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7:02:18 PM CDT
Wednesday, July 23, 2014

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Disputing a Claim Decision

If a Claim or a Benefit is Reduced or Denied, and You Disagree With the Decision:

You still have options. Please read the 6 steps listed below that outline the hearing process (appeals):

  1. Notice of Decision

    If you receive a Notice of Decision, and you believe this decision is wrong, you must write to WSI within 30 days of the date the Notice was mailed to you, asking to have the decision reconsidered (this must be in writing). You must explain why you think the decision is wrong, the relief being sought, and any additional information you want WSI to consider. Please include your claim number on all correspondence. If you do not request written reconsideration within 30 days, the decision becomes final. If you do request reconsideration, one of two things will happen next:

    • If, after reviewing the additional information you provided, WSI agrees with you that its decision was wrong, WSI will reverse the Notice of Decision and award benefits

    • - or -
    • If WSI does not agree that its decision was wrong, WSI will issue an administrative order further explaining the reasons for the decision.

  2. Administrative Order

    The administrative order either awards benefits or denies benefits and provides greater detailed facts and legal analysis. If you receive an order from WSI and you believe the decision is wrong, you have two choices.

    • You can contact the Decision Review Office within 30 days from the date the order was mailed to you. In your letter, explain why you think the decision is wrong or explain what other assistance you would like (see #3 below - also see the Attorney Fees section)

    • - or -
    • If you choose not to seek the assistance of the Decision Review Office, you can write to WSI and request a hearing (see #4 below). If you do not request assistance from the Decision Review Office or request a hearing within 30 days from the date the order was mailed to you, the order becomes final and may not be appealed.

  3. Decision Review Office (DRO)

    DRO provides no-cost assistance to workers attempting to resolve disputed issues on a claim. Decision review specialists help avoid costly and lengthy litigation. The program opens the lines of communication between parties and offers an independent review of the claim. Decision review specialists act on behalf of the worker and communicate with WSI staff.

    A worker typically makes contact with DRO due to the following:

    • Receipt of a legal order
    • Receipt of a Notice of Decision (NOD)
    • Receipt of a Notice of Intention to Discontinue / Reduce Benefits (NOID)

    A worker may also contact DRO:

    • If 60 days have passed from the time WSI received all the initial claim reporting forms from the worker, the employer, and the medical provider and a decision of acceptance or denial has not yet been made on the claim
    • If a worker has concerns about a vocational consultant's report (return-to-work plan).

    DRO provides the following services:

    • General information regarding workers' compensation processes
    • An explanation of the basis of WSI's decision
    • A review of the claim to identify factors that may justify reconsideration of the claim
    • Possible resolutions (with the worker's input) of the dispute
    • A letter outlining DRO's findings

    The information assembled by DRO, including communications from a worker, are privileged and may not be released without the worker's permission.

    You may contact the Decision Review Office by:

    • Visiting our office at 1611 East Century Avenue, Suite 402 in Bismarck, ND. No appointment is necessary, but you may wish to call ahead to ensure an decision review specialist is available to meet with you upon arrival.
    • Calling (701) 328-9900 or 1-800-701-4932
    • E-mailing us at: Decision Review Office
    • Faxing (701) 328-9911
    • Writing to 1611 East Century Avenue, Suite 402, Bismarck, ND, 58503-0780


  4. Administrative Hearing

    A hearing request must be made to WSI in writing, and you must explain why you disagree with WSI's decision. Don't worry about legal terminology or format, just state in your own words what you feel is specifically wrong with WSI's decision and what you feel should be done to correct it. You should also include any additional information that you believe will show why the order is wrong. Your written request for hearing must be received by WSI within 30 days from the mailing date of the Certificate of Completion which you received from the Decision Review Office or within 30 days from the date the administrative order was mailed to you if you chose not to have the Decision Review Office review your order.

    WSI will review your request for a hearing, and, if WSI still believes its decision is correct, your claim will be assigned to one of the attorneys who represent WSI in claims disputes. These attorneys work in private law firms throughout the state. WSI's attorney will request that the Office of Administrative Hearings appoint an Administrative Law Judge (ALJ) to conduct a hearing.

    The Administrative Law Judge is an attorney, independent of WSI, who will hear the facts of your claim and make a recommendation to WSI on whether WSI's decision is correct. Once an Administrative Law Judge has been appointed, a notice of the date, time, and location of the hearing will be mailed to you. You may attend the hearing and testify, and you may also bring witnesses or other evidence you have which supports your claim. You may hire an attorney to represent you during the hearing process (payment of attorney fees is explained below). Your employer may also attend the hearing.

    Prior to the hearing, WSI's attorneys may contact you for additional information, and they may send you written questions to answer. This may take anywhere from a few weeks to a few months, depending on the complexity of the case. If you have an attorney, he or she will work with you and answer most questions. If you do not have an attorney and do not understand any part of the process, you should contact the WSI lawyer assigned to your case or your claims adjuster.

    After the hearing, the ALJ will usually issue a decision within 30 days.

  5. District Court Appeal

    If you disagree from the final decision of the Administrative Law Judge after an administrative hearing, you may appeal to a North Dakota District Court. While not required, it is strongly urged that you retain an attorney for any appeals to District Court or the Supreme Court. The appeal must be in writing and must be filed with the Clerk of District Court within 30 days of the date the administrative order was mailed to you. If you live in North Dakota, you may file in either the county where you live or the county where the injury occurred. You should contact the Clerk of Court for your county if you have any questions on procedures or costs in filing an appeal to District Court.

    In an appeal to the District Court, the District Court judge will review the documents contained in WSI's file and make a determination as to whether the Administrative Law Judge’s findings are supported by the evidence and by the law. Testimony is not taken, but the judge may ask you and WSI for additional information on the law. You and WSI (and your employer if they choose to be involved) will explain to the court, in writing, their positions, and then the judge will make a decision and enter judgment.

  6. Supreme Court Appeal

    If you disagree with the opinion of the District Court judge, you may file a written appeal with the clerk of the District Court for a North Dakota Supreme Court appeal. This appeal must be filed within 60 days of the date judgment is entered in District Court.

    You and WSI (and your employer if they choose to participate) will submit written briefs to the court explaining their positions. Oral arguments are normally held before five Supreme Court Justices. The Supreme Court reviews WSI's decision, not the decision of the District Court judge, and will ensure that it is in accordance with the law and supported by the facts of the case. The Supreme Court does not hear new evidence or listen to testimony of witnesses. It may take anywhere from one month to several months for the Supreme Court to render a decision on your claim.

Deciding Whether You Need to Hire an Attorney:

Hiring an attorney is advisable at the District Court and Supreme Court levels of appeal.

Attorney Fees:

A worker is not required to seek assistance from DRO. However, attorney fees will only be paid by WSI, up to the caps provided in the North Dakota Administrative Code, if the worker first seeks DRO's assistance and subsequently prevails on further appeal of an order.

The Hearing Process:

It can take anywhere from six weeks to several months for a hearing to be scheduled.

Employer Attendance at the Hearing:

While your employer is not required to attend the hearing, they may be asked to attend and present testimony by you or WSI. They also may choose to take part on their own.

If you disagree with the Administrative Law Judge’s Order issued after an Administrative Hearing.:

An appeal may be filed with the District Court within 30 days of the date you receive the Administrative Law Judge’s order.

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