Mo. Code Regs. tit. 8 § 20-3.010

Current through Register Vol. 49, No. 24, December 16, 2024

Section 8 CSR 20-3.010 - Jurisdiction

PURPOSE: This amendment clarifies the procedure for seeking commission approval of a lump sum settlement or commutation, provides guidance to parties seeking modification of final awards, and establishes new procedures for disputes pertaining to future medical treatment.

(1) The Division of Workers' Compensation shall have and exercise the following powers, duties and functions on behalf of the commission in the administration of the Workers' Compensation Law, section 287.410, RSMo:

(A) The receiving and filing of all reports of injury, claims for compensation, answers to claims for compensation, receipts, notices of termination of compensation and all other forms, instruments and documents required to be used or filed in connection with Workers' Compensation claims before the time of the issuance of a final award, order or decision of any administrative law judge;

(B) The receiving, filing, processing and recordkeeping of all exempted employers' acceptances of the Workers' Compensation Law and withdrawals of exempted employers' acceptances of the law;

(C) The duties and responsibilities given the commission by the legislature under section 287.280, RSMo relative to employers who carry their own insurance (self-insurers);

(D) The duties and responsibilities given the commission by the legislature under section 287.220, RSMo relative to the Second Injury Fund;

(E) The duties and responsibilities given the commission by the legislature under section 287.810, RSMo relative to a change of administrative law judge; and

(F) All documents and instruments referred to in subsections (1)(A)-(E) and required to be filed by either the employer or employee shall be filed with the division.

(2) Original Hearings-Administrative Law Judges, Authority and Power.

(A) All original hearings in contested cases shall be heard by the administrative law judges of the division. In any case which has been regularly assigned to an administrative law judge by the director of the division, that administrative law judge shall have full power, jurisdiction and authority to issue all interlocutory orders necessary to the proper and expeditious handling of the case.

(B) Those interlocutory orders, including formal dismissal of unnecessary parties, shall be entered in the minutes of hearings and shall become final upon the issuance of a final award by the administrative law judge.

(C) An administrative law judge shall not have any authority to change or modify a final award issued by an administrative law judge after the lapse of twenty (20) days from the date of issuance of an award or after an application for review (see 8 CSR 20-3.030) has been filed with the commission in connection with any final award, order or decision of an administrative law judge.

(D) Any administrative law judge shall have authority and power to approve motions for settlement of workers' compensation claims; provided, the claim is pending in the division for adjudication. No administrative law judge shall have authority to approve settlement of workers' compensation claims pending before the commission.

(3) Original Hearings-Compromise Settlements.

(A) No original hearings in contested cases shall be heard by the commission or any member of the commission. No compromise settlement of a workers' compensation claim shall be accepted for consideration by the commission or any of its members for approval if the claim is pending in the division.

(B) All motions for settlement of claims pending before the commission shall be submitted to the commission for approval.

(C) All compromise settlements of workers' compensation claims pending in the circuit or appellate courts shall be submitted to the commission for approval. Before filing the settlement for consideration by the commission, the parties seeking to settle the claim shall first petition the court for an appropriate order remanding the matter or otherwise restoring jurisdiction to the commission for consideration of the settlement. The commission cannot act on any request to consider a settlement until the court so disposes of the matter.

(4) Modifying Benefit Awards. The commission shall have sole authority to modify final awards allowing benefits to employees or dependents. The commission may modify benefit awards from time-to-time upon motion by an interested party. All motions for modification of final awards shall be made to the commission and the movant shall have the burden to submit proof of the change of condition or status of the parties receiving the benefits, and will also be responsible for providing to the commission, with the motion, contact information for the employee and/or each dependent affected by the motion, including current addresses. Moving parties are advised that if the commission is unable to provide due notice of the sought modification to each interested party, the commission will not take any action to modify the award. Proof of the remarriage of the dependent surviving spouse shall be made by filing a copy of the marriage license of the remarried dependent surviving spouse or affidavit of the surviving spouse admitting remarriage. Proof of the death of the employee or any dependent shall be made by filing a copy of the death certificate of the employee or dependent. Evidence of the remarriage of the dependent surviving spouse or the death of the employee or dependents may be made by deposition or other evidence as the commission may specify.

(5) Lump Sum Payment of Compensation (Motion for Commutation).

(A) A motion for commutation of compensation due may be filed with the division or one of its administrative law judges at the time a hearing is held and evidence shall be heard on the motion. If payment of compensation is awarded by the administrative law judge, a decision shall be made by the administrative law judge relative to the motion for lump sum payment.

(B) The commission has jurisdiction over any motion for commutation in all cases in which the award has become final.

(C) Where the motion for commutation is not jointly agreed by the parties, the moving party has the burden to:

(1) file a copy of the motion for commutation with the commission; and

(2) serve a copy of the motion to all interested parties.

(D) When interested parties are notified of the motion, they may file a response with the commission upon where the motion is pending, within twenty (20) days of notification. If no objection is filed, the commission will review the motion upon the facts and evidence submitted by the movant and make a decision without ordering a formal hearing.

(E) If objections to the commutation are filed, the commission may remand the matter to the division for a hearing. Upon return of the file, the commission shall review the evidence and render its decision.

(F) The commission shall send an order allowing or denying the motion by United States mail to all interested parties.

(G) A commutation of compensation due a minor dependent shall not be approved or ordered until a legal guardian for the dependent has been appointed by the probate court of the county in which the dependent resides and proof of the appointment of a guardian and a certificate of the probate court certifying that the guardian has qualified shall be filed with the commission.

(H) In cases where there is a prior award of benefits or a duly approved settlement that has finally resolved the parties' respective rights and duties with regard to periodic benefits payable in the claim, the commission cannot consider a joint motion for payment of a lump sum as a compromise settlement under section 287.390, RSMo, unless the parties are able to identify, in their motion, a legitimate, presently justiciable dispute, over which the commission would have jurisdiction. In the absence of such dispute, and where the parties desire merely to close out or redeem the remaining obligations under the award or settlement via payment of a lump sum, the commission will treat the motion as one for commutation pursuant to section 287.530, RSMo.

(I) Where a motion for commutation is jointly agreed by the parties, the commission will consider the motion provided it includes the following:

1. For motions to commute permanent total disability or death benefits:

A. The employee or dependent's date of birth and presumed life expectancy, including, in the event the parties are requesting that the commission presume a life expectancy that substantially differs from that indicated in the most recent edition of the National Vital Statistics Reports published by the U.S. Department of Health & Human Services, a written opinion from a medical professional explaining why the life expectancy so differs;

B. The discount rate and actuarial assumptions utilized by the parties in calculating the present-day or commutable value of the future installments that may be expected under the award or settlement;

C. The specific facts and circumstances that would support a determination by the commission that commutation will be in the best interests of the employee or dependents; or will avoid undue expense or undue hardship to either party; or that the employee or dependent has removed or is about to remove from the United States; or that the employer has sold or otherwise disposed of the greater part of its business or assets; and

D. In the event the parties are seeking commutation on the basis that such will be in the best interests of the employee or dependents, or will avoid undue expense or undue hardship to either party, the specific facts and circumstances that would support a determination by the commission that unusual circumstances exist in the case that warrant a departure from the normal method of payment; and

2. For motions to commute open future medical benefits where the underlying award or settlement does not expressly preserve to the employer/insurer the discretionary right to close future medical benefits by funding an annuity or Medicare Set-Aside trust account-

A. The employee's date of birth and presumed life expectancy, including, in the event the parties are requesting that the commission presume a life expectancy that substantially differs from that indicated in the most recent edition of the National Vital Statistics Reports published by the U.S. Department of Health & Human Services, a written opinion from a medical professional explaining why the life expectancy so differs;

B. The medical expenses incurred by the employee in connection with the claim for at least the last five (5) years, if any, listed by date, provider, treatment, and amount;

C. The discount rate and actuarial assumptions utilized by the parties in calculating the commutable value of the future installments of medical expenses that may be expected under the award or settlement;

D. Whether the employee is currently, or reasonably anticipated to become, within the next thirty (30) months, a Medicare beneficiary, and if so, whether Medicare has made any conditional payments for medical treatment related to the work injury;

E. If a Medicare Set-Aside trust account is proposed to commute the future installments of medical care, whether all reasonably anticipated future medical expenses are of the type that will be covered by Medicare upon exhaustion of the commutation funds, or, in the alternative, an identification of what additional sums are being paid to cover expenses not covered by Medicare, including any evidence, attestation, or other information that would support a finding by the commission as to the sufficiency of such additional sums;

F. A signed statement from the employee memorializing his or her understanding and agreement that the funds from the proposed commutation should be used exclusively for the purpose of paying for medical treatment related to the work injury, and that failure to expend the commutation funds for such purpose may jeopardize the employee's later ability to obtain any financial assistance (via Medicare, private insurance, or otherwise) for future medical expenses related to the work injury; and

G. The specific facts and circumstances that would support a determination by the commission that commutation will be in the best interests of the employee or dependents; or will avoid undue expense or undue hardship to either party; or that the employee or dependent has removed or is about to remove from the United States; or that the employer has sold or otherwise disposed of the greater part of its business or assets.

(6) The commission retains jurisdiction over disputes pertaining to the parties' respective rights and obligations with regard to future medical treatment whenever a final award or settlement in the case leaves the issue of future medical treatment "open" or otherwise indeterminate. See State ex rel. ISP Minerals, Inc. v. Labor & Indus. Rels. Comm'n, 465 S.W.3d 471 (Mo. 2015). The commission will only consider issues falling within its statutory authority, such as whether a disputed treatment is reasonably required to cure and relieve the effects of the work injury for purposes of section 287.140, RSMo, and will not entertain requests to "compel" or "enforce" any award or settlement, because such powers are reserved to the judiciary.

(A) Upon receipt of a motion identifying a dispute pertaining to future medical treatment, the commission will allow opposing parties to respond within twenty (20) days from the date of the commission's correspondence acknowledging the motion; provided, however, that the commission, in its discretion, may extend or accelerate the period for filing such a response. If the commission determines that there is a presently justiciable dispute between the parties over which the commission would have jurisdiction, and that the movant has alleged a prima facie claim for relief of a type that the commission would be authorized to provide, the commission will remand the matter to the division of workers' compensation for a hearing to take evidence on the parties' allegations set forth in the motion and responsive pleadings, if any. Otherwise, the commission may dismiss the motion.

(B) Parties will be entitled to reasonable discovery in advance of the hearing. Any disputes pertaining to discovery should be brought to the commission's attention for a ruling. The administrative law judge will hold in abeyance any action in connection with the commission's order of remand until the discovery dispute is resolved. The administrative law judge will hear and rule upon all evidentiary objections made at the hearing, and will allow the proponent to make an offer of proof where evidence is ruled inadmissible. At the close of the hearing, the division will return the file to the commission for a determination of the disputed issues.

(C) Mediation may be pursued at the discretion of the administrative law judge assigned to the matter. If such mediation is successful, the administrative law judge may sign, if the parties so request, an informal memorandum of understanding outlining and memorializing the parties' agreement, which should be executed by all parties and/or their attorneys; provided, however, if the parties desire approval of a formal settlement agreement resolving the disputed issue of future medical treatment, such should be forwarded to the commission for approval pursuant to section 287.390, RSMo. Any formal settlement agreement should be submitted to the commission in accordance with the guidelines for compromise settlements set forth in these rules.

(D) If, at any time, the dispute becomes moot, the parties are directed to advise the commission, and also the division in the event proceedings are pending in connection with an order of remand from the commission, that no further action is necessary in connection with the motion, whereupon the commission will dismiss the motion.

(E) Where the parties' dispute pertains to future medical treatment which is alleged to be imminently necessary to prevent harm to the health or well-being of the employee, the commission will entertain a request to hear the dispute on an expedited or hardship basis. Such request should include a written opinion from a medical professional explaining why the requested medical treatment is imminently necessary to prevent harm. Where the commission grants such expedited review, the commission may issue an order resolving the dispute based on its own review of the documentary evidence submitted by the parties, without the formality of ordering an evidentiary proceeding before the division. To be considered, such documentary evidence should be certified or otherwise sworn to be authentic via affidavit.

(F) All parties to awards or settlements are hereby advised that the commission generally disfavors the practice of ordering further proceedings in open future medical cases except where strictly necessary; and that the process set forth in this rule does not constitute an invitation or opportunity to relitigate issues in the case that were previously adjudicated or stipulated. Accordingly, if the record before the commission reveals that any party has failed, without reasonable ground, to fully and faithfully comply with its obligations under the law pursuant to an award or settlement previously entered in the case, the commission may assess an award of costs and attorney's fees against said party, pursuant to section 287.560, RSMo. All parties are thus strongly encouraged to resolve their disputes without recourse to the commission except in those extraordinary cases where intervention by an impartial, fact-finding tribunal is necessary.

8 CSR 20-3.010

AUTHORITY: section 286.060, RSMo 1986.* This version of rule filed Dec. 18, 1975, effective Dec. 28, 1975. Amended: Filed July 11, 1991, effective Dec. 9, 1991. Amended: Filed Sept. 30, 1992, effective April 8, 1993. Rule action notice invalidating subsection (2)(C) March 12, 1996. Rule action notice validating subsection (2)(C) Aug. 28, 1998.

Amended by Missouri Register September 2, 2019/Volume 44, Number 17, effective 10/31/2019

*Original authority: 286.060, RSMo 1945, amended 1947, 1980.