Opinion ID: 2101620
Heading Depth: 1
Heading Rank: 2

Heading: level of incapacity

Text: The only difficult issue in interpreting this statute is determining what it is that an employer must begin paying within the first 14 daysfor whatever it is, the employer is committed to that amount until it obtains Commission review: If, at the end of the 44-day period the employer has not filed a notice of controversy,... the payments may not be decreased or suspended, except as provided in section 100 [concerning petitions for review]. 39 M.R.S.A. § 51-B(7) (Pamph.1988). There are three choices: benefits at the level of incapacity that the employee actually suffered; benefits for total incapacity in all cases; or benefits at the level of incapacity that the employee claimed when he or she attributed lost work time to a work-related injury. The Commission and the Appellate Division concluded in both cases that benefits for total incapacity were due regardless of the employees' actual degree of incapacity. In Stickles' case, the Commission reached that conclusion as a matter of law because of UPS's failure to file a notice of controversy. In Faloon's case, it reasoned that Combustion's liability was determined by Faloon's claim, a claim that it found was for total incapacity benefits. UPS and Combustion, on the other hand, argue that because section 51-B(3) requires compensation for either total or partial incapacity (sections 54-B and 55-B respectively), the level of incapacity is always an open question and the Commission must base any award, not on what the employees claimed nor on any presumption of total incapacity, but on what Stickles' and Faloon's degree of incapacity actually was as of the time of work loss. We conclude that the Commission and the Appellate Division employed the correct approach in Faloon's case by determining the nature of the original claim, and erred in Stickles' case by determining that, as a matter of law, a claim is for total incapacity. First, we reject UPS's and Combustion's argument that the statute limits the effect of their defaults solely to the concession that the incidents were work-related and that they are free now, despite their failure either to pay benefits or to file a notice of controversy, to litigate the issue of past incapacity. Such a narrow reading of the language (constitutes acceptance by the employer of the compensability of the injury or death) makes no sense within the overall structure of the early pay provisions, which are designed to encourage early and prompt payment of benefits. Accepting the employers' argument would permit employers to delay all payments for a work-related injury and to contest the level of benefits retroactively no matter how late they filed a notice of controversy. This outcome would increase employers' incentive to delay payment in work-related injuries, a result directly contrary to the statute's objectives. Second, we see no basis in the statute for the Commission's ruling in Stickles that every employee notice of lost time due to a work-related injury is conclusively presumed to be a claim for total incapacity. Instead, the statute specifically contemplates that under the early pay system, benefits may be due at a level of either partial or total incapacity. 39 M.R.S.A. § 51-B(3) (Pamph.1988). Third, we conclude that the overall structure of section 51-B contemplates an employee claim and that this claim should determine the level of incapacity when no payments have been made and no notice of controversy filed. It is true that the statute does not contemplate formal claims at this early stage; nowhere is there reference to a claim procedure. Instead, once an employee reports to an employer that lost work time is attributable to a work-related injury, the employer is obligated to report that injury to the Commission within seven days. 39 M.R.S.A. § 106(1) (Pamph. 1988). The Commission is then directed to contact the employee immediately and inform the employee of his or her rights. 39 M.R.S.A. § 94-A(1) (Pamph.1988). Thereafter the Commission is supposed to monitor cases to insure that [e]ither payments are initiated or notice of controversy is filed within the time limits established in section 51-B, subsections 3, 4 and 7 and that the claimant receives the full amount of compensation to which he is entitled. 39 M.R.S.A. § 94-A(2)(A) & (B) (Pamph. 1988). But it is apparent that the statute contemplates a claim of some sort. In its very first subsection concerning the effective date, section 51-B refers to all claims arising out of injuries. In its second subsection requiring prompt and direct payment to employees, it excepts instances where the claim to compensation is controverted.... Subsection 4 dealing with compensation for medical expenses refers to a request ... made for payment. Subsection 7, dealing with the notice of controversy, provides that an employer shall file such a notice before making early payments if the employer controverts the claim to compensation ... Subsections 8, 9 and 10 likewise refer to a claim for compensation. Although subsection 3 requires payment for either total or partial incapacity not within 14 days of a claim, but within 14 days of the date the employee asserts to the employer that ... lost time is related to the injury (within 14 days of employer notice or knowledge of the injury or death in the case of immediately lost work time), it is difficult to read this language as not contemplating some sort of claim or request by an employee. It would be impossible for an employer to know how much to pay within the first 14 days without some indication of an employee's demand. And clearly there must be something to controvert before an employer can know what to file in its notice of controversy. The knowledge that lost time is workrelated is only one element in deciding what benefits, if any, to pay; in addition, the employer will want to know what level of incapacity the employee claims. Thus, it is the employee's claim that we conclude is retroactively binding upon the employer who fails to comply with the statute's command to pay benefits or file a notice of controversy. Since the employee is obligated only to notify the employer of lost time, we recognize that the claim will sometimes be only implicit and will require reconstruction by the Commission. [1] But this is the only interpretation of the statute that is consistent with its objective of encouraging early payment of benefits with a minimum of lawyer involvement and litigation. The Legislature must simply have believed that the nature of an employee's claim would be sufficiently obvious in most cases that no further specificity was necessary. UPS and Combustion argue that this construction of the statute will generate unjustified windfalls to employees who are not totally incapacitated or at least not incapacitated to the degree they claim. It is true that under our holding, an employer's failure to file a notice of controversy compels it to pay retroactively whatever its employee's claim was; that is the penalty the statute levies for the employer's failure to comply with its notice requirements. The statute also provides adequate safeguards against future overpayments, however. Specifically, nothing in the statute prevents an employer from filing a petition for review under 39 M.R.S.A. § 100 (Pamph.1988) as soon as it becomes aware that an employee has petitioned the Commission to award such benefits. The Commission could then hear both petitions on a consolidated basis (unless that would unduly delay hearings on the employee's petition). The result, of course, would be that the employer would be ordered to pay retroactively at the level of the claim until the date of the Commission's decision, but thereafter only at the level of incapacity decreed by the Commission on the petition for review.