Fund (Disallowed Claims Reimbursement)
Revised Code (ORC) 4123.35, 4123.512
; Ohio Administrative Code (OAC) 4123-17-32
Warren, Interim Chief Employer Services
Insured Department/Employer Services
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), SI employers that elect to participate
in the surplus fund (disallowed claims reimbursement), and their authorized
third-party administrators (TPAs) and representatives.
A. Overturned Claim: A claim allowance (in
whole or in part) 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.
A. Eligibility: 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 claims reimbursement):
employer must be an active SI employer as of the date of injury; and
employer must have paid the optional assessments for surplus fund (disallowed
claims reimbursement) as of the date of injury; and
for which SI employer applies for reimbursement must qualify as an overturned
applications for surplus fund (disallowed claims reimbursement) must be fully
completed using the SI-52 form and include the
Administrator (if applicable);
and date periods for indemnity, medical, and prescriptions;
documentation for all expenses paid; and
determination or claim settlement confirmation.
Violations of Specific Safety Requirement (VSSR) awards overturned through a
final administrative or judicial order are not eligible for reimbursement
through the surplus fund (disallowed claims reimbursement). Pursuant to
ORC4123.512(H)(1), SI employers deduct the amounts paid on overturned VSSRs
from the paid compensation reported to BWC during semi-annual assessments.
from Program: SI employers may withdraw from participation in the surplus fund
by submitting the Election to Withdraw from Claims Reimbursement Fund form SI-44.
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.
employer’s decision to withdraw from the surplus fund (disallowed claims
reimbursement) is irrevocable.
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 Dispute/Protest Policy.
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