Chapter ETF 11

Chapter ETF 11

APPEALS

ETF 11.01   Purpose and scope.

ETF 11.02   Definitions.

ETF 11.03   Process and proceedings.

ETF 11.04   Hearing examiner.

ETF 11.05   Discovery.

ETF 11.06   Evidence at hearing.

ETF 11.07   Informal disposition.

ETF 11.08   Final disposition by hearing examiner.

ETF 11.09   Proposed decision.

ETF 11.10   Ex parte communications.

ETF 11.105   Board member conflict of interest.

ETF 11.11   Counsel for the board.

ETF 11.12   Final decision.

ETF 11.13   Record.

ETF 11.14   Petition for rehearing.

ETF 11.15   Judicial review.

ETF 11.16   Miscellaneous provisions.

Ch. ETF 11 Note Note: Corrections made under s. 13.93 (2m) (b) 6., Stats., Register, January 2004 No. 577.

ETF 11.01 ETF 11.01 Purpose and scope.

ETF 11.01(1) (1) The purpose of this chapter is to establish a regular and uniform system of procedures and rules governing the review of appealable department determinations by the board responsible for the subject matter. This chapter interprets the provisions of ss. 227.44 to 227.48, 227.485, 227.49 and 227.50, Stats., concerning the conduct of proceedings, as those provisions apply to the deferred compensation board, group insurance board, teachers retirement board and Wisconsin retirement board and establishes rules for appeals to the employee trust funds board and its designees. Any appeal to a board of a determination made by the department shall be conducted in accordance with this chapter.

ETF 11.01(2) (2) The deferred compensation board shall hear the timely appeal of a determination made by the department with respect to a right or benefit under the deferred compensation plan provided by ss. 40.80 to 40.82, Stats. This authority is delegated from the employee trust funds board under s. 40.03 (1) (L), Stats.

ETF 11.01(3) (3) The group insurance board shall hear the timely appeal of a determination made by the department affecting any right or benefit under any group insurance plan provided under ch. 40, Stats.

ETF 11.01(4) (4) The teachers retirement board shall hear the timely appeal of a determination made by the department regarding a disability annuity for a teachers participant, pursuant to s. 40.63 (5) and (9) (d), Stats.

ETF 11.01(5) (5) The Wisconsin retirement board shall hear the timely appeal of a determination made by the department regarding a disability annuity for a participant other than a teacher, in accordance with s. 40.63 (5) and (9) (d), Stats. In addition, the department shall make the initial determination of the amount of a duty disability benefit and whether to terminate or reduce a benefit under s. 40.65 (3) or (5), Stats., and the Wisconsin retirement board shall hear the timely appeal of these determinations.

ETF 11.01(6) (6) The employee trust funds board shall hear the timely appeal of any other determination made by the department.

ETF 11.01(7) (7) Nothing in this section shall prevent the board responsible for hearing the subject matter of an appeal from delegating that responsibility to a hearing examiner.

ETF 11.01 Note Note: See ss. 40.03 (1) (j), (6) (i), (7) (f) and (8) (f), and 40.65 (3) and (5), Stats.

ETF 11.01 History History: Cr. Register, June, 1992, No. 438, eff. 7-1-92.

ETF 11.02 ETF 11.02 Definitions. Words, phrases and terms used in this chapter have the same meanings as set forth in s. 40.02, Stats., and s. ETF 10.01, except as defined in this chapter or where the context clearly indicates a different meaning. In this chapter:

ETF 11.02(2) (2) “Administrative agent” means a person who has entered a contract with a board or the department to provide administrative services to a program administered by that board or the department under ch. 40, Stats. The term includes the administrative agent of the group insurance board or department who assists in the administration of a group insurance plan under ch. 40, Stats., for which the public employee trust fund is the insurer.

ETF 11.02(3) (3) “Appeal” means the review of a written finding, notification or decision specifically set forth in a determination made by the department conducted by a board under s. 40.03 (1) (j), (6) (i), (7) (f), or (8) (f), Stats.

ETF 11.02(3m) (3m) “Appeals coordinator” means the department staff responsible for receiving appeals, forwarding appeals to the hearing examiner, and working directly with the hearing examiner and board on administrative matters regarding an appeal.

ETF 11.02(4) (4) “Appellant” means the person, including a participant, annuitant, beneficiary, employer, insured, insurer or deferrer who initiates an appeal to the board. “Appellant” also includes a person appealing an adverse determination of participating employee status.

ETF 11.02(5) (5) “Board” means the employee trust funds board, deferred compensation board, group insurance board, teachers retirement board or Wisconsin retirement board according to the context of its application.

ETF 11.02(6) (6) “Board staff” means the department employees assigned by the secretary to perform tasks in support of the board.

ETF 11.02(7) (7) “Deferrer” means an employee who participates in the deferred compensation program under ch. 40, Stats.

ETF 11.02(8) (8) “Determination made by the department” means a written finding, notification or decision of the department, which includes a notice of appeal rights and applies law or contract terms to actual facts to determine a benefit, right, obligation or interest under ch. 40, Stats., including contracts authorized by ch. 40, Stats., of a person who is, or claims the status of, a participant, annuitant, beneficiary, employer, insured, insurer or deferrer.

ETF 11.02(9) (9) “E-mail” means to send via electronic mail over a computer network.

ETF 11.02(10) (10) “Hearing examiner” means the person who presides over each appeal of a determination made by the department of employee trust funds including an administrative law judge employed by the division of hearings and appeals.

ETF 11.02(11) (11) “Insured” means a person covered under a group insurance plan provided under ch. 40, Stats.

ETF 11.02(12) (12) “Insurer” means the person bearing the financial risk and liability for payment of claims under a group insurance plan provided under ch. 40, Stats., including where applicable the public employee trust fund.

ETF 11.02(13) (13) “Mail” means to send via the U.S. mails as at least first class mail, and includes sending by express mail, special or overnight delivery, certified or registered mail.

ETF 11.02(14) (14) “Respondent” with respect to an appeal means the department of employee trust funds. In addition:

ETF 11.02(14)(a) (a) The employer is a respondent in the appeal of a department determination which was based on the employer’s determination that a person is not a participating employee or protective occupation participant or based on the employer’s certification, or failure to certify, under s. 40.63 (1) (c), Stats.

ETF 11.02(14)(b) (b) The insurer and administrative agent are respondents in the appeal of a department determination affecting any right or benefit under any group insurance plan provided under ch. 40, Stats., except that the department shall represent the interests of the public employee trust fund as insurer.

ETF 11.02(15) (15) “Substantial interest” means, with respect to an appeal under this chapter, a direct and material interest in the particular determination made by the department, which interest is specially and adversely affected, either by the particular determination itself or by the result sought by the appellant of that determination, beyond the effect common to other similarly situated persons. The term does not include a derivative, indirect or mere nominal interest.

ETF 11.02 History History: Cr. Register, June, 1992, No. 438, eff. 7-1-92; renum. (1) to be ETF 10.01 (1h), Register, July, 1999, No. 523, eff. 8-1-99; CR 11-040: renum. (9), (10), (11), (12), (13) to be (11), (12), (13), (14), (15), cr. (9), (10) Register July 2012 No. 679, eff. 8-1-12; CR 11-044: am. (3), cr. (3m), am. (8) Register July 2012 No. 679, eff. 8-1-12.

ETF 11.03 ETF 11.03 Process and proceedings.

ETF 11.03(1) (1) Limitations on appeals. In addition to the requirements under sub. (3), the following time limitations apply to appeals:

ETF 11.03(1)(a) (a) An appeal seeking correction of an alleged error with respect to service credits or contribution, premium or benefit payments is barred unless commenced within 7 years after the date of the alleged error, except as some other limitation is specifically provided by statute or this chapter. Where an alleged error has been incorporated in department records and relied upon in subsequent administration of ch. 40, Stats., benefits, the date of the alleged error for the purposes of this section and s. 40.08 (10), Stats., is the earliest date on which the aggrieved person discovered, or should reasonably have discovered, the alleged error.

Example: If an alleged error involves creditable service for a given year, and the amount of service credited was first reported to the participant on an annual statement the following year, the date of the alleged error is the date of the report to the participant, not a subsequent date on which the alleged error in creditable service is used to calculate retirement benefits or repurchase of forfeited service

ETF 11.03(1)(b) (b) Notwithstanding par. (a), an appeal seeking correction of an alleged error with respect to service credits or contribution, premium or benefit payments, based on a claim of fraud, is barred unless commenced within 3 years from the date of the discovery by the aggrieved person of the facts constituting the fraud.

ETF 11.03 Note Note: See ss. 40.08 (10) and 893.93 (1m) (b), Stats.

ETF 11.03(1)(c) (c) All other appeals are barred unless commenced within the appropriate statutory limitation period, including but not limited to those provided by ss. 893.43 and 893.93 (1m) (a), Stats.

ETF 11.03(1)(d) (d) An appeal barred by operation of s. 41.04 (2) (c), 1979 Stats., or similar predecessor statute, is barred regardless of longer time limits set by s. 40.08 (10), Stats., or this section.

ETF 11.03(1m) (1m) Limitation on requesting department determination. An employee’s appeal to the department under s. 40.06 (1) (e) 1., Stats., of an employer’s classification, or denial of classification, as a teacher, protective occupation participant, or other classification specified by the department must be made within 90 days after the employer notifies the employee of the classification action, the right to appeal and this time limit. An appeal of a protective occupation participant classification reviewed by the office of state employment relations under s. 40.06 (1) (dm), Stats., must be made to the department within 90 days after the employee is notified by the office of state employment relations of its determination, the right to appeal and this time limit.

ETF 11.03(2) (2) Limitations on board remedies. Limitations on the boards’ powers include the following:

ETF 11.03(2)(a) (a) The deferred compensation board, group insurance board, teachers retirement board and Wisconsin retirement board have no equity powers. The employee trust funds board has no equity powers, except as provided under s. 40.03 (1) (a), Stats., to correct inequity in the computation of the amount of an annuity or death benefit resulting from a participant’s combination of full-time and part-time service, a change in annual earnings period during the high years of earnings or the previous receipt and termination of an annuity.

ETF 11.03(2)(b) (b) In accordance with the limitations on board remedies established by ch. 40, Stats., a right or benefit may not be granted by the board as the result of an appeal unless under the facts proven and the provisions of ch. 40, Stats., and other applicable law, the appellant is eligible for the right or benefit, and meets all qualifications established by statute, administrative rule and any applicable contract authorized by ch. 40, Stats., as of the commencement of the appeal. Erroneous or mistaken advice or negligence in performance of a duty may not be the basis for granting a right or benefit to an appellant under ch. 40, Stats.

ETF 11.03(2)(bm) (bm) There is no remedy in an appeal before a board based on a theory of undue influence. Regardless of proof offered by an appellant, the board may not change or void any choice, designation, application or other action of a participant, annuitant, beneficiary, insured, or deferrer on the grounds that person was acting under the undue influence of another. Nothing in this paragraph shall be construed to prevent an aggrieved party from bringing an action against the beneficiary of the alleged undue influence in a court of competent jurisdiction and seeking any remedy available under the law.

ETF 11.03(2)(c) (c) In an appeal involving a right or benefit under a group insurance plan provided under ch. 40, Stats., the group insurance board may grant the right or benefit claimed, including payment of a claim at issue, only if the public employee trust fund is the insurer. With respect to other insurers, the group insurance board may treat a continued failure of the insurer to grant a right or benefit awarded in the board’s final decision as a breach of the insurer’s contract with the board.

ETF 11.03(2)(d) (d) 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.

ETF 11.03(2)(e) (e) 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.

ETF 11.03(3) (3) 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.

ETF 11.03(3m) (3m) 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.

ETF 11.03(4) (4) 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:

ETF 11.03(4)(a) (a) 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: [phone] or toll free at [phone]. The form also is available on the department’s website: etf.wi.gov.

ETF 11.03(4)(b) (b) 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.

ETF 11.03(4)(c) (c) 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.

ETF 11.03(4)(d) (d) The request for an appeal is a timely appeal.

ETF 11.03(4)(e) (e) 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.

ETF 11.03(5) (5) Case file. 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.