AP Rules Carrier Had No Obligation to Send SIBs Application to Claimant
The appeals panel has reversed the decision and order of a benefit contested case hearing officer that found a claimant to be entitled to Supplemental Income Benefits. The appeals panel ruled that the claimant was not entitled to the SIBs based on his argument that the carrier failed to send him a correctly completed DWC-52 form for the second quarter. The panel concluded that no obligation had been triggered under the facts of the case. The appeal is posted in Texas Division of Workers’ Compensation Appeals Panel Decision No. 170747, decided June 14, 2017.
The Division issued an initial determination that the claimant was not entitled to SIBs for the first compensable quarter. The carrier sent the claimant a second quarter SIBs application for the dates based on the certification of MMI and IR assigned by the DD. Shortly thereafter, the Division issued a decision and order that certified MMI on a different date with a 15 percent IR. The carrier send the claimant another SIBs application for the second quarter based upon the dates calculated using the hearing officer’s determinations. However, the claimant filed his SIBs application using the first DWC-52. That application indicated that the claimant had failed to engage in an active work search effort for at least two of the weeks reflected on the application.
Although it was undisputed that the claimant failed to demonstrate an active effort to obtain employment by meeting at least one or any combination of the work search requirements contained in Rule 130.102(d)(1) each week during the entire qualifying period, the claimant argued that he was entitled to SIBs for the second quarter. The claimant argued that the carrier had failed to send him a properly completed application for SIBs and that it was not entitled to challenge his entitlement to SIBs because of that failure. He hearing officer agreed and order the carrier to pay claimant SIBs for the second quarter.
The appeals panel reversed the hearing officer’s decision of entitlement. The panel first observed that Rule 130.104(b) requires that a carrier send a DWC-52 for a subsequent quarter with either the first payment for a quarter of SIBs to which the claimant is determined to be entitled or with the carrier’s determination of nonentitlement for that quarter. Citing Appeals Panel Decision 021776. Thus, the appeals panel reasoned that duty of a carrier to send the application arises only with either the first payment of SIBs or a determination of nonentitlement for any quarter. Because it was undisputed that the Division determined the claimant was not entitled to SIBs for the first quarter, the carrier’s obligation to send the claimant a SIBs application for the second quarter had never been triggered at the time it first did so.
Nevertheless, the hearing officer clearly based her determination that the claimant was entitled to SIBs for the second quarter upon her finding that the carrier failed to comply with its purported obligation under Rule 130.104(b) to provide the claimant with a DWC-52 containing accurate information regarding the dates of the qualifying period and her further finding that the claimant performed the required number of work search contacts after he received the second DWC-52 on June 27, 2016, containing the correct dates of the qualifying period at issue.
The appeals panel held that the hearing officer erred, as a matter of law, in basing her decision on the carrier’s failure to send a DWC-52 form for the second quarter as required by Rule 130.104(b), because no such obligation was triggered under Rule 130.104(b), since the carrier never sent a monthly payment for a SIBs quarter nor did it make a determination of nonentitlement after the Division’s initial nonentitlement determination for the first quarter.
Rule 130.102(d)(2) provides that an injured employee who has not met at least one of the work search requirements in any week during the qualifying period is not entitled to SIBs unless the injured employee can demonstrate that he or she had reasonable grounds for failing to comply with the work search requirements under this section. As mentioned earlier, it is undisputed that the claimant failed to demonstrate an active effort to obtain employment by meeting at least one or any combination of the work search requirements contained in Rule 130.102(d)(1) each week during the entire qualifying period; however, the hearing officer made no finding in her Decision and Order regarding whether the claimant had reasonable grounds under the evidence presented for failing to comply with work search requirements in weeks one and four of the qualifying period for the second quarter.
The appeals panel did not render a decision of entitlement for the carrier, however. Instead, it remanded the issue of entitlement to SIBs for the second quarter to the hearing officer to determine whether the claimant had reasonable grounds for failing to comply with the work search requirements under Rule 130.102 during each week of the qualifying period for the second quarter of SIBs.
FOLIO
