§ 10 — Claims for benefits; complaints requesting modification or discontinuation of benefits; conciliation

Section 10. (1) Any claim for benefits shall be filed with the division of administration and the insurer on a form prescribed by the division, and shall specifically state the benefits claimed to be due and unpaid. No claim for weekly compensation shall be accepted by the department unless it is either accompanied by a copy of an insurer's notification of denial pursuant to section seven, or at least thirty days have passed from the alleged onset of disability.Unless otherwise expressly provided, on the receipt of a claim for compensation, a complaint from the insurer requesting a modification or discontinuance of benefits, or a complaint from any party requesting resolution of any other issue arising under this chapter, the division of administration shall notify the parties that it is in receipt of such claim or complaint, and may request the parties to appear and submit relevant information. The conciliation unit within the division of dispute resolution may attempt to resolve the claim or complaint by informal means and the parties shall cooperate with any conciliator assigned to the case. The assigned conciliator shall withdraw without prejudice the claim or complaint of any party that fails to cooperate or to produce requested material.In order for an attorney's fee to be required under section thirteen A, pursuant to a dispute over a claim for benefits under this chapter, such claim shall have been sent to the insurer by certified mail. No attorney's fee shall be due for services involving a claim sent to the insurer which does not include a copy of a medical report relevant to the alleged claim in the possession of the employee or his attorney. In order for any attorney's fee to be due for services involving a claim for health care services, such claim shall include a copy of any relevant bill and a description from the health care provider of the services rendered. No attorney's fee shall be due for services involving claim for benefits for loss of function or disfigurement under section thirty-six unless such claim includes a copy of a letter from a physician describing the location and extent of the alleged loss of function or disfigurement and the specific amount requested for compensation therefor. No attorney's fee shall be due for services involving claims for mileage reimbursement unless such claims delineate the date and purpose for the travel, identity of the medical provider and mileage of each trip for which reimbursement is sought. No attorney's fee shall be due for any claim solely involving unpaid attorney's fees or expenses for past services.(2) Any claim or complaint shall be referred to the industrial accident board within fifteen business days of its receipt by the division of administration unless:(a) the moving party fails to appear on request of the conciliation unit or provide requested information;(b) a conciliator authorizes an extension of the conciliation period, attaching the reasons therefor to the case file, or(c) the conciliator receives an agreement signed by the parties, on a form prescribed by the department, indicating that they will abide by the findings of an independent arbitrator chosen by such parties to make findings as to compensation pursuant to section ten B. Any conciliator, within their departmental capacity, may also be chosen by the parties to serve as the arbitrator. Said agreement may specify that any subsequent claim or complaint regarding the instant injury shall, after having been filed with the department, and, provided that such subsequent claim or complaint has not been successfully mediated by the assigned conciliator, be forwarded to the same or other agreed upon arbitrator and not be referred to the division of dispute resolution. When presented with such a signed agreement, the assigned conciliator shall mark the case as forwarded to arbitration.Any party aggrieved by an extension of the conciliation period or by the conciliator's withdrawal of a claim or complaint may file a written appeal with the senior judge who, if all requested information has been submitted, shall set a date for referral to the industrial accident board.(3) In any instance in which the respondent to a claim or complaint either fails to appear or is not authorized to negotiate, enter into and sign agreements as to compensation at a conciliation, said claim or complaint shall forthwith be referred to the industrial accident board.(4) In each instance in which a claim or complaint is referred to the industrial accident board following a conciliation, the conciliator to whom the case was assigned shall forward a written report setting out the issues in controversy and the information he deems to support:(a) his recommendation that weekly compensation or other benefits should or should not be paid;(b) his recommendation that weekly compensation or other benefits should or should not be modified or terminated; or(c) his report that the information available at the conciliation is insufficient for determining whether weekly compensation or other benefits should be paid, modified, or terminated.(5) In each instance in which a claim for compensation is referred to the industrial accident board, the insurer shall pay a fee of sixty-five percent of the average weekly wage in the commonwealth at that time; provided, however, that in the event that the insurer failed to appear at a scheduled conciliation, and such failure was not beyond the control of said insurer, the referral fee shall be one hundred and thirty percent of the average weekly wage in the commonwealth at that time. In such event the referral fee shall not be included in any formula utilized to establish premium rates for workers' compensation insurance. Any referral fee shall be paid into the Special Revenue Fund established pursuant to section sixty-five. If, prior to a claim or complaint being scheduled before an administrative judge, the parties shall forward to the senior judge a written arbitration agreement pursuant to section ten B, the department shall refund any referral fee for such claim or complaint paid under this section.(6) Whenever, with respect to a case in which liability is not an issue, a claim for additional compensation or a complaint to discontinue or modify compensation is the subject of conciliation the case shall not be referred to the industrial accident board until each party shall have filed with the conciliator a written offer which such party believes to be the amount of weekly compensation due the claimant under this chapter. If the claimant fails to file such offer within any time limit set forth by the conciliator assigned to the case, such conciliator shall file, on behalf of such claimant, an amount equal to the last best offer made by such claimant, or if no offer was made, the maximum compensation rate in the commonwealth, indicating that it was filed by said conciliator. If the insurer fails to file such offer within any time limit set forth by the conciliator assigned to the case, such conciliator shall file, on behalf of such insurer, an amount equal to the last best offer made by such insurer, or if no offer was made, the amount of zero, indicating that it was filed by said conciliator.