Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 15 - PENALTIES › Section 351-15-8 - Assessment of Penalties under 39-A M.R.S.A. section 359(2)

Current through 2024-29, July 17, 2024
1. Pursuant to
				39-A M.R.S.A.
				§152(7), the Maine
				Workers' Compensation Board delegates to the Workers' Compensation Board Abuse
				Investigation Unit the authority to recommend the imposition of penalties
				pursuant to §359(2). The Board designates the Executive Director, or the
				Executive Director's designee, to be the Presiding Officer for hearings
				conducted pursuant to this rule. The Presiding Officer shall have the authority
				to assess civil penalties, after hearing, pursuant to §359(2).
2. Any party in interest may file a
				§359(2) complaint with the Abuse Investigation Unit. The Abuse
				Investigation Unit may also initiate action, either on its own, or on referral
				from the Monitoring, Audit, and Enforcement (MAE) Program. The Abuse
				Investigation Unit will investigate all complaints and, as part of the
				investigation, may require the parties to submit written evidence concerning
				the complaint or complaints, including position papers.
3. Upon completion of the investigation, the
				Abuse Investigation Unit will determine whether the allegations, if true,
				demonstrate that an employer, insurer, or 3rd-party administrator for an
				employer has engaged in a pattern of questionable claims-handling techniques or
				repeated, unreasonably-contested claims. For purposes of this rule, a claim is
				unreasonably contested if there is no articulable basis for contesting the
				claim, or the claim is contested upon a basis that is contrary to law or
				rule.
4. If so, the subject of the
				investigation will be notified that the matter is being referred for hearing
				and possible imposition of civil penalties. If not, further investigation under
				§359(2) will be denied.
5. The
				Presiding Officer will schedule and hold a hearing in referred cases. The
				Presiding Officer will issue a hearing order to the parties concerning the
				procedure to be followed before and during the hearing, including the
				submission of additional evidence and the filing of motions. In cases where a
				party is alleging that an employer, insurer, or 3rd-party administrator for an
				employer has engaged in a pattern of questionable claims-handling techniques or
				repeated, unreasonably-contested claims, the burden will be upon the
				complaining party to prove its contentions. In cases where there is no specific
				complaining party, the Abuse Investigation Unit will present evidence acquired
				during, or as a result of the investigation. In all cases, the Presiding
				Officer will actively participate to ensure that all relevant information is
				considered prior to issuing findings. If necessary, the Presiding Officer may
				request further investigation by the Abuse Investigation Unit if circumstances
				warrant.
6. To prevail, the moving
				party must show by a preponderance of the evidence that an employer, insurer,
				or 3rd-party administrator for an employer has engaged in a pattern of
				questionable claims-handling techniques or repeated, unreasonably-contested
				claims.
7. In cases where there is
				a finding that an employer, insurer, or 3rd-party administrator for an employer
				has engaged in a pattern of questionable claims-handling techniques or
				repeated, unreasonably-contested claims, the Presiding Officer, in determining
				the amount of penalty to be assessed, shall consider the severity of the
				offense, and any previous adverse determinations under §359(2) against the
				employer, insurer, or 3rd-party administrator for an employer.
8. All findings and conclusions shall issue
				in a written order. Decisions rendered by the Presiding Officer shall be
				appealable to the Law Court as provided in
				39-A M.R.S.A.
				§322.
9. All decisions rendered by the Presiding
				Officer shall be presented to the Board. The Board shall certify its findings
				to the Superintendent of Insurance. This certification by the Board is exempt
				from the provisions of the Maine Administrative Procedure Act.