The group insurance board may not hear an appeal of a group health insurance issue involving a group health plan other than the standard plan unless the appeal involves a provision of the contract between the group insurance board and the insurer or a provision of the board's guidelines for comprehensive medical plans seeking group insurance board approval to participate under the state of Wisconsin group health benefit program. Otherwise, the dispute is directly between the insured and the insurer and does not involve the department or the board.
When the group insurance board has contracted with an insurer other than the public employee trust fund, the board may not hear the appeal of a group insurance issue which the contract reserves to the insurer for determination.
Determination; timely appeal.
An appeal is not timely unless the request is received within 90 days of the date a written determination was mailed to the person aggrieved by the department determination. A request which fails to meet this requirement is untimely. An appeal may not be commenced on an untimely request. The department shall notify a person making an untimely appeal request.
New determination; new time limits.
The department may internally review a previous determination made by the department. If the department then issues a new determination that revises the original determination, reaches a different result from the original determination, or relies upon different material facts or law from those stated in the original determination, any person aggrieved by the new determination shall have 90 days from its issuance to request an appeal.
Commencement of appeal.
An appeal is commenced upon receipt of a request for review of the department determination provided the request meets the following requirements:
The request is in writing. No appeal may be commenced based upon an oral request. The requestor may, but is not required to, file the request for an appeal by using form ET-4938, “Appeal Form."
ETF 11.03 Note
Note: The Appeal Form can be obtained at no charge by writing to: department of employee trust funds, P. O. Box 7931, Madison, WI 53707-7931, or by calling: (608) 266-3285 or toll free at (877) 533-5020. The form also is available on the department's website: etf.wi.gov.
The request identifies the particular department determination being challenged and the factual and legal basis for the appeal, including specifically identifying the particular material facts and legal interpretations underlying the department determination which the appellant believes are erroneous. Any question about the sufficiency of the pleading under this paragraph shall be resolved by the hearing examiner at the pre-hearing conference.
The request for an appeal is mailed, sent by e-mail, sent by facsimile, or delivered to the appropriate board in care of the appeals coordinator at the department of employee trust funds by the person requesting the appeal. Appeal requests received which erroneously name a board with respect to a subject matter reviewed by another board shall be redirected to the appropriate board by the appeals coordinator.
The person requesting the appeal has a substantial interest in the determination made by the department. Any question about the appellant's interest shall be resolved by the hearing examiner at the earliest opportunity.
Upon commencement of an appeal, the department shall open a case file for the hearing examiner, consisting of copies of the determination made by the department and the appeal request by the appellant, including any attachments and referenced documents.
An appeal to the board shall be treated as a class 3 contested case.
Only a person with a substantial interest in the particular issue to be decided, as it affects the specific participant, annuitant, beneficiary, employer, insured, insurer or deferrer may be an appellant or a party to the appeal. No person without a substantial interest may be admitted as a party. When an appeal is filed, the department shall notify any respondent or other person known to have a substantial interest directly affected by an issue raised in the appeal, including the following persons:
The department shall be a party to each appeal of a determination made by the department.
In an appeal concerning a participant's or annuitant's death benefits, the interested parties include any beneficiary with a direct interest in the death benefits not yet paid by the department or insurer as they may be calculated or distributed as a result of either the department determination or the board's final decision on the issues raised by the appeal.
In an appeal concerning disability benefits under s. 40.63
, Stats., or the determination of participating employee or protective occupation participant status, the interested parties include the participant, or the appellant claiming the status of participating employee, and the employer. The office of state employment relations is deemed to be the employer if the appeal involves a state employee claiming the status of a protective occupation participant.
In an appeal concerning a program in which an administrative agent is involved, the administrative agent may participate as a party.
In an appeal of a group health insurance determination, the insurer is an interested party.
Burden of proof.
The appellant shall have the burden of proceeding and the burden of proving each element necessary to establish that the appellant is entitled to, and has fully qualified for,
the claimed right or benefit provided by ch. 40
Agent for a party.
Any party may appear in person or by an attorney or agent provided the following requirements are met:
Any person who appears as an agent for a party, other than the registered agent of a participating employer or an attorney, shall obtain and file with the department an original power-of-attorney signed by the party authorizing the agent, as attorney-in-fact, to act in all matters involving the appeal with the same authority and effect as the party personally. The person officially designated by a participating employer as its registered agent to represent the employer to the Wisconsin retirement system is deemed to have full authority to act for the participating employer regarding the appeal.
Any party represented by an attorney or agent, other than the department or the participating employer, shall file a written authorization in the form prescribed by the department for the disclosure of confidential personal information to the agent or attorney, to the same extent as is authorized to the party under s. 40.07
, Stats., and s. ETF 10.70
. The authorization shall be part of the appropriate participant file.
ETF 11.03 Note
The “Limited Power-Of-Attorney For Appeal" form, ET-4944, “Authorization To Disclose Non-Medical Individual Personal Information" form, ET-7406, and “Authorization To Disclose Medical Information" form, ET-7414, required by ch. ETF 11
may be obtained at no charge by writing to: department of employee trust funds, P. O. Box 7931, Madison, WI 53707-7931, or by calling: (608) 266-3285 or toll free at (877) 533-5020. The forms also are available on the department's website: etf.wi.gov.
Notice of any hearing or pre-hearing conference shall be mailed to each party, or the party's attorney of record, at least 10 days prior to the hearing or conference, respectively. The notice shall include:
The time, place and nature of the hearing or conference, including a statement that the case is class 3 contested case proceeding.
A statement of the legal authority and jurisdiction for the hearing.
A short and plain statement of the matters asserted. If specificity is not possible when notice is served, the notice may state issues involved.
The hearing examiner shall hold a pre-hearing conference for the purpose of determining the proper parties, defining the issues to be resolved, identifying the material factual and legal disputes between the parties, setting a deadline for the parties to reach agreement on a stipulation of facts or advising the examiner that they are unable to do so, and setting the date for the evidentiary hearing. The pre-hearing conference may be held by telephone with the call initiated by the hearing examiner. Following the pre-hearing conference, the hearing examiner shall prepare a memorandum to the parties summarizing the actions taken, amendments allowed to the pleading, recording agreements of the parties, specifying the issues to which the hearing is limited and making appropriate orders to the parties. This memorandum shall control the subsequent course of the appeal, unless modified at the hearing to prevent manifest injustice.
Witness attendance; subpoena.
Upon receipt of the notice of hearing, it is the responsibility of each party to contact any witnesses necessary for that party's case and to make arrangements to have them attend the hearing. The hearing examiner or a party's attorney of record may issue a subpoena to compel attendance of witness or production of evidence at hearing or at a deposition authorized under this chapter. Where a party is represented by an agent, rather than an attorney at law, the party shall request the hearing examiner to issue the subpoena. Witness fees shall be paid in advance as provided under s. 885.06
, Stats., except witnesses for a state agency shall be paid in the manner provided by s. 885.07
Extension of time and postponement.
Requests for postponements and continuances shall be considered by the hearing examiner only if received within a reasonable time before the date of the hearing. Postponements and continuances may be granted by the hearing examiner due to extraordinary circumstances and a postponement, continuance or extension of time may be granted upon the mutual agreement of all the parties.
The evidentiary hearing shall be held at the offices of the hearing examiner except as may otherwise be necessary for the convenience of all parties to the appeal.
Expedited appeal process.
Requests for an expedited appeal process shall be considered by the hearing examiner upon receipt of a written request from a party to the appeal. The hearing examiner shall allow for written objections to be filed within ten days of the date that notice is sent to the parties that such a request has been received. Upon receipt of such a request, the hearing examiner shall schedule a pre-hearing conference for the specific purpose of discussing with the parties the reasons for the request, any objections, and a possible procedure for expediting the time period for issuing a final decision in the appeal. The hearing examiner may grant a request for an expedited appeal process based on financial hardship or other extraordinary circumstances demonstrated by a party. Following the pre-hearing conference, the hearing examiner shall prepare a memorandum to the parties summarizing the expedited process to which the parties have agreed and the hearing examiner has approved. If the parties did not reach an agreement during the pre-hearing conference, the hearing examiner may issue an order either approving or denying the request for an expedited appeal.
Decision without holding a hearing.
The parties may agree to have the appeal decided without holding an evidentiary hearing and on the basis of filing legal briefs with the hearing examiner. If there is such an agreement, the parties shall inform the hearing examiner in writing. Upon submission of the legal briefs by the parties, the hearing examiner shall prepare a proposed decision in the manner set forth in s. ETF 11.09
ETF 11.03 History
Cr. Register, June, 1992, No. 438
, eff. 7-1-92; CR 11-040
: am. (4) (a), (b), (c) Register July 2012 No. 679
, eff. 8-1-12; CR 11-044
: am. (2) (b), (3m), (4) (b), (8), (11), cr. (14) to (16) Register July 2012 No. 679
, eff. 8-1-12; correction in (1) (c) made under s. 13.92 (4) (b) 7.
, Stats., Register November 2018 No. 755
; CR 19-126: am. (1) (b) Register May 2021 No. 785, eff. 6-1-21.
Examiner to hear appeal.
A hearing examiner shall preside over each appeal to the board.
The department shall contract with a person to serve as a hearing examiner. The person shall be an attorney or administrative law judge knowledgeable in administrative law practice and ch. 40
, Stats., or similar statutory benefit programs, or a person deemed otherwise qualified by the board. No person who directly participated in making the determination appealed from may be designated or serve as hearing examiner.
The hearing examiner shall perform all functions in an impartial manner. An examiner shall disqualify himself or herself with respect to a particular appeal if by reason of personal interest in, or knowledge of the determination appealed from, he or she is unable to act fairly or impartially. If bias of the hearing examiner is raised as an issue, the hearing examiner shall determine that issue as part of the appeal. The board shall appoint or contract with another hearing examiner if the original hearing examiner is disqualified.
In addition to other powers expressly granted or delegated to the hearing examiner by this chapter, the hearing examiner may:
Rule on offers of proof and receive relevant evidence at hearing.
Limit testimony to only those matters which are disputed.
Rule on all objections and motions made prior to issuance of the proposed decision.
The hearing examiner shall have the following duties:
The hearing examiner shall conduct the hearing, and any pre-hearing conference.
For purposes of proceeding to a hearing, the hearing examiner shall determine the parties having a substantial interest in the appeal. The hearing examiner shall exclude as a party any person not having a substantial interest in the issues raised.
When authorized by this chapter or by motion of the board, the hearing examiner shall prepare the final decision in the form required by this chapter.
Except when authorized to make the final decision of an appeal, the hearing examiner shall prepare a proposed decision for the consideration of the board.
A hearing examiner who receives an ex parte communication, other than a communication described in s. 227.50 (1) (a) 1m.
and (1) (am) 1.
, Stats., shall make a record of the violation, and notify all parties.
The hearing examiner's mailing address, unless otherwise specified by the hearing examiner is:
c/o Appeals Coordinator
Department of Employee Trust Funds
P.O. Box 7931
Madison, Wisconsin 53707
A party sending any communication or document to the hearing examiner by mail, e-mail, or facsimile shall also provide a copy to each party, including the department. This requirement does not pertain to the appeals coordinator when submitting documents for the hearing examiner's signature for subsequent mailing to all parties.
Final decision-making authority.
The hearing examiner shall make the final decision of the board only if authority to make the final decision is expressly delegated to the examiner in this chapter or if final decision making authority in a particular appeal is granted in a motion adopted by the board.
In the course of presiding over the appeal, the hearing examiner shall maintain the official record of the appeal, as well as filing correspondence to the examiner relating directly to the appeal but not part of the record. The hearing examiner may delegate some or all of this responsibility to the appeals coordinator. After preparing the final or proposed decision, the hearing examiner shall forward the record and hearing examiner's file to the appeals coordinator for the department. The examiner's personal notes shall not be forwarded to the department and are not part of the official record. Disposition of the examiner's personal notes is at his or her discretion.
ETF 11.04 History
Cr. Register, June, 1992, No. 438
, eff. 7-1-92; CR 11-040
: am. (6) (b) Register July 2012 No. 679
, eff. 8-1-12; CR 11-044
: am. (2), (8) Register July 2012 No. 679
, eff. 8-1-12; CR 14-055
: am. (5) (e) Register May 2015 No. 713
, eff. 6-1-15; CR 19-126: am. (6) (b), (8) Register May 2021 No. 785, eff. 6-1-21.
There is no right to take and preserve evidence prior to the hearing, except as provided in this section.
No party to an appeal shall have access to individual personal information in the records of the department except as expressly authorized under s. 40.07
, Stats., and this section.
In an appeal of the denial of an application for a disability annuity or duty disability benefits under s. 40.63 (5)
or (9) (d)
or 40.65 (2) (b) 3.
, Stats., the department may provide the hearing examiner, employer, participant and any other party to the appeal with copies of any physician certifications under s. 40.63 (1) (d)
or 40.65 (2) (b) 2.
, Stats., received in connection with the application.
The department may disclose to the board's hearing examiner individual personal information it deems both relevant to the appeal and required to be disclosed for the proper administration of a benefit program under ch. 40
, Stats. Any information disclosed by the department under this subsection shall also be provided to the parties to the appeal. A person receiving information under this subsection shall maintain the confidentiality of the information.
A party to the appeal may request that the hearing examiner review individual personal information in the records of the department in camera. If the hearing examiner determines that the information is relevant to the appeal and disclosure is required to assure proper administration of a benefit program under ch. 40
, Stats., the examiner may order the department to disclose the information as provided in sub. (3)
Testimony may be taken and preserved of a witness:
Who is beyond the reach of the subpoena of the agency, any other party, or the hearing examiner;
Who is about to go out of the state, not intending to return in time for the hearing;
Who is so sick, infirm or aged as to make it probable that the witness will not be able to attend the hearing; or,
Who is a member of the legislature, if any committee of the legislature or the house of which the witness is a member is in session, provided the witness waives his or her privilege.
A party may make a request for admissions as provided in s. 804.11
By advance written agreement between all parties, the oral or written deposition of a witness, as described by ss. 804.05
, Stats., may be taken and used at the hearing in its entirety, so far as it is admissible under this chapter, as if the witness were then present and testifying.
ETF 11.05 History
Cr. Register, June, 1992, No. 438
, eff. 7-1-92; CR 11-040
: am. (2), (5) (a) Register July 2012 No. 679
, eff. 8-1-12; CR 11-044
: am. (4), (7) Register July 2012 No. 679
, eff. 8-1-12.
Privileges; rules of evidence.
Rules of privilege recognized by law shall be given effect. However, common law or statutory rules of evidence do not apply except as provided in s. ETF 11.12 (2) (b)
concerning hearsay. The hearing examiner shall admit all testimony having a reasonable probative value. The hearing examiner shall exclude from the record irrelevant, immaterial, or unduly repetitious testimony.
Failure of a party to object on the record to admission of any evidence shall be deemed a waiver of that objection.
In addition to any other presumptions under applicable law:
A signature purporting to be that of a participant, annuitant, named survivor, or beneficiary on a document previously accepted and filed by the department is presumed to be that of the participant, annuitant, named survivor, or beneficiary absent clear and convincing proof to the contrary.
A participant, annuitant, named survivor, beneficiary, insured or deferrer is presumed mentally competent at the time of making any application, election, designation or taking any other action affecting rights or benefits under ch. 40
, Stats., accepted and acted upon by the department, whether affecting only the person or others. This presumption may be rebutted only by proof in the form of a certified copy of the judgment showing that, at the time of the event at issue, the person was adjudged incompetent with respect to management of his or her property.
For the purpose of determining timeliness of an appeal request, notice of the department determination is conclusively presumed to have been given to the addressee and all listed recipients of copies on the date the determination was sent by mail or e-mail. Absent clear and convincing proof to the contrary, the day the determination is dated is presumed to be the date the determination was sent by mail or e-mail. Absent clear and convincing proof to the contrary, a request for an appeal is presumed received on the day stated by the date stamp affixed to incoming department correspondence. If the request for an appeal is made by e-mail, the request is presumed to be received by the department on the date the e-mail enters the information processing system designated or used by the department for the purpose of receiving electronic mail provided the following are true:
The e-mail transmission is in a form capable of being processed by the department's information processing system.
The department is able to retrieve the e-mail from the information processing system.
The hearing examiner shall take notice of all rules published in the Wisconsin administrative code or register and the written opinions of the attorney general. The hearing examiner may take official notice of any generally recognized fact or established technical or scientific fact, provided the parties are notified of the facts to be noticed and given opportunity to contest their validity.
No additional identification or evidence of authenticity, beyond a statement or certification from a custodian or deputy custodian, is required as a pre-requisite for admitting into evidence documents or photocopies of documents from the department record of a particular participating employer, participant or annuitant, including beneficiary claim documents. When a photocopy of a departmental record is offered under this subsection, any party shall be permitted, upon request, to compare the photocopy and the original.
Close of hearing and evidence.
Evidence in any appeal shall be closed when due opportunity to furnish relevant evidence, including proper examination of witnesses and rebuttal, has been afforded to all parties. If by stipulation of the parties or direction of the examiner, documentary evidence is introduced after close of testimony, the evidence is closed when the document is received or when the specified time for furnishing it has expired without it being submitted. The examiner may extend the original time limit for filing documentary evidence. Before the examiner makes a proposed or final decision, the examiner may reopen the hearing for the taking of further evidence.
ETF 11.06 History
Cr. Register, June, 1992, No. 438
, eff. 7-1-92; CR 07-066
: am. (1), Register March 2008 No. 627
, eff. 4-1-08; CR 11-040
: am. (4) (c) Register July 2012 No. 679
, eff. 8-1-12; CR 19-126: r. (3), am. (4) (a), (b) Register May 2021 No. 785, eff. 6-1-21; correction in (4) (a) made under s. 35.17, Stats., Register May 2021 No. 785.