The words “federal black lung (FBL) adjudication process” alone might sound too complicated to comprehend but, to those the process affects, understanding and appreciating the complex and lengthy legal process surrounding these claims is imperative for proper claim handling.
A brief history of black lung benefits
As noted in a related Milliman paper, the United States has enacted workers’ compensation laws to protect employees from work-related injuries since 1911,1 but there was no federal law compensating coal miners from disabling restrictive lung disease until the late 1960s. The Federal Coal Mine Health and Safety Act of 1969 (Coal Act) was the first federal mechanism designed to compensate black lung claimants. Administered by the Social Security Administration, benefits in those early years of black lung compensation were liberally paid to miners who filed claims—with approval rates greatly exceeding those seen today. The Coal Act has been amended several times since its enactment, with the most recent changes occurring in 2010 with the passage of the Affordable Care Act (ACA), which includes the Byrd Amendment. The Coal Act as amended now provides the following:
- The U.S. Department of Labor (DOL) now administers the black lung program and the benefits are paid first by coal mine employers or “responsible operators.” The Federal Black Lung Disability Trust Fund was established to pay benefits in cases where the responsible operator does not meet its obligations.
- Pneumoconiosis is deemed latent and progressive in the current legal definition, meaning that there is now a presumption that restrictive lung disease will progress and develop years after the exposure to coal dust has ceased. Medical experts argue that, while complicated pneumoconiosis (PMF) is progressive, simple coal workers’ pneumoconiosis is not. This legal definition of pneumoconiosis is broader than the medical definition, allowing a finding of disability and benefits even for unrelated respiratory conditions, such as chronic obstructive pulmonary disease (COPD), caused by smoking, and for aggravation of existing non-work-related respiratory ailments.
- For miners who worked 15 years or more, the burden is shifted to the responsible operator to prove that the miner is not disabled from coal dust exposure. In other words, it is presumed that a miner who has worked for 15 years is disabled as a result of black lung disease. With other workers’ compensation programs, the burden of proof is on the claimant to show that they are disabled as a result of a work-related injury. This shift in the burden of proof makes it difficult to defend black lung claims.
- Surviving spouses are automatically entitled to survivor benefits if the miner had been receiving benefits, even without proof that the miner’s death was work-related.
Once awarded, disability benefits, with cost-of-living increases, are paid for life. Upon death, dependents may file for survival benefits as well. This is the case even for miners who did not die as a result of coal mine dust exposure. Currently, no statute of limitations exists for claimants to file a federal black lung claim. Once an employee leaves the workforce, that person can file for benefits. If denied, the claimant can refile repeatedly on an unlimited basis.
The legal process for filing a federal black lung claim
Given the complexity of the aforementioned legislative environment surrounding federal black lung claims, legal proceedings and the journey from filing to final claim decision can feel interminable, particularly given the lack of a statute of limitations and regulation surrounding the number of times a claimant may file. When a federal black lung claim is filed, the timeframes and requirements for an insurer or self-insured entity are more involved than those for traditional workers’ compensation claims. The typical federal black lung claim goes through the adjudication process summarized in Figure 1.
Figure 1: Black lung claim adjudication process
First, a miner, upon retirement, or a survivor, upon the death of a miner, files a claim with the DOL. Once the claim is with the DOL, a Notice of Claim is issued, naming the potential responsible operator. At this point, the responsible operator has 30 days to respond and 90 days to submit evidence.
The next step in the adjudication process is the initial finding, also known as the Schedule for the Submission of Additional Evidence. After filing with the DOL, a miner undergoes a medical examination to diagnose the presence of pneumoconiosis. As mentioned above, pneumoconiosis can be diagnosed as simple or complicated—the difference being the severity of damage to the lungs (i.e., the amount of scar tissue present). In order to make a diagnosis, a doctor may evaluate a miner’s work history, perform a physical examination, order a chest x-ray or CT scan, conduct pulmonary function studies, or perform biopsies of the lungs.2 These examination costs are fronted by the DOL.
If a miner passes away and had a claim pending—but not yet awarded—the survivor assumes the role of “claimant” and the medical examination conducted pre- or post-mortem on the miner is used as evidence. If the deceased miner never filed a claim, the survivor is still able to file a claim for survivor’s benefits. If a miner dies and had been receiving benefits, the survivor is automatically entitled to benefits.
The schedule submitted into evidence includes the preliminary analysis of the medical examination by the District Director (Director). This evidence is then sent to the assigned responsible operator. The operator has 30 days to respond to this submission; the schedule gives the claimant and operator 60 days to submit additional evidence. Once evidence has been submitted by either party, the opposing party has an additional 30 days to respond, though this time period may be extended for good cause with an extension request to the Director. The Director reviews the claim once all evidence has been submitted at the end of the allowed submission period.
Determination on a federal black lung claim
Once the evidence has been reviewed by the Director, an initial determination of the claim—either an award or a denial of benefits—is issued, known as the initial determination or decision or the proposed decision and order (PD&O). A hearing may be requested prior to the Director rendering a decision at the PD&O level. Otherwise, within 30 days of the PD&O, any party may request a revision of the PD&O or a hearing. If a hearing is requested within the 30-day period, the claim is referred to the Office of the Administrative Law Judges (ALJ) and the DOL begins to pay benefits to the claimant. If no party requests a hearing or responds to the PD&O, the decision becomes final upon expiration of the 30-day period. The average time from filing to PD&O is approximately one year.3
If a claim is appealed after the PD&O, an ALJ is assigned to the case. The ALJ holds a hearing, receives testimony and other evidence, and renders a decision on the claim. The claimant and responsible operator have 30 days to appeal this decision. If appealed, the claim is sent to the Benefits Review Board (BRB). If a decision awarding benefits is not appealed, the responsible operator must start paying monthly benefits to the claimant, including any retroactive benefits the DOL has been paying to the entitled claimant. If no party requests a hearing or responds to the decision made by the ALJ—or any higher court—and the claimant is denied, then the claimant must reimburse the DOL, unless claiming undue hardship.
If the claim reaches the BRB level, the board reviews and issues its decision on the claim. The claimant and responsible operator have 60 days to appeal that decision. If appealed, the claim is sent to the Circuit Court. Similar to the ALJ appeal process, the responsible operator must start paying monthly benefits to the claimant on a decision awarding benefits, if not appealed, including any retroactive benefits the DOL has been paying to the entitled claimant.
Similarly, there are strict processes and timelines in place at the federal Circuit Court and U.S. Supreme Court levels.
Modifying a black lung claim
Finally, once a decision becomes final, if there is a change in physical condition or mistake in a determination of fact within one year of the decision or last payment of benefits, either party can file a request for modification without refiling and re-adjudicating. In other words, even a “final” decision is not necessarily final.
According to the DOL, even if more than a year passes since the final decision, the claim may still be refiled, restarting the adjudication process. A claimant whose previous claim was ultimately denied at least one year earlier may file another claim seeking benefits. The refiled claim is processed and adjudicated in the same manner as the initial claim, except that the claim is considered “denied unless the claimant demonstrates that one of the applicable conditions of entitlement has changed since the date on which the order denying the prior claim became final.”4
Navigating the FBL adjudication process is complex and fraught with potential pitfalls. When in doubt, it is advisable to consult a black lung claims expert. For more details regarding timeframes for the adjudication process, visit: https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blbenact.
1 Guyton, G.P. (1999). A Brief History of Workers' Compensation. Iowa Orthop J;19:106-10. PMID: 10847524; PMCID: PMC1888620.
2 Johns Hopkins Medicine. Pneumoconiosis. Retrieved July 24, 2024, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/pneumoconiosis.
3 Based on data from the Federal Black Lung DOL database as of March 31, 2024.
4 DOL. Office of Workers' Compensation Programs: Black Lung Program: General. Retrieved July 24, 2024, from https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blbenact.