days prior to the scheduled medical examination.
4. Parties may conduct depositions pursuant
to the Utah Rules of Civil Procedure and Section
34A-1-308.
5. Requests for production of documents are
allowed, but limited to matters relevant to the claims and defenses at issue in
the case, and shall not include requests for documents provided with the
petitioner's Application for Hearing, nor the respondents' answer.
6. Parties shall diligently pursue discovery
so as not to delay the adjudication of the claim. If a hearing has been
scheduled, discovery motions shall be filed no later than 45 days prior to the
hearing unless leave of the administrative law judge is obtained.
7. Discovery motions shall contain copies of
relevant documents pertaining to the discovery at issue, such as mailing
certificates and follow up requests for discovery. The responding party shall
have ten days from the date the discovery motion is mailed to file a response
to the discovery motion.
8. Parties
conducting discovery under this rule shall maintain mailing certificates and
follow up letters regarding discovery to submit in the event Division
intervention is necessary to complete discovery. Discovery documents shall not
be filed with the Division at the time they are forwarded to opposing
parties.
9. Any party who fails to
obey an administrative law judge's discovery order shall be subject to the
sanctions available under the Utah Rules of Civil Procedure, Rule 37.
10. Notwithstanding the disclosures required
under Section R602-2-1, parties shall remain obligated to respond timely and
appropriately to discovery requests.
G. Subpoenas.
1. Commission subpoena forms shall be used in
discovery proceedings to compel the attendance of witnesses. Subpoenas shall be
signed by the administrative law judge assigned to the case, or the duty judge
where the assigned judge is not available. Subpoenas to compel the attendance
of witnesses shall be served at least 14 days prior to the hearing consistent
with the Utah Rules of Civil Procedure, Rule 45. Witness fees and mileage shall
be paid by the party which subpoenas the witness.
2. A subpoena to produce records shall be
served on the holder of the record at least 14 days prior to the date specified
in the subpoena as provided in the Utah Rule of Civil Procedure, Rule 45. Fees
associated with the production of documents shall be paid by the party which
subpoenas the record.
H.
Medical Records Exhibit.
1. The parties are
expected to exchange medical records during the discovery period.
2. Petitioner shall submit all relevant
medical records contained in his possession to the respondent for the
preparation of a joint medical records exhibit at least twenty working days
prior to the scheduled hearing.
3.
The respondent shall prepare a joint medical record exhibit containing all
relevant medical records. The medical record exhibit shall include all relevant
treatment records that tend to prove or disprove a fact in issue. Hospital
nurses' notes, duplicate materials, and other non-relevant materials need not
be included in the medical record exhibit.
4. The medical records shall be indexed,
paginated, arranged by medical care provider in chronological order and bound.
The medical records shall be filed via electronic transmittal.
5. The medical record exhibit prepared by the
respondent shall be delivered to the Division and the petitioner or
petitioner's counsel at least ten working days prior to the hearing. Late-filed
medical records may or may not be admitted at the discretion of the
administrative law judge by stipulation or for good cause shown.
6. The administrative law judge may require
the respondent to submit an additional copy of the joint medical record exhibit
in cases referred to a medical panel.
7. The petitioner is responsible to obtain
radiographs and diagnostic films for review by the medical panel. The
administrative law judge shall issue subpoenas where necessary to obtain
radiology films.
I.
Hearing.
1. Notices of hearing shall be mailed
to the addresses of record of the parties. The parties shall provide current
addresses to the Division for receipt of notices or risk the entry of default
and loss of the opportunity to participate at the hearing.
2. Judgment may be entered without a hearing
after default is entered or upon stipulation and waiver of a hearing by the
parties.
3. No later than 45 days
prior to the scheduled hearing, parties shall file a signed pretrial disclosure
form that identifies:
(a) fact witnesses the
parties actually intend to call at the hearing;
(b) expert witnesses the parties actually
intend to call at the hearing;
(c)
language translator the parties intend to use at the hearing;
(d) exhibits, including reports, the parties
intend to offer in evidence at the hearing;
(e) the specific benefits or relief claimed
by the petitioner;
(f) the specific
defenses that the respondent actually intends to litigate;
(g) whether, or not, a party anticipates that
the case will take more than two hours of hearing time;
(h) the job categories or titles the
respondents claim the petitioner is capable of performing if the claim is for
permanent total disability, and;
(i)
any other issues that the parties intend to ask the administrative law judge to
adjudicate. The administrative law judge may exclude witnesses, exhibits,
evidence, claims, or defenses as appropriate of any party who fails to timely
file a signed pre-trial disclosure form as set forth above. The parties shall
supplement the pre-trial disclosure form with information that newly becomes
available after filing the original form. The pre-trial disclosure form does
not replace other discovery allowed under these rules.
4. If the petitioner requires the services of
language translation during the hearing, the petitioner has the obligation of
providing a person who can translate between the petitioner's native language
and English during the hearing. If the respondents are dissatisfied with the
proposed translator identified by the petitioner, the respondents may provide a
qualified translator for the hearing at the respondent's expense.
5. The petitioner shall appear at the hearing
prepared to outline the benefits sought, such as the periods for which
compensation and medical benefits are sought, the amounts of unpaid medical
bills, and a permanent partial disability rating, if applicable. If mileage
reimbursement for travel to receive medical care is sought, the petitioner
shall bring documentation of mileage, including the dates, the medical provider
seen and the total mileage.
6. The
respondent shall appear at the hearing prepared to address the merits of the
petitioner's claim and provide evidence to support any defenses timely
raised.
7. Parties are expected to
be prepared to present their evidence on the date the hearing is scheduled.
Requests for continuances may be granted or denied at the discretion of the
administrative law judge for good cause shown. Lack of diligence in preparing
for the hearing shall not constitute good cause for a continuance.
8. Subject to the continuing jurisdiction of
the Labor Commission, the evidentiary record shall be deemed closed at the
conclusion of the hearing, and no additional evidence will be accepted without
leave of the administrative law judge.
J. Motions-Time to Respond.
Responses to all motions shall be filed within ten days from the date the motion was filed with the Division. Reply memoranda shall be filed within five days from the date a response was filed with the Division.
K. Motions - Length and Type
1. Without prior leave of the Administrative
Law Judge, supporting memorandum shall not exceed a total of 10 pages, opposing
memorandum shall not exceed seven pages and reply memorandum shall not exceed
three pages. Pleadings shall be double spaced.
a. The page limitations are inclusive of
headings, table of contents, introduction, background, conclusion, statement of
issues and facts, and arguments.
b.
The text of motions and memoranda shall be typeset in 12-point.
c. The Administrative Law Judge shall not
consider anything contained on pages which exceed the page limits.
d. If a memorandum is to exceed the page
limitations set forth in this rule, leave of the Administrative Law Judge must
first be obtained. A motion for leave to file a lengthy memorandum must include
a statement of the reasons why additional pages are needed and specify the
number required. The Administrative Law Judge will approve such requests only
for good cause and a showing of exceptional circumstances that justify the need
for an extension of the specified page limitations. Absent such a showing by
the requesting party, such requests will not be approved. A lengthy memorandum
must not be filed with the Division prior to an entry of an order authorizing
its filing.
2. Other
than one supporting and one opposing and one reply memoranda, no other
memoranda shall be considered by the Administrative Law Judge.
L. Orders on Continuances.
The Administrative Law Judge may rule, ex parte, on requests for continuances.
M.
Notices.
1. Orders and notices mailed by the
Division to the last address of record provided by a party are deemed served on
that party.
2. Where an attorney
appears on behalf of a party, notice of an action by the Division served on the
attorney is considered notice to the party represented by the
attorney.
N. Form of
Decisions.
Decisions of the presiding officer in any adjudicative proceeding shall be issued in accordance with the provisions of Section 63G-4-203 or 63G-4-208.
O. Motions for Review.
1. Any party to an adjudicative proceeding
may obtain review of an Order issued by an Administrative Law Judge by filing a
written request for review with the Adjudication Division in accordance with
the provisions of Section
63G-4-301
and Section
34A-1-303.
Unless a request for review is properly filed, the Administrative Law Judge's
Order is the final order of the Commission. If a request for review is filed,
other parties to the adjudicative proceeding may file a response within 15
calendar days of the date the request for review was filed. If such a response
is filed, the party filing the original request for review may reply within
five calendar days of the date the response was filed. Thereafter the
Administrative Law Judge shall:
a. reopen the
case and enter a Supplemental Order after holding such further hearing and
receiving such further evidence as may be deemed necessary;
b. amend or modify the prior Order by a
Supplemental Order; or
c. refer the
entire case for review under Section
34A-2-801.
2. Motions for Review shall not
exceed a total of 15 pages. Response briefs shall not exceed a total of 12
pages. Reply briefs shall not exceed a total of five pages. All motions and
briefs shall be double spaced.
a. The page
limitations herein are inclusive of headings, table of contents, introduction,
background, conclusion, statement of issues and facts, and arguments.
b. The text of motions and memoranda shall be
typeset in 12-point font.
c. The
Commission and the Appeals Board may disregard argument or other writing
contained on pages which exceed the page limits.
3. If the Administrative Law Judge enters a
Supplemental Order under Subsection (1)(a) or (b), it shall be final unless a
request for review of the same is filed.
P. Procedural Rules.
In formal adjudicative proceedings, the Division shall generally follow the Utah Rules of Civil Procedure regarding discovery and the issuance of subpoenas, except as the Utah Rules of Civil Procedure are modified by the express provisions of Section 34A-2-802 or as may be otherwise modified by these rules.
Q. Requests for Reconsideration and Petitions
for Judicial Review.
A request for reconsideration of an Order on Motion for Review may be allowed and shall be governed by the provisions of Section 63G-4-302. Any petition for judicial review of final agency action shall be governed by the provisions of Section 63G-4-401. R. Request for Abstract.
1. Timing of
Request.
a. A petitioner who seeks an
abstract relative to an award of benefits other than permanent total disability
benefits shall file the request after the order of the commission becomes
final.
b. A petitioner who seeks an
abstract relative to an award of permanent total disability benefits may file
the request:
i. after the order of the
commission becomes final; or
ii.
where the award has been subject to agency review, after a preliminary
determination is issued by the commissioner or the appeals board affirming that
the petitioner is permanently and totally disabled, unless that preliminary
decision is stayed under Subsection
34A-2-212(3),
Section
63G-4-405
or set aside by the Utah Court of Appeals.
c. A motion to stay a preliminary permanent
total disability determination shall be filed with the body that conducted
agency review pursuant to Subsections
R612-200-5(C)(1)(d)
and
R612-200-5(e).
2. Content of Filing. A request
for abstract shall:
a. set forth verbatim the
language of the final order or preliminary decision that awards the benefits at
issue;
b. set forth the specific
monetary sums claimed for each benefit that has been awarded and that is at
issue;
c. include evidence
available to the petitioner that corroborates the specific monetary sums
claimed, such as:
i. billing
statements;
ii. RBRVS
calculations;
iii. interest
calculations; and
iv. evidence of
amounts paid; and
d.
include an exact copy, in its entirety, of each order that awards benefits for
which the abstract is sought.
3. Adjudication of Contest.
a. A request for abstract may be adjudicated
by the administrative law judge who issued the order awarding the benefits at
issue, unless reassigned to another judge.
b. Any objection to the request for abstract
shall be filed within ten days of the filing date of the request.
c. If an objection is filed, any reply shall
be filed within five days of the filing date of the objection.
d. If a proffer of conflicting evidence
demonstrates a need to clarify or modify the abstract, the administrative law
judge may schedule a hearing. Any such hearing may be held using electronic
means.
e. The administrative law
judge shall issue an order adjudicating the request for abstract within 20 days
of:
i. the respondent's objection deadline, if
the respondent does not object to the abstract;
ii. the petitioner's reply deadline, if the
briefing does not demonstrate a need to clarify or modify the abstract;
or
iii. the date on which the
administrative law judge conducts a hearing on the abstract.
f. The administrative law judge's
decision regarding the request for abstract shall be subject to agency review
only if agency review is requested before the abstract is filed with the
district court.
Notes
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