How to appeal a Fondo decision to the Industrial Commission

The Industrial Commission of Puerto Rico is an administrative agency whose role, according to its own portal, is to review the decisions issued by the State Insurance Fund Corporation. It is not a second opinion inside the CFSE or an internal complaint: it is a separate forum, with its own regional hearing rooms, that an injured worker reaches when they believe the CFSE did not recognize something they are entitled to. The Commission describes its mandate in two directions: ensuring injured workers receive in full the services they are entitled to, and guaranteeing insured employers that premiums are set correctly.

An injured worker who disagrees with a CFSE decision about their case may appeal. The CFSE expressly names three situations: medical treatment, unrecognized disability, and unpaid compensation. The window is 30 days. It is worth not confusing this term with another that appears in the same CFSE documentation: uninsured employers also have 30 days to appeal, but that is a different situation and not that of a worker claiming their case.

• Filing the appeal within 30 days of the CFSE decision you want to challenge.Verified against the official source
• That what you are appealing is a CFSE decision about your case: medical treatment, unrecognized disability or unpaid compensation are the examples the CFSE itself publishes.Verified against the official source

• The CFSE decision you are appealing, with its date, which is what starts the 30-day clock.
• Your medical file for the case, including Form CFSE-395 with the leave and discharge determinations.

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   Step 1: Pin down the exact date of the decision

   The 30 days run from the decision you want to appeal, so the first thing is to know which document and which date we are talking about. If you were notified by mail, keep the envelope. If you were told at an appointment, ask for the document. A well-founded appeal filed late is useless, and this is the fact everything else depends on.

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   Step 2: Identify what you are appealing

   The CFSE publishes three examples and it helps a great deal to fit your case into one: medical treatment you believe is owed and are not receiving, a disability that was not recognized, or compensation that has not been paid. Asking for a disability to be reassessed is not the same as claiming a late payment, and the Commission needs to know what you are asking it to review.

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   Step 3: File with the Industrial Commission, not with the CFSE

   This is the point most people miss. The appeal goes to the Industrial Commission of Puerto Rico, which is a separate agency whose role is to review CFSE decisions. The Commission has regional hearing rooms in addition to its San Juan headquarters, and publishes its forms, its rules of procedure and its contact information on its portal. Its physical address is 677 Calle Teniente César González, San Juan, and its mailing address is PO Box 364466, San Juan, PR 00936-4466.

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   Step 4: Gather the medical evidence before the hearing

   The Commission reviews determinations that were made on medical grounds, so medical evidence is the ground on which it is decided. Have your file, your primary doctor’s determinations and the CFSE-395. If your argument is that new information has appeared, that new evidence is exactly what needs to be put forward.

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   Step 5: Consider legal representation: if you win, the CFSE covers the fees

   The CFSE publishes that if the appeal is favorable, it covers the attorney’s fees in proportion to the benefit granted. It is a fact that changes the decision for many people who assume they cannot afford representation. It does not mean it is free in every scenario, but it does mean a favorable outcome carries proportional payment of fees.

With the Industrial Commission of Puerto Rico. Its portal is cipr.pr.gov, its physical address is 677 Calle Teniente César González, San Juan, Puerto Rico 00918, and its mailing address is Comisión Industrial de Puerto Rico, PO Box 364466, San Juan, PR 00936-4466. The Commission also operates regional hearing rooms; check its portal for the one that corresponds to you.

• Filing the appeal with the CFSE instead of the Industrial Commission.
• Letting the 30 days pass hoping the CFSE will reconsider on its own.
• Not keeping the decision with its date, which is what starts the clock.
• Confusing the worker’s window with the one for uninsured employers, which the CFSE mentions separately.
• Ruling out legal representation without knowing the CFSE covers fees in proportion to the benefit if the appeal is favorable.
• Using an appeal for a dismissal problem, which is handled through the labor route.

These are the government pages this guide is based on.

• Comisión Industrial de Puerto Rico (CIPR)

  Comisión Industrial

  www.cipr.pr.gov

• Benefits for the injured worker (CFSE) — appeal window

  CFSE

  www.cfse.pr.gov

• CFSE frequently asked questions — what can be appealed

  CFSE

  www.cfse.pr.gov