Workers’ Compensation Practice in Massachusetts

Preliminary Pages
PREFACE
ACKNOWLEDGMENTS
ABOUT THE EDITOR
ABOUT THE JUDICIAL COMMENTATORS
ABOUT THE AUTHORS
TABLE OF CONTENTS
TABLE OF EXHIBITS
Chapter 1
Who Are Covered Employees?
§ 1.1 INTRODUCTION
§ 1.2 EMPLOYMENT STATUS
§ 1.3 INDEPENDENT CONTRACTORS OR EMPLOYEES
§ 1.4 LENT EMPLOYEES
§ 1.5 EMPLOYEES SUPPLIED BY EMPLOYMENT CONTRACTORS
§ 1.6 STATUTORY EMPLOYEES AND INSURER LIABILITY
§ 1.7 DOMESTIC SERVANTS
§ 1.8 SALESPEOPLE
§ 1.9 PROFESSIONAL ATHLETES
§ 1.10 TAXI DRIVERS
§ 1.11 PUBLIC EMPLOYEES
§ 1.12 EMPLOYMENT EXEMPT FROM COVERAGE
§ 1.13 IMMIGRATION STATUS
EXHIBIT 1A—Attorney General Advisory
Chapter 2
Defining Personal Injury Under Chapter 152
§ 2.1 INTRODUCTION
§ 2.2 ORIGINS OF THE DEFINITION OF “PERSONAL INJURY”
§ 2.3 BODILY INJURIES
§ 2.3.1 Prior to December 23, 1991
§ 2.3.2 Since December 23, 1991
§ 2.3.3 Diseases
§ 2.4 VOLUNTARY ACTIVITIES
§ 2.5 NEGLIGENT AND INTENTIONAL INFLICTION OF EMOTIONAL DISTRESS
§ 2.6 MENTAL AND EMOTIONAL INJURIES
§ 2.6.1 Prior to 1986
§ 2.6.2 From January 1, 1986 to December 22, 1991
§ 2.6.3 Since December 23, 1991
§ 2.7 CONCLUSION
Chapter 3
Types of Workers’ Compensation Benefits*
§ 3.1 INTRODUCTION
§ 3.2 AVERAGE WEEKLY WAGE
§ 3.3 CONCURRENT EMPLOYMENT
§ 3.4 LATENCY CLAIMS UNDER SECTION 35C
§ 3.5 SECTION 35B
§ 3.6 TEMPORARY TOTAL DISABILITY UNDER SECTION 34
§ 3.7 TEMPORARY PARTIAL DISABILITY UNDER SECTION 35
§ 3.8 PERMANENT AND TOTAL DISABILITY BENEFITS UNDER SECTION 34A
§ 3.9 DEATH BENEFITS UNDER SECTION 31
§ 3.10 INCREASING BENEFITS FOR YOUNG OR INEXPERIENCED WORKERS
§ 3.11 INCREASING BENEFITS UNDER SECTION 51A
§ 3.12 DEPENDENCY BENEFITS UNDER SECTION 35A
§ 3.13 COLA BENEFITS UNDER SECTION 34B AND SECTION 35F
§ 3.14 INCREASING THE CURRENT FIVE-YEAR PARTIAL MAXIMUM TO TEN YEARS
§ 3.15 INTEREST UNDER SECTION 50
§ 3.16 PENALTY SECTIONS
§ 3.17 SERIOUS AND WILLFUL MISCONDUCT ON THE PART OF THE EMPLOYER UNDER SECTION 28
§ 3.18 CONCLUSION
Chapter 4
Scarring and Disfigurement: Calculating Section 36 Benefits*
§ 4.1 INTRODUCTION
§ 4.2 SCHEDULED SPECIFIC INJURIES—SECTION 36(1)(a)–(j)
§ 4.2.1 Section 36(1)(a)—Total Loss of Vision in One Eye
§ 4.2.2 Section 36(1)(b)—Total Loss of Vision in Both Eyes
§ 4.2.3 Section 36(1)(c)—Total Loss of Vision in One or Both Eyes as a Proportion
§ 4.2.4 Section 36(1)(d)—Loss of Hearing in One or Both Ears
§ 4.2.5 Section 36(1)(e)–(h)—Total Loss of Use of Arm(s), Hand(s), Leg(s), or Foot (Feet)
§ 4.2.6 Section 36(1)(i)—Partial Losses in Function of Arms, Legs, Hands, or Feet
§ 4.2.7 Section 36(1)(j)—Losses of Bodily Function or Sense Not Specified in Section 36(1)(a)–(i)
§ 4.2.8 Section 36(1)(k)—Bodily Disfigurement
§ 4.3 FILING A CLAIM FOR SECTION 36 BENEFITS
§ 4.3.1 Filing Requirements
§ 4.3.2 Attorney Fees
§ 4.3.3 Claims for Functional Loss
§ 4.3.4 Reserving Claims Under Section 36
§ 4.4 THE RELATIONSHIP BETWEEN SECTION 36 AND OTHER SECTIONS OF CHAPTER 152
§ 4.4.1 The Application of Section 8(1)
§ 4.4.2 The Application of Section 11A(2)
§ 4.4.3 The Application of Section 11D(3) to Section 36 Benefits
§ 4.4.4 Section 36 and the Application of Attorney Fees Under Section 13A
§ 4.4.5 The Application of Section 28 to Section 36
§ 4.4.6 The Application of Section 37 to Section 36
§ 4.4.7 The Application of Section 50 to Section 36
§ 4.4.8 The Application of Section 51A to Section 36
EXHIBIT 4A—Guide for Calculating Loss-of-Function Benefits
EXHIBIT 4B—Guidelines for Calculating Disfigurements Other than Scars
EXHIBIT 4C—Payments for the Amputation of a Hand, Fingers, or Parts Thereof
Chapter 5
Psychiatric Claims*
§ 5.1 COMPENSABILITY IN GENERAL
§ 5.2 RELATIONSHIP TO PHYSICAL INJURY
§ 5.3 DEFINITION OF BONA FIDEPERSONNEL ACTION
Chapter 6
Representing the Claimant from Initial Intake to Filing of Claim
§ 6.1 INTRODUCTION
§ 6.2 THE INITIAL INTERVIEW
§ 6.2.1 General Principles
§ 6.2.2 Background Information
§ 6.2.3 Employment and Injury
§ 6.2.4 Medical Information
§ 6.2.5 Insurance Information
§ 6.3 OTHER CONSIDERATIONS IN THE INITIAL INTERVIEW
§ 6.3.1 Available Workers’ Compensation Benefits
§ 6.3.2 Other Available Benefits
§ 6.3.3 Attorney Fees
§ 6.3.4 Statute of Limitations Concerns
§ 6.3.5 Identifying Potential Third-Party Claims
§ 6.3.6 Uninsured Employers
§ 6.3.7 Jurisdictional Issues
§ 6.4 FILING THE CLAIM
§ 6.4.1 Preliminary Steps
§ 6.4.2 Filing Procedure
EXHIBIT 6A—Checklist for Initial Interview Regarding Workers’ Compensation Claim
EXHIBIT 6B—DIA Form 115 (Third Party Claim/Notice of Lien)
EXHIBIT 6C—reserved
EXHIBIT 6D—reserved
EXHIBIT 6E—Checklist for Filing a Workers’ Compensation Claim
EXHIBIT 6F—DIA Form 114 (Notice of Change/ Appearance of Counsel)
EXHIBIT 6G—DIA Form 110 (Employee’s Claim)
Chapter 7
Representing the Employer/‌Insurer in the Initial Stages of Claim Filing or Litigation
§ 7.1 INTRODUCTION
§ 7.2 THE INITIAL CONTACT
§ 7.3 INITIAL REVIEW OF FILE
§ 7.4 RESPONSE REQUIRED WITHIN FOURTEEN DAYS
§ 7.5 DENIAL OF CLAIM
§ 7.6 NOTICE REQUIREMENTS
§ 7.7 FACTUAL FOLLOW-UP
§ 7.8 DISABILITY
§ 7.9 PAST MEDICAL CONDITION
§ 7.10 HEALTH-CARE PROVIDER
§ 7.11 INDEPENDENT MEDICAL EXAM
§ 7.12 INVESTIGATION OF POSTINJURY ACTIVITY
§ 7.13 INVESTIGATION OF PRIOR CLAIMS
§ 7.14 REQUESTS FOR PRODUCTION OF DOCUMENTS AND REQUESTS TO ENTER PREMISES
§ 7.15 RETURN TO WORK IN THE CASE OF PARTIAL DISABILITY
§ 7.16 EMPLOYABILITY ASSESSMENT AND LABOR MARKET SURVEY
§ 7.17 UNEMPLOYMENT BENEFITS IN THE CASE OF PARTIAL DISABILITY
§ 7.18 ALTERNATIVES TO LITIGATION
EXHIBIT 7A—DIA Form 114 (Notice of Change/‌Appearance of Counsel)
EXHIBIT 7B—DIA Form 104 (Insurer’s Notification of Denial)
EXHIBIT 7C—DIA Form 126 (Employee’s Earning Report)
Chapter 8
Practice and Procedure Before the Department of Industrial Accidents: The Department’s Perspective
§ 8.1 INTRODUCTION
§ 8.2 THE DIA’S PUBLIC INFORMATION OFFICE
§ 8.3 THE DIA’S WEBSITE
§ 8.3.1 Information on Filing with the DIA
§ 8.3.2 Statutes, Regulations, and Forms
§ 8.3.3 Guides to the Workers’ Compensation System
§ 8.3.4 Circular Letters
§ 8.4 APPEARANCES IN DIA PROCEEDINGS
§ 8.4.1 Appearances by Attorneys
§ 8.4.2 Appearances by Nonattorneys
§ 8.4.3 Withdrawal from Representation
§ 8.5 DISPUTE RESOLUTION
§ 8.5.1 Conciliation—G.L. c. 152, § 10; 452 C.M.R. § 1.08
(a) Informal Meeting
(b) Penalties
(c) Representation
(d) Requirements
(e) Withdrawal Without Prejudice
(f) Medical Records
(g) Disposition
(h) Last Best Offer
(i) Expedited Conference—G.L. c. 23E, § 6
Requests Based on Hardship
Motions Based on Other Considerations
§ 8.5.2 Conferences—G.L. c. 152, § 10A; 452 C.M.R. § 1.10
(a) Assignment to an Administrative Judge
(b) Conference Memorandum—Form 140
(c) Prohibition on Ex Parte Communications
(d) Inquiries and Investigations
(e) Stenographic Transcript
(f) Conference Order
(g) Appeal of a Conference Order
(h) Failure to Perfect an Appeal
(i) Waiver of Fee for Indigents
§ 8.5.3 Impartial Medical Examiners—G.L. c. 152, § 11A; 452 C.M.R. § 1.14
(a) The Roster
(b) Limitations on Impartial Physicians
Agreement That No Impartial Physician’s Report Is Required
Opt Out
Medical Records
(c) Procedures for Assignment or Selection of Impartial Physicians
Ten-Day Window for Selection
Information for Impartial Physician
Scheduling Deposition
Impartial Physician’s Request to Providers
Fee for Services
Reasonable and Necessary Treatment
Voluntary Examination
(d) Impartial Physician’s Report
(e) Evidentiary Issues and the Impartial Physician’s Report
§ 8.5.4 Hearings—G.L. c. 152, §§ 11, 11B;452 C.M.R. § 1.11
§ 8.5.5 Discovery and Depositions—452 C.M.R. § 1.12
(a) Discovery Requests
(b) Discovery Motions
(c) Medical Evidence
Right to Depose Impartial Physician
Deposition Fee for Impartial Physicians
Conference Appeals
Discretionary Discovery
Procedural Requirements
Unavailability of Impartial Physician
Impartial Physician’s Right to Review
Scheffler’s Case
§ 8.5.6 Reviewing Board
§ 8.5.7 Enforcement of Orders; Appeal from Decisions of the Reviewing Board—G.L. c. 152, § 12
§ 8.5.8 Attorney Fees—G.L. c. 152, § 13A; 452 C.M.R. § 1.19
§ 8.5.9 Lump Sums—G.L. c. 152, § 48
(a) General Procedures
(b) Opioid Alternative Treatment Pathway
§ 8.5.10 Third-Party Liability—G.L. c. 152, § 15; 452 C.M.R. § 1.21
(a) General Guidance on Filing
(b) “Do I Have to File a Section 15 Petition?”
(c) Who Pays the Attorney Fee?
(d) The Hunter Question
(e) Lump Sum and Third-Party Settlements
(f) Definition of “All Payments Due an Employee”—452 C.M.R. § 1.02
§ 8.5.11 Cancellation/Termination of Policy/Review—G.L. c. 152, § 65B; Independent Contractor Versus Employee Status
(a) Cancellation/Termination of Policy/Review—G.L. c. 152, § 65B
(b) Independent Contractor Versus Employee
§ 8.6 CONCLUSION
EXHIBIT 8A—An Overview of the Document Management System (DMS) of the Massachusetts Department of Industrial Accidents
Chapter 9
Practice and Procedure Before the Department of Industrial Accidents: The Employee’s Perspective
§ 9.1 INTRODUCTION
§ 9.2 INITIAL CLIENT INTERVIEW
§ 9.3 ACCUMULATION OF MEDICAL RECORDS
§ 9.4 VOCATIONAL HISTORY
§ 9.5 HOW THE INJURY OCCURRED
§ 9.6 RECORDS FROM THE INSURER’S FILE
§ 9.7 SHOULD YOU FILE A CLAIM? AN APPEARANCE? SHOULD YOU DO ANYTHING?
§ 9.8 AVERAGE WEEKLY WAGE AND CONCURRENT EMPLOYMENT
§ 9.9 WHO IS THE INSURER?
§ 9.10 INSURER’S MEDICAL EXAMINATION
§ 9.11 FILING OF A CLAIM
§ 9.12 CONCILIATION
§ 9.13 TIME LAGS AND REQUEST FOR EXPEDITED CONFERENCE
§ 9.14 CONFERENCE
§ 9.15 FEES
§ 9.16 LAST BEST OFFER AND CONFLICT OF INTEREST ISSUES
§ 9.17 ISSUES REGARDING THE IMPARTIAL
§ 9.18 CONTENTS OF CONFERENCE ORDER
§ 9.19 HEARING
§ 9.20 ENHANCEMENTS TO WEEKLY WORKERS’ COMPENSATION
§ 9.20.1 Section 35B
§ 9.20.2 Section 35C
§ 9.20.3 Section 51A
§ 9.20.4 Section 34B
§ 9.20.5 Section 35F
§ 9.20.6 Section 35A
§ 9.20.7 Average Weekly Wage
§ 9.20.8 Section 51—Increases for Young Workers
§ 9.20.9 Conclusion
EXHIBIT 9A—Employee Biographical Data Sheet (DIA Form 160)
EXHIBIT 9B—Narrative Report of First Medical Visit
EXHIBIT 9C—Requests for Doctor’s Narrative Report
EXHIBIT 9D—Sample HIPAA Release Form*
EXHIBIT 9E—Authorization for Representation
EXHIBIT 9F—Petition for Approval of ThirdParty Settlement
EXHIBIT 9G—Employee’s Request for Production of Documents
EXHIBIT 9H—Insurance Inquiry Form
EXHIBIT 9I—DIA Form 110 (Employee’s Claim)*
EXHIBIT 9J—DIA Form 110 (Employee’s Claim) with Cover Letter*
EXHIBIT 9K—DIA Form 113 (Agreement to Pay Compensation)*
EXHIBIT 9L—DIA Form 131 (Request for Speedy Conference Because of Hardship)
EXHIBIT 9M—DIA Form 132 (Affidavit in Support of Employee’s Request for Speedy Conference Because of Hardship)
EXHIBIT 9N—DIA Form 112A (Affidavit in Support of Request for Waiver of Filing Fee)
EXHIBIT 9O—Conference Memorandum Cover Sheet
EXHIBIT 9P—DIA Form 121 (Appeal of Conference Proceeding)*
EXHIBIT 9Q—DIA Circular Letter No. 352 (October 2, 2017; Effective October 1, 2017)
EXHIBIT 9S—Last Best Offer Form
EXHIBIT 9T—Agreement That No Impartial Physician Report Is Required
EXHIBIT 9U—Notice of Taking Deposition
EXHIBIT 9V—Explanation of Computation of Interest
EXHIBIT 9W—Notification of Medical Evidence to Be Introduced
EXHIBIT 9X—Social Security Form CR-28 (COLA Data Form)*
EXHIBIT 9Y—COLA Offset Worksheet
EXHIBIT 9Z—Form SSA-149, Waiver of Benefit Payments
Chapter 10
Practice and Procedure Before the Department of Industrial Accidents: The Employer’s/‌Insurer’s Perspective
§ 10.1 INTRODUCTION / FIDUCIARY DUTY OF DEFENSE COUNSEL
§ 10.2 CONCILIATION
§ 10.2.1 Prior to the Conciliation
§ 10.2.2 At Conciliation
§ 10.2.3 Following the Conciliation
§ 10.3 SECTION 10A CONFERENCE
§ 10.3.1 Prior to the Section 10A Conference
§ 10.3.2 At the Section 10A Conference
§ 10.3.3 Following the Section 10A Conference
Chapter 11
Impartial Examiners—A Guide to Section 11A Practice
§ 11.1 INTRODUCTION
§ 11.2 SOME HISTORICAL PERSPECTIVE
§ 11.3 THE STATUTORY PROVISION
§ 11.4 TITLE 452
§ 11.5 CASE LAW
§ 11.5.1 Constitutionality
§ 11.5.2 Fee Provisions
§ 11.5.3 Application
(a) Ruiz v. Unique Application, 11 Mass. Workers’ Comp. Rep. 399 (1997)
(b) Franco v. Winston’s Rest., 10 Mass. Workers’ Comp. Rep. 645 (1996)
(c) Bourassa v. D.J. Reardon Co., 10 Mass. Workers’ Comp. Rep. 213 (1996)
(d) Oliveira v. Scrub-a-Dub Wash Ctr., 10 Mass. Workers’ Comp. Rep. 61 (1995)
(e) LaFleur v. H.P. Hood, Inc., 22 Mass. Workers’ Comp. Rep. 91 (2008)
§ 11.5.4 Bias
(a) Martin v. Red Star Express Lines, 9 Mass. Workers’ Comp. Rep. 670 (1995)
(b) Matto v. RCA Serv. Co., 9 Mass. Workers’ Comp. Rep. 759 (1995)
(c) Tallent v. MBTA, 9 Mass. Workers’ Comp. Rep. 794 (1995)
(d) Sellick v. Trailways of New England, 12 Mass. Workers’ Comp. Rep. 384 (1998)
(e) Barrett v. Kiewit Atkinson Cashman, 19 Mass. Workers’ Comp. Rep. 286 (2005)
§ 11.5.5 Translators
§ 11.5.6 Form of Judge’s Ruling
§ 11.5.7 Timing for Judge’s Ruling
§ 11.5.8 Inadequacy as a Matter of Law
§ 11.5.9 Complexity
(a) General Principles
(b) Allowance of Additional Evidence Sua Sponte
§ 11.5.10 Prima Facie Evidence
§ 11.5.11 Limitations of Prima Facie Weight
§ 11.5.12 Actually Submitting the Additional Medical Evidence
Chapter 12
Tips for Obtaining Discovery and Preparing for Hearing: The Insurer’s Perspective
§ 12.1 OBTAINING DISCOVERY
§ 12.1.1 Requests for Production of Documents
§ 12.1.2 Depositions
§ 12.1.3 Additional Discovery Techniques
(a) Medical Records
(b) Employee’s Work History
(c) Exposure Investigation
(d) Surveillance
(e) Internet Searches
§ 12.2 TIPS FOR PREPARING FOR HEARING
§ 12.2.1 Cross-Examination of the Claimant
§ 12.2.2 Examination of the Investigator
§ 12.2.3 Vocational Experts
§ 12.2.4 The Employee’s Medical Expert
§ 12.2.5 Employer Testimony
§ 12.2.6 Impartial Examiner
§ 12.3 CONCLUDING THOUGHTS ON PREPARING FOR HEARING
EXHIBIT 12A—Sample Insurer’s Request for Production of Documents
EXHIBIT 12B—Sample Subpoena
EXHIBIT 12C—Sample HIPAA Release Form
EXHIBIT 12D—Sample Insurer’s Hearing Memorandum
EXHIBIT 12E—Checklist of Potential Areas for Cross-Examination of a Workers’ Compensation Claimant
EXHIBIT 12F—Sample Outline for Cross-Examination of a Claimant
EXHIBIT 12G—Checklist of Tips for Working with Vocational Experts
EXHIBIT 12H—Sample Outline for Direct Examination of a Vocational Expert
EXHIBIT 12I—Sample Motion in Limine with Supporting Memorandum
EXHIBIT 12J—Sample Motion to Submit Additional Medical Evidence
Chapter 13
Considerations for Hearing
§ 13.1 INTRODUCTION
§ 13.2 OVERVIEW OF IMPARTIAL MEDICAL EXAMINATIONS
§ 13.3 THE HEARING
§ 13.3.1 Prehearing Motions and Discovery
§ 13.3.2 Conduct of the Hearing
§ 13.3.3 The Effect of the Exclusivity Provisions of G.L. c. 152
§ 13.3.4 Overview of Issues That Should Be Explored Prior to Hearing
(a) Date of Injury Governs Claim
(b) Employee Status
Illegal Aliens
Independent Contractors
Leased Employees
(c) “Injury” Defined
(d) Notice and Claim
(e) Right to Compensation
(f) Average Weekly Wage
Seasonal Employment
Retroactive Pay Increases
Prospective Pay Increases
Concurrent Employment
Vacation Pay
Fringe Benefits
Partial Incapacity Compensation and Average Weekly Wage
Unemployment Benefits
Benefits Rate and Section 35B
Out-of-State Employment
Other Statutory Enhancements
(g) Employee’s Death and Testimonial Incapacity—Section 7A
(h) Going and Coming Rule
Employer’s Premises
Leased Premises
Special Errand
Street Risk Doctrine
Employer’s Conveyance
Resident Employees—On-Call Employees
Traveling Employees
(i) Old Age Benefits—Section 35E
(j) Employee Misconduct, Misrepresentation, and Fraud
Willful Misconduct of the Employee
Misrepresentation on Employment Application
Fraud
§ 13.3.5 Lump Sum Settlement
Chapter 14
Appeal Practice Before the Department of Industrial Accidents and the Courts
§ 14.1 APPEALS TO THE REVIEWING BOARD
§ 14.1.1 Filing the Notice of Appeal
§ 14.1.2 The Pretranscript Conference
§ 14.1.3 Filing the Brief
§ 14.1.4 Assignment to the Reviewing Board Panel
§ 14.1.5 Authority of the Reviewing Board
§ 14.2 ENFORCEMENT OF DEPARTMENT DECISIONS
§ 14.2.1 Compliance with Orders of the Department
§ 14.2.2 Reversal on Appeal
§ 14.3 JUDICIAL APPEALS
§ 14.3.1 Grounds for Appeal
§ 14.3.2 Perfecting the Appeal
§ 14.3.3 The Brief
§ 14.3.4 Standard of Review
§ 14.3.5 Petition for Rehearing and Petition for Further Appellate Review
Chapter 15
Scientific Evidence and the Use of Lanigan and Daubert
§ 15.1 INTRODUCTION
§ 15.2 SCIENTIFIC EVIDENCE UNDER LANIGAN AND DAUBERT
§ 15.2.1 Scientific Knowledge Requires Appropriate Validation
§ 15.2.2 Fit Is a Precondition
§ 15.2.3 Key Aspects of the Lanigan Reliability Inquiry
§ 15.2.4 Using Differential Diagnosis for Reliability
§ 15.3 SCIENTIFIC EVIDENCE AT THE SECTION 11 HEARING
§ 15.3.1 The Lanigan Foundation
§ 15.3.2 Lanigan, Daubert, and Other Pitfalls
§ 15.3.3 Handling Lanigan Considerations at Hearing
§ 15.4 CONCLUSION
Chapter 16
Use of the Department’s Vocational Rehabilitation Component
§ 16.1 INTRODUCTION/STATUTORY PROVISIONS
§ 16.2 MANDATORY MEETINGS
§ 16.3 PENALTIES FOR NONCOOPERATION
§ 16.4 HIERARCHY OF SERVICES
§ 16.5 INDIVIDUAL WRITTEN REHABILITATION PROGRAM (IWRP)
§ 16.6 DISPUTES REGARDING THE IWRP
§ 16.7 DURATION OF PROGRAM
§ 16.8 LUMP SUM SETTLEMENTS AND THE OEVR
§ 16.9 USE OF VOCATIONAL SERVICES
Chapter 17
Utilization Review in Massachusetts
§ 17.1 INTRODUCTION
§ 17.2 HISTORY AND LEGISLATIVE AUTHORITY
§ 17.3 UTILIZATION REVIEW AND QUALITY ASSESSMENT (452 C.M.R. § 6.00)
§ 17.4 TREATMENT GUIDELINES
§ 17.5 RESPONSIBILITIES OF THE INSURER
§ 17.6 UTILIZATION REVIEW AGENTS
§ 17.7 UTILIZATION REVIEW DETERMINATION LETTERS
§ 17.8 QUALITY ASSURANCE MEASURES
§ 17.9 COMPLAINTS AGAINST INSURERS AND SELF-INSURERS
§ 17.10 PRACTICE ISSUES FOR ATTORNEYS FILING A CLAIM WITH THE DIA
§ 17.10.1 Assessing the UR Process
§ 17.10.2 Filing a Claim
§ 17.11 MEDICAL PROVIDER CONDUCT
Chapter 18
Alternative Dispute Resolution in Workers’ Compensation Cases
§ 18.1 INTRODUCTION
§ 18.2 STATUTORY AUTHORITY FOR ARBITRATION AND MEDIATION OF WORKERS’ COMPENSATION DISPUTES
§ 18.3 USE OF ADR AS AN EXCLUSIVE ALTERNATIVE TO THE DIA DISPUTE RESOLUTION PROCESS
§ 18.4 PRACTICE TIPS FOR ARBITRATION OF WORKERS’ COMPENSATION DISPUTES
§ 18.4.1 Speed of Process
§ 18.4.2 Choice of Neutral Arbitrator
§ 18.4.3 Flexibility of Process
§ 18.5 PRACTICE TIPS FOR MEDIATION OF WORKERS’ COMPENSATION DISPUTES
Chapter 19
Lump Sum Settlements: The Law, the Procedure, and Some Practical Tips
§ 19.1 INTRODUCTION
§ 19.2 G.L. c. 152, § 48(1)
§ 19.2.1 The Employer’s Consent
§ 19.2.2 Review of the Lump Sum Settlement by an Administrative Judge or an Administrative Law Judge
§ 19.2.3 The Claimant’s Best Interest
§ 19.3 ACCEPTED LIABILITY VERSUS CONTESTED LIABILITY SETTLEMENTS FOR INJURIES BEFORE AND AFTER NOVEMBER 1, 1986
§ 19.4 ANY QUID PRO QUO FOR LUMP SUM SETTLEMENT?
§ 19.5 THE ROLE OF THE OFFICE OF EDUCATION AND VOCATIONAL REHABILITATION
§ 19.6 THE EFFECT OF A LUMP SUM SETTLEMENT ON OTHER WORKERS’ COMPENSATION CLAIMS BY THE EMPLOYEE
§ 19.7 ATTORNEY FEES
§ 19.8 PRESENTING A PROPOSED LUMP SUM SETTLEMENT TO THE JUDGE
§ 19.9 SOME PRACTICAL TIPS AND CONSIDERATIONS FOR COUNSEL
§ 19.9.1 For Employee Counsel
§ 19.9.2 For Insurer Counsel
EXHIBIT 19A—DIA Form 116A (Employer’s Consent to Settlement)
EXHIBIT 19B—DIA Form 116 (Request for Lump Sum Conference)
EXHIBIT 19C—Bulletin from Senior Judge Hernandez
EXHIBIT 19D—The Request for Section 46A Conference in Conjunction with Lump Sum Under Section 48
EXHIBIT 19E—Lump Sum Settlement Agreement for Injuries Prior to November 1, 1986
EXHIBIT 19F—Lump Sum Settlement Agreement for Injuries on and After November 1, 1986
EXHIBIT 19G—Office of Education and Vocational Rehabilitation Memorandum on Lump Sum Procedure
EXHIBIT 19H—DIA Form 116B (Vocational Rehabilitation Status Addendum)
EXHIBIT 19I—DIA Form 116C (Employee’s Lien Disclosure)
EXHIBIT 19J—Sample Letter of Notice Pursuant to G.L. c. 175, § 24D
EXHIBIT 19K—Checklist for Lump Sum Settlements
Chapter 20
Recovering from Third Parties: Settlements, Section 15 Liens, and Hunter Fees
§ 20.1 INTRODUCTION
§ 20.2 ANALYSIS
§ 20.3 APPROACH
§ 20.4 SOME PRACTICAL ADVICE
§ 20.4.1 Compromise of the Section 15 Lien
§ 20.4.2 When the Employee Proposes Allocations in the Third-Party Settlement
§ 20.5 THE STRUCTURED THIRD-PARTY SETTLEMENT AND THE HUNTER BENEFIT
§ 20.5.1 The Effect of a Lump Sum Settlement of the Workers’ Compensation Case on the Insurer’s Obligation to Pay a Hunter Benefit
§ 20.5.2 Securing Approval of a Third-Party Settlement
§ 20.5.3 Some Other Section 15 Decisions Worthy of Note
EXHIBIT 20A—DIA Circular Letter No. 319
EXHIBIT 20B—DIA Circular Letter No. 341
EXHIBIT 20C—Superior Court Memorandum and Order on Rhode v. Beacon Sales Company (1993)
EXHIBIT 20D—Checklist for Petitions Under G.L. c. 152, § 15
Chapter 21
Interaction Between Workers’ Compensation and Other Disability Benefits
§ 21.1 BASICS OF SOCIAL SECURITY DISABILITY
§ 21.2 SOURCES OF LAW AND INFORMATION
§ 21.3 DEFINITIONS
§ 21.4 THE DETERMINATION OF OFFSET
§ 21.5 PURPOSE OF OFFSET PROVISIONS
§ 21.5.1 Overview
§ 21.5.2 When Does Offset Cease?
§ 21.5.3 Tax Ramifications of Receipt of Social Security Disability Benefits
§ 21.5.4 Early Retirement and Social Security Disability Benefits
§ 21.5.5 The Effect of a Third-Party Settlement on Offset
§ 21.5.6 Miscellaneous Considerations
(a) Offset for Concurrent Entitlement
(b) Wage Continuation
(c) Penalties
§ 21.6 SUGGESTED ALLOCATIONS
§ 21.6.1 Excludable Expenses
(a) Attorney Fees
(b) Medical Bills
§ 21.6.2 Inchoate Rights
§ 21.6.3 Past Weekly Benefits
§ 21.6.4 Specific Benefits
§ 21.6.5 Future Disability—The Sciarotta / “Life Expectancy” Allocation
§ 21.6.6 Structured Settlements
§ 21.7 CONCLUSION AS TO SOCIAL SECURITY DISABILITY ISSUES
§ 21.8 INTRODUCTION TO ACCIDENTAL DISABILITY RETIREMENT
§ 21.9 COORDINATION OF PUBLIC EMPLOYEE’S WORKERS’ COMPENSATION BENEFITS WITH ADR BENEFITS
§ 21.9.1 Offset in General
§ 21.9.2 Exclusions from Offset
(a) Loss of Function and Disfigurement
(b) Medical Bills
(c) Vocational Rehabilitation Expenses
(d) Inchoate Rights
(e) Recovery of Offset Amount
EXHIBIT 21A—Department of the Treasury Letter (April 23, 2009)
EXHIBIT 21B—Sample Lump Sum Agreement
EXHIBIT 21C—Sample Letter to SSA
EXHIBIT 21D—SSA 1709
Chapter 22
The Relationship Between the Americans with DisabilitiesAct, Massachusetts Handicap Discrimination Law, and the Massachusetts Workers’ Compensation Act
§ 22.1 INTRODUCTION
§ 22.2 WORKERS’ COMPENSATION AND DISABILITY DISCRIMINATION LAWS: A BRIEF SUMMARY
§ 22.3 MASSACHUSETTS AND FEDERAL LAWS PROHIBITING DISCRIMINATION BASED ON DISABILITY
§ 22.3.1 Definitions of “Disability”
§ 22.3.2 Definitions of “Major Life Activity”
§ 22.3.3 Definitions of “Qualified” Individual
§ 22.4 THE RELATIONSHIP BETWEEN WORKERS’ COMPENSATION AND DISABILITY DISCRIMINATION LAW: SPECIFIC ISSUES
§ 22.4.1 Who’s Covered? Is an Employee Injured at Work “Disabled”?
(a) The “Substantial Limitation” Standard
Under the ADA
Under Massachusetts Law
(b) Does an Employee on Workers’ Compensation Necessarily Have a “Substantially Limiting” “Physical or Mental Impairment”?
In General
Under Massachusetts Law
Under the ADA
(c) Can Temporary Impairments Be “Substantially Limiting”?
Under the ADA
Under Massachusetts Law
(d) Do Mitigating Measures Preclude an Impairment from Being “Substantially Limiting”?
(e) Discrimination Based on a “Record of” an Impairment
Under the ADA
Under Massachusetts Law
(f) Discrimination Based on Being “Regarded as” Impaired
§ 22.4.2 “Working” as a Major Life Activity
(a) Under Massachusetts Law
(b) Under the ADA
§ 22.4.3 Preemployment Medical Examinations and Inquiries
(a) Relationship Between Prohibitions Against Inquiry and Employee Misrepresentation
Under Massachusetts Law
Under the ADA
(b) Relationship Between Prohibitions Against Inquiry and Employer Reimbursement
§ 22.4.4 Medical Examination and Inquiry of Current Employees
(a) Under Massachusetts Law
(b) Under the ADA
§ 22.4.5 Disclosure of Medical Exam and/or Inquiry Results
§ 22.5 REASONABLE ACCOMMODATION
§ 22.5.1 Reassignment to a Vacant Position
(a) Under Massachusetts Law
(b) Under the ADA
(c) Significance of Reasonable Accommodation for Injured Workers Seeking to Return to Work
§ 22.5.2 “Direct Threat” to Health or Safety
(a) Under Massachusetts Law
(b) Under the ADA
§ 22.5.3 Cost
§ 22.5.4 Collective Bargaining Agreements
§ 22.6 CONTRACTING WITH NONCOVERED ENTITIES
§ 22.6.1 Under Massachusetts Law
§ 22.6.2 Under the ADA
§ 22.7 RECOVERY OF DAMAGES AND APPLICABILITY OF THE COLLATERAL SOURCE RULE
§ 22.7.1 Under Massachusetts Law
§ 22.7.2 Under the ADA
Chapter 23
Medicare Reimbursement Rights and Enforcement Relating to Workers’ Compensation Cases
§ 23.1 BACKGROUND
§ 23.2 INSURER’S NOTICE OBLIGATIONS
§ 23.3 SETTLEMENT WHERE MEDICARE’S INTERESTS ARE IMPLICATED
§ 23.4 MEDICARE APPROVAL OF WCMSAs
§ 23.5 CONCLUSION
Chapter 24
Tips for Working with Insurance Company Claims Adjusters, SelfInsurance Groups, and SelfInsureds
§ 24.1 INSURANCE COMPANY CLAIMS ADJUSTERS, SELF-INSURANCE GROUPS, AND SELF-INSUREDS
§ 24.2 THE CLAIMS MANAGEMENT PROCESS FROM THE PERSPECTIVE OF THE SIGs AND THE SELF-INSURED EMPLOYER
§ 24.3 GOOD COMMUNICATION IS ESSENTIAL IN SETTLING A CLAIM
§ 24.4 SPECIAL ACCOUNT INSTRUCTIONS
§ 24.5 CREATE A “WIN-WIN” ENVIRONMENT
Chapter 25
The View from the Bench at Conference and Hearing*
§ 25.1 INTRODUCTION
§ 25.2 THE PARTIES AT CONFERENCE
§ 25.3 THE ADMINISTRATIVE JUDGE AT CONFERENCE
§ 25.4 PROCEDURE AT CONFERENCE
§ 25.5 PRESENTING THE MERITS AT CONFERENCES
§ 25.6 REMEDIES AVAILABLE AT CONFERENCE
§ 25.7 FEES AT THE CONFERENCE LEVEL
§ 25.8 APPEALS TO HEARING
§ 25.9 HEARINGS
Table of Cases
Table of Statutes, Rules and References
FEDERAL
MASSACHUSETTS
ADDITIONAL REFERENCES AND RESOURCES
Index