Section EMP.04.13 — Dispute Resolution Procedures

(a) Application. Any party to a worker's compensation claim can initiate dispute resolution by filing a written petition for dispute resolution with the Mohican Nation Insurance Department of the Stockbridge-Munsee Community within 30 days of the insurer's initial decision regarding a claim. Parties are allowed a 5 day grace period for filing this petition. A filing fee of $25.00 must be submitted with the petition.

(1) The petition may be in any written format and shall at least contain the following:

(A) the name and address of the petitioner;

(B) a statement identifying the controversy for which dispute resolution is sought;

(D) a summary of the previous proceedings and decision regarding the claim; and

(E) a specific request stating the required relief.

(2) The petitioner shall serve a copy of the petition on all other parties in interest.

(3) The ALJ may bring in additional parties by service of a copy of the petition, if necessary.

(b) Answer. The respondent shall file an answer to the petition for dispute resolution within 20 days. The answer shall also be filed with the Mohican Nation Insurance Department and a copy served on the petitioner and provided to all other parties in interest.

(1) the petition is incomplete and the petitioner does not complete it upon request; or

(2) review of the petition and answer indicate that the petition is groundless.

(d) Notice. If dispute resolution proceedings are appropriate, the ALJ shall schedule a hearing based on the petition and provide notice of the hearing to each interested party, by serving such notice on the interested party personally or by mailing a copy to the interested party's last-known address at least 10 days before such hearing.

(e) Hearing. The parties shall have a full, fair hearing on the merits of the dispute.

(1) Prior to a hearing on the merits, the ALJ may order the parties to clarify issues and disclose or exchange information that may assist in the disposition of the disputed matter.

(2) If a hearing is required, the ALJ shall schedule an initial informal conference to discuss preliminary matters with the parties, including scheduling, motions, and discovery within 30 days after the respondent's answer is filed. The hearing shall be scheduled no later than 30 days following this conference, except that this time may be extended for an additional 30 days upon a finding of good cause.

(f) Record. The ALJ shall develop and maintain a full record of dispute resolution proceedings.

(g) Participation. All parties concerned have the right to be present at any hearing, in person or by attorney or other agent, and to present such testimony as may be pertinent to the controversy before the ALJ. Participation via telephone will be allowed upon the ALJ's discretion.

(h) Burden of Proof. The petitioner has the burden of proof to establish his or her claim beyond a legitimate doubt.

(i) Subpoena. Any party, including the ALJ, may issue a subpoena to compel the attendance of a witness or the production of evidence at the hearing by service of a subpoena upon the person, along with a tender of witness fees.

(j) Evidence. The parties have a right to present relevant evidence regarding the disputed claim. Opposing parties have the right to cross-examine persons testifying as to such evidence and present information to question such evidence. The ALJ shall take care to ensure that the evidence presented is credible.

(k) Medical Evidence. The contents of certified medical reports by licensed practitioners, who have examined or treated the worker, may be used as prima facie evidence regarding the matter contained in them, instead of requiring the practitioner to testify in person. The ALJ may not admit into evidence a certified report that was not filed with the ALJ and all parties in interest at least 10 days before the date of the hearing, unless the ALJ is satisfied that there is good cause for the failure to timely file the report.

(l) Independent Evidence. The ALJ may, with or without notice to any party, cause testimony to be taken, an inspection of the premises where the injury occurred to be made, the time books and payrolls of the employer to be examined, or may direct any worker claiming compensation to be examined by an independent doctor, if such information is needed to resolve the dispute.

(1) The testimony so taken, and the results of any such inspection or examination, shall be reported to the ALJ for its consideration.

(2) All information gathered for the ALJ shall be provided to the parties and any party shall have opportunity to question the evidence at the hearing.

(3) The expense of such examination shall be paid out of the ALJ's budget.

(m) Time Limitations. The right to proceed in dispute resolution shall not extend beyond 4 years from the date of the injury or the date that compensation, other than treatment or burial expenses, was last paid. Payment of wages by the employer, during disability or absence from work to obtain treatment, shall be deemed payment of compensation for the purpose of this Section, if the employer knew of the worker's condition and its alleged relation to the employment.

(n) Expense Statement. Unless otherwise agreed to by all parties, an injured worker shall file with the ALJ and serve on all parties, at least 10 days before the date of the hearing, an itemized statement of all expenses claimed by the injured worker.

(1) The itemized statement shall include, if applicable, information relating to any travel expenses incurred by the injured worker in obtaining treatment, including the destination, number of trips, round trip mileage, and meal and lodging expenses.

(2) The ALJ may not admit into evidence any information relating to expenses claimed by an injured worker, which was not filed in a timely manner, unless the ALJ is satisfied that there is good cause for the failure to file and serve the itemized statement.