By Donna Motley, Vice President of Claims

Michigan Workers’ Compensation Administrative Rules dictate that once a claim form concerning an employee work related injury is submitted to the Workers’ Compensation carrier, the Workers’ Compensation carrier has 30 days to make a determination “of some kind”. A definite or final determination of benefits does not have to be made when a claim is first filed with the carrier; BUT the claim has to be addressed. If the initial investigation results in the carrier being able to make a determination that the claim is valid, benefits commence. Benefits would include authorization for medical testing and/or treatment, payment of related bills submitted and payment of wage loss benefits if/when applicable.

If the carrier is unable to make a valid determination within 30 days, it usually means additional investigation is necessary, medical records need to be obtained, written statements requested, a medical evaluation scheduled, etc. The 30 day clock is ticking, so the carrier has to file a form with the State of Michigan entitled Notice of Dispute. The Dispute includes the reason why it is being filed – under the above circumstances the reason would be “Further Investigation Required”, “Additional Information Required from Employee” or “Other”.

A Dispute can be filed for multiple reasons. If, after review of all the information provided or obtained in relation to the claim, it is determined the claim is not going to be accepted as a work related injury, a Dispute is filed indicating “Injury Not Work Related”. If we receive medical bills that are unrelated to a claimed injury, a Dispute is filed indicating “Medical Treatment not Related to Injury”. If an employee submits a request for mileage reimbursement and the carrier is unable to verify the dates of service within 30 days of receipt, a Dispute is filed to explain the employee has not been reimbursed (and why). If a treating physician imposes restrictions in relation to the work injury and the employer is able to accommodate said restrictions but the injured worker refuses to return to the light duty work, a Dispute is filed indicating “Work Avoidance”. When injured workers have refused to attend medical appointments and/or therapy, we have filed a Dispute indicating “Non-complaint with Recommended Medical Treatment” or “Claimant Refusing Medical Treatment”.

Even if a claim has been accepted and benefits are being paid, we can stop benefits by filing a Dispute. We’ve had cases where the injured worker became incarcerated, cannot be located, or no one can get in touch with them – filing a Dispute will “suspend” their benefits. If a claim has been accepted and benefits are being paid but additional information or medical records become available that contradict the validity of the claim, we can stop benefits by filing a Dispute.

There is no expiration date in terms of the Dispute. But, because a Dispute is filed at some point in time during the life of a claim, does not mean the claim won’t or can’t be accepted at a later date. Again, filing a Dispute protects the Workers’ Compensation carrier by indicating the Rules are not being violated and the alleged claim and injured worker is being acknowledged.

Filing a Dispute keeps the State informed that the claim is not proceeding as it should, but that we are performing our due diligence. The State of Michigan publishes statistics for the year listing the Total Claims filed and the percent of Disputed Claims of those filed. While I am not totally sure how they calculate the Total Claims filed, I would assume they are only referring to Indemnity Claims where wage loss would be due/paid. The most recent State statistic covering 1/1/2021 through 12/31/2021 for Manufacturing Technology Mutual Insurance Company indicates Disputes filed were 7.59% of claims.

Per the Rules, most of claims handling is to be conducted in 30 day windows. Filing a Dispute more or less “Stops the Clock”.