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DIA Did Not Always Meet Its Mandated Timeframes for Completing Certain Case Claim Events.

68% of the conferences that were completed during the audit period were not processed within the mandated timeframe.

Table of Contents

Overview

DIA did not always meet timeframes for the overall completion of four types of single-case claim event for which it has mandated timeframes: conferences, conference orders, hearings, and hearing decisions. As a result, cases could become backlogged and individuals could suffer economic losses because of delays in case processing.

For the 10,114 single-case claims that were heard during our audit period, 4,540 (42%) of the 10,695 associated claim events were completed within the mandated timeframes. For example, as detailed in the table below, 68% of the conferences that were completed during our audit period were not processed within the mandated timeframe; on average, they were 89 days late.

Analysis of Completed Single-Case Claims by Claim Event

Claim Event

Timeframe (Days to Complete)

Completed Claim Events

Claim Events Exceeding Timeframe

Percentage of Claim Events Exceeding Timeframe

Average Days Past Timeframe

Maximum Days Past Timeframe

Minimum Days Past Timeframe

Conference

28

6,659

4,537

68%

89

203

29

Conference Order

7

2,532

178

7%

19

123

8

Hearing

28

1,479

1,419

96%

159

785

29

Hearing Decision

28

25

21

84%

134

324

71

 

In addition, DIA did not consistently meet timeframes for three types of group-case claim event for which it has mandated timeframes: conferences, hearings, and hearing decisions. Of the 11,451 claim events of these three types whose cases were heard during our audit period, 7,561 (66%) to 9,554 (83%) were not completed within the mandated 28-day timeframe. In addition, 1 of the 24 conference orders we tested did not meet the mandated 7-day timeframe.

Authoritative Guidance

According to Section 10A(1–3) of Chapter 152 of the General Laws,

The administrative judge shall require the parties to appear before him for a conference within twenty-eight days of receipt of the case by the division of dispute resolution. . . .

Within seven days of the conclusion of the conference the administrative judge shall file:

(a)  a written order requiring or denying that weekly compensation or other benefits be paid; or

(b)  a written order modifying, terminating, or denying modification or termination of weekly compensation or other benefits. . . .

[An appeal] hearing shall be held within twenty-eight days of [DIA’s] receipt of such appeal.

According to Section 11 of Chapter 152 of the General Laws, a hearing decision “shall issue within twenty-eight days of the conclusion of the hearing.”

Reasons for Issue

DIA management stated that these timeframes were impractical because DIA has to coordinate the availability of the court, the judge, and all parties involved, along with their respective attorneys. Additionally, DIA management cited case law, Rapo v. American Optical Corp. 1988 MA Workers’ Comp Rep. 245–247, and stated that their interpretation of Section 11 of Chapter 152 of the General Laws was that the 28-day timeframe is advisory and not a mandate.

However, our conclusion is that the statute is mandatory regarding the timeframes. The case sent by DIA (Mass. Workers’ Comp. Rep. 245), and the Superior Court and Supreme Judicial Court cases from which it was derived (e.g., Cheney v. Coughlin, 201 Mass. 204 [Mass. 1909]), stand for the proposition that a late decision is valid. The timeframes are still statutorily required, and “officers may be liable to legal animadversion [adverse criticism], perhaps to punishment, for not observing” such timeframes (Cheney at 212).

In addition, DIA management stated that they did not have written policies and procedures to ensure that case events were completed within the required timeframes.

Recommendation

DIA should develop policies and procedures regarding the completion of single- and group-case claim events to ensure consistency in meeting its timeframes.

Auditee’s Response

The Department of Industrial Accidents (DIA) is responsible for facilitating the fair allocation of all claims and complaints, for ensuring each administrative judge receives a balanced and equitable case load during the calendar year, and for adjudicating each claim in a timely manner. To ensure progression of each case, the DIA regularly contacts parties of each case to ensure necessary information has been received, or any conflicts preventing receipt of information [are] resolved. The DIA will continue its efforts to meet the 28-day timeframe specified in the statute. Because each case presents its own unique facts and considerations, the 28-day timeframe may not be consistently achievable. Cases delayed beyond the 28-day timeframe are a direct result of the processes completed by external parties to ensure that complete and accurate information is available and presented in each case. Accordingly, for almost three decades, the extended timeframe between Conciliation and Conference has been viewed by insurance carriers, attorneys, and the DIA as an acceptable best practice.

Auditor’s Reply

The Office of the State Auditor acknowledges that certain case claim event processing times vary widely because of several factors, some of which may not always be in DIA’s control. However, as noted above, during our audit period, 58% of single-case claim events, and a minimum of 66% group-case claim events for conferences, hearings, and hearing decisions, did not meet mandated timeframes prescribed by Sections 10A(1–3) and 11 of Chapter 152 of the General Laws. We believe this indicates significant problems in this area, which DIA needs to address as far as possible. As noted above, delays in case processing could cause economic losses for some individuals. Therefore, we recommended that DIA should develop policies and procedures regarding the completion of single- and group-case claim events to ensure consistency in meeting its timeframes.

We acknowledge that it is ultimately up to DIA management to determine what measures it can and should take to improve this process given DIA’s available resources. Based on its response, DIA is taking some measures to address our concerns in this area. We urge DIA to fully implement our recommendation.

Date published: March 23, 2021
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