Fund (Disallowed Claims Reimbursement)
Revised Code (ORC) 4123.35, 4123.512; Ohio Administrative Code (OAC) 4123-17-32.
Blateri, Interim Chief Employer Services
Insured Department/Employer Services
Fund policy effective February 4, 2022.
(September 12, 2022); New policy issued February 4, 2022.
I. Policy Purpose
The Ohio Bureau of
Workers' Compensation (BWC) permits self-insuring employers to participate in
the surplus fund (disallowed claims reimbursement) by paying an assessment and
obtaining reimbursement for claim costs paid on approved claims that were
subsequently overturned through an administrative or judicial process.
This policy applies to the
Self-Insured Department (SI Department), self-insuring employers that elect to
participate in the surplus fund (disallowed claims reimbursement), and their
authorized third-party administrators (TPAs) and legal representatives.
A. Overturned Claim: A claim allowance that
was appealed, overturned, and ultimately disallowed through a final
administrative, or if applicable, final judicial order.
B. Self-Insured Claims
Reimbursement Application (SI-52): Required form to be
completed by an SI employer, or their TPA or legal representative, to apply for
reimbursement of claim costs paid on an overturned claim.
Employer (SI Employer): An employer that BWC has granted the privilege of paying
compensation and benefits directly.
D. Surplus Fund
(Disallowed Claims Reimbursement): The fund used to reimburse eligible SI
employers for claim costs associated with overturned claims.
All SI employers must meet the following criteria to be eligible for reimbursement
of claims costs paid on overturned claims from the surplus fund (disallowed
1. The SI employer must be
an active SI employer as of the date of injury;
2. The SI employer must
have paid the optional assessments for surplus fund (disallowed claims
reimbursement) as of the date of injury; and
3. The claim for which SI
employer applies for reimbursement must qualify as an overturned claim.
B. Application Criteria: All
applications for surplus fund (disallowed claims reimbursement) must be fully
completed using the SI-52 form and include the
1. Employer demographics;
demographics (if applicable);
3. Injured Worker demographics;
4. Basis for request:
a. Amount and date periods
for indemnity, medical, and prescriptions;
documentation for all expenses paid; and
c. Final determination or
claim settlement confirmation.
C. Withdrawal from Program:
SI employers may withdraw from participation in the surplus fund (disallowed claims reimbursement) by submitting the
Election to Withdraw from Claims Reimbursement Fund form SI-44.
1. After the SI employer
withdraws from the surplus fund (disallowed claims reimbursement), the employer
is ineligible for reimbursement for claims with a date of injury incurred on or
after the withdrawal effective date.
2. The SI employer’s
decision to withdraw from the surplus fund (disallowed claims reimbursement) is
3. The effective date of the
SI employer’s withdrawal from the surplus fund (disallowed claims
reimbursement) is July 1 on, or following receipt of, the SI-44.
V. Resolution of
A. Any complaints or disputes related to this policy must be submitted
in writing to the SI Department
via mail or email as detailed in
the Self-Insured Employer
Bureau of Workers’ Compensation
W. Spring St., L-22
B. The SI employer may file a written appeal of the SI Department’s
decision to the Self-Insured Review Panel