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Letters of Determination

In Nevada worker’s compensation claims, a letter of determination is issued by the industrial insurance carrier. It is the insurer’s way of telling the injured worker whether the insurance adjuster is going to approve or deny something. For example, it may give the injured worker notice that the claim is accepted, or denied; that treatment is approved or denied; or whether or not the injured worker is going to receive a settlement (permanent partial disability award). Some injured worker’s confuse determinations with decisions. Remember, the insurer issues determinations, while the Hearing Officers and Appeals Officers hear evidence and legal arguments on the determinations and then render decisions.

There are several rules surrounding letters of determination. NRS 616C.315 provides that any person who is subject to the jurisdiction of the hearing officers pursuant to chapters 616A to 616D, inclusive, or chapter 617 of NRS may request a hearing before a hearing officer of any matter within the hearing officer's authority. The statues further provides that with a few exceptions, a person who is aggrieved by a written letter of determination of an insurer may appeal the determination to the Hearings Officer. The injured worker must file their appeal with the Hearing Officer within the deadline after the date on which the notice of the insurer's determination was mailed by the insurer. Some mistakes that I have seen unrepresented injured workers make is being upset about the determination of the insurer, setting the letter aside, and then later filing the appeal late. This will normally result in the dismissal of the appeal. Or sometimes the injured worker will mail the appeal to the insurer, and not the Hearing Office. Big mistake. It must be filed with the Hearing Officer under NRS 616C.315.

NRS 616C.315 does provide limited excuse provisions for the late filing of an appeal. The deadline may be extended if the injured worker shows to the Hearing Officer, by a preponderance of the evidence, that the injured worker was diagnosed with a terminal illness or was informed of the death or diagnosis of a terminal illness of his or her spouse, parent or child. Another potential excuse provision for a late filed appeal is if the injured worker shows to the Hearing Officer, by a preponderance of the evidence, that the injured worker did not receive the notice of the determination and the forms necessary to request a hearing. It should be noted that the injured worker is required to notify the insurer of a change of address. (An injured worker moving to a different address presents a whole list of potential issues, that I will discuss in a future blog). So you can see, there is not much room for error.

The bottom line. Make sure that your appeal is timely filed with the Hearing Officer. If an appeal is filed early, and then later the issue is worked out prior to the hearing, a settlement can be reached in order to change the determination letter and not proceed to hearing. But if an appeal is filed outside of the deadline and there is no statutory excuse, the injured worker may have just fallen into quicksand and lost their ability to challenge the issues on the letter of determination.

There are many other rules concerning the appealing of letters of determination from the insurer. This blog just deals with the basics and it may or may not apply to the facts of your case. I would recommend that all injured workers work with their attorney to make sure that all letters of determination are received, discussed, and if necessary, timely appealed pursuant to the laws and regulations pertaining to that specific letter of determination.

I hope that this has been helpful and informative. Please read the other blogs for more free, valuable information.

Joel A. Santos, Esq., is a Nevada worker’s compensation attorney. He is certified by the State Bar of Nevada as a Worker’s Compensation Expert and Specialist.

Copyright 2021 - Joel A. Santos, Esq.