§ Title 34 Appx. r. 622-1-.04 - Filing claims against the Subsequent Injury Trust Fund - Georgia Statutes

O.C.G.A. Title 34 Appx. r. 622-1-.04 (2010)
622-1-.04. Filing claims against the Subsequent Injury Trust Fund

(1) An employer or insurer shall notify the administrator of the Subsequent Injury Trust Fund of any possible claim against the Fund as soon as practical, but in no event later than Seventy-Eight (78) calendar weeks following the injury or the payment of an amount equivalent to Seventy-Eight (78) weeks of income or death benefits, whichever occurs last. Notification shall be in writing, transmitted on facsimile machine, or transmitted electronically and shall be effective on the date of receipt of the notice by the Subsequent Injury Trust Fund. The employer or insurer must submit or electronically transmit Subsequent Injury Trust Fund Form "A", referred to as "Notice of Claim." In addition, the employer or insurer must provide the following:

(a) Employer's knowledge statement pursuant to Rule 622-1-.05 of the Rules and Regulations of the Subsequent Injury Trust Fund;

(b) Documentation supporting merger between the subsequent injury and prior impairment; and

(c) Proof of payment of weekly income benefits to the injured employee in excess of 104 weeks and/or payments for medical benefits in excess of $5,000.00.

(d) The required format to complete the above will be available from the Subsequent Injury Trust Fund or its website.

(2) The Reimbursement Agreement will contain a section for the insurer to certify that reserves have been reduced to the appropriate threshold levels. In addition, the reimbursement request form will contain a section for continued certification that reserves have been lowered to the appropriate threshold levels.

(a) Failure to provide certification as required above, or if evidence indicates failure to reduce reserves, reimbursement from Subsequent Injury Trust Fund will be suspended.

(3) When the employer returns an individual to work, and that employer has had a reimbursement claim in reference to that employee previously accepted by the Fund, the employer need not comply with additional mandatory indemnity or medical deductibles in the event that the employee sustains a new accident that merges with the prior impairment that originally resulted in fund acceptance. Examples of reimbursement are as follows:

(a) If the employee, in a case accepted by the Subsequent Injury Trust Fund for reimbursement, returns to work with the same employer, and the same employer has exhausted both indemnity and medical deductibles, the Subsequent Injury Trust Fund will resume reimbursements without further deductibles applicable to the employer.

(b) In the above example, if the employee returns to work and sustains a new injury, and the employer has exhausted the indemnity deductible but not the medical deductible, the Subsequent Injury Trust Fund will resume indemnity reimbursements without further indemnity deductibles applicable to the employer, and the employer will exhaust the remaining portion of the medical deductible on the previous accident that resulted in Subsequent Injury Trust Fund acceptance for reimbursement before the Fund will reimburse medical expenses.

(c) If the employee returns to work and sustains a new accident, and the employer has not exhausted the indemnity deductible but has exhausted the medical deductible, the Subsequent Injury Trust Fund will resume reimbursement of medical expenses with no further medical deductibles applicable to the employer. The employer will be required to exhaust the remaining indemnity deductible as a result of the previous claim that required Subsequent Injury Trust Fund reimbursement before the Fund will reimburse indemnity expenses.

(d) Paragraphs (a), (b) and (c) will apply in the event a new insurer has assumed coverage for the employer.

(e) This provision does not apply if the employee returns to work for a new employer or there has been a break in service by the employee and employer.

(4) The fund shall reimburse only those indemnity, medical, and rehabilitation expenses that the employer or insurer was legally obligated to pay, and has actually paid, to the employee or claimant, including, but not limited to discounts granted by the service provider. The fund shall reimburse such expenses at a rate not exceeding the usual and customary charges. The fee schedules adopted by the State Board of Workers' Compensation shall be presumed to indicate the usual charges to any given service; except, however, where the employer or insurer was eligible for further cost reductions, the fund will reimburse the lesser amount.

Authority O.C.G.A. Sec. 34-9-354(d). Administrative History. Original Rule entitled "Filing Claims Against the Subsequent Injury Trust Fund" was filed on May 26, 1987; effective June 15, 1987. Amended: F. Dec. 20, 1990; eff. Jan. 9, 1991. Amended: July 1, 1998. Amended: July 11, 2000.
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