Ga. Comp. R. & Regs. R. 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 the 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.
Notes
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