Ramos Law Firm Workers' Comp Blog » reimbursement

New York Prepares to Close Second Injury Fund

Julia Lindsey — Tue, 03 Mar 2009 14:34:22 +0000

As of 07/01/07, the self-insured employers and the carriers in New York can no longer file claims for reimbursement with the Special Funds Conservation Committee under Section 15-8. In other words, for claims with dates of accident or dates of disablement of 07/01/07 or later, the employers and carriers cannot look to the Special Funds Conservation Committee for reimbursement under Section 15-8 or Section 14-6, the concurrent employment provision.

The recent law also provides that no C-250′s may be filed after 07/01/10, for claims with dates of accident or dates of disablement prior to 07/01/07, for the purpose of seeking 15-8 relief. Regardless of the filing dates of the C-250′s, again for claims prior to 07/01/07, all written submission of evidence in support of a 15-8 claim must be filed prior to 07/01/10 for consideration by the Special Funds Conservation Committee.

The Statute also requires that all requests for reimbursement for cases with established 15-8 or 14-6 findings be submitted to the Special Funds Conservation Committee within one year from the date of the expenditure or one year from the effective date of this legislation, 03/13/07, whichever is later. The reimbursement request would be deemed waived if the employers or the carriers do not comply with this provision.

Second Injury Fund in North Carolina Still Active

Julia Lindsey — Fri, 27 Feb 2009 14:24:47 +0000

In North Carolina, the Industrial Commission disburses moneys from the Second Injury Fund. In order to qualify for compensation for a second injury, the original and the subsequent injury must be at least twenty percent (20%) of the entire body, and, the additional compensation cannot exceed the amount which would have been payable for both injuries had both been sustained in the subsequent accident.

The Fund may also pay compensation and medical expenses in cases of permanent and total disability resulting from an injury to the brain or spinal cord. In the claims that pertain to total and permanent disability due to paralysis or loss of mental capacity, the Fund may cover expenses related to medical, nursing, hospital, institutional, equipment, and other treatment expenses reasonable and necessary during the life of the injured employee.

Types of Second-Injury Funds

Julia Lindsey — Thu, 19 Feb 2009 13:51:49 +0000

The two major types of second-injury funds are reimbursement funds and take-over funds. In both of these situations, the employer/insurer can reduce liability when the fund becomes liable.

States, such as Georgia and New York, which have reimbursement funds which actually reimburse the carrier for indemnity and medical benefits made to a claimant. The employer/insurer remains the primary claims handler and must request periodic reimbursements from the fund for payments made on the claim. These funds will also take an active role in any settlement discussions.

States which have take-over funds will pay the claimant directly once the liability has been determined. In New Jersey, for example, once the fund’s liability has been established, it can pay the claimant’s permanent and total benefits for the life of the claims. The employer remains liable for the medical expenses.

There are many active second-injury funds in the U.S. Since many of them have different rules and regulations, strict attention must be paid to the statutory requirements for each state.

Are expenses incurred prior to 2003 reimbursable?

Julia Lindsey — Fri, 02 Jan 2009 17:20:03 +0000

The 2003 amendment to O.C.G.A. § 34-9-203, effective July 1, 2003, added paragraph (c)(4), imposing a one year limitation period on the filing of reimbursement claims. While this amendment imposed a one year filing limitation on all of the employee’s medical expenses incurred after July 1, 2003, it did not affect those expenses incurred prior to that date. O.C.G.A. § 34-9-203 will not be applied retroactively to pre-2003 claims. Therefore, any medical expenses or reimbursement claims incurred prior to July 1, 2003 are not subject to the one year limitation.

Who, What, and How will the Georgia SITF reimburse me?

Julia Lindsey — Mon, 13 Oct 2008 17:15:49 +0000

Any insurance company licensed in Georgia to issue workers’ compensation policies or self-insured employer authorized by the State Board of Workers’ Compensation is eligible to file a claim for potential reimbursement from the Subsequent Injury Trust Fund. The employer/insurer should forward a letter to the fund stating a desire to actively pursue the claim. The fund requires medical documentation of the prior and subsequent injuries and, where indicated, investigative reports supporting compensability. In addition, the fund requires the statement of merger.

The employer/insurer files a claim for reimbursement directly with the fund. The Fund investigates the claim to determine eligibility for reimbursement. When a reimbursement agreement is reached between the Fund and the employer or insurer, it must be approved by the Sate Board of Workers’ Compensation. If an agreement cannot be reached, either party may request a mediation conference or a hearing with the State Board of Workers’ Compensation.

Employers/insurers may be reimbursed for all weekly income benefits payable after 104 weeks, for 50% of all medical and rehabilitation expenses between $5,000 and $10,000, and for 100% of all medical and rehabilitation expenses in excess of $10,000. If the subsequent injury was not caused by or related to a prior impairment, the reimbursement for medical expenses may be reduced or denied completely.