OhioBWC - Basics: (Policy library) - File

 

Policy Name:

 Surplus Fund (Disallowed Claims Reimbursement)

Policy #:

 SI-03-01

Code/Rule Reference:

Ohio Revised Code (ORC) 4123.35, 4123.512 ; Ohio Administrative Code (OAC) 4123-17-32

Effective Date:

New

Approved:

Winnie Warren, Interim Chief Employer Services

Origin:

Self Insured Department/Employer Services

History:

New

Review Date:

11/01/2024

 

 

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.

 

II.  Applicability

 

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.

 

III.  Definitions

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.

 

C. Self-Insuring 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.

 

IV.  Policy

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):

1. The SI employer must be an active SI employer as of the date of injury; and

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:

1. All applications for surplus fund (disallowed claims reimbursement) must be fully completed using the SI-52 form and include the following information:

a.         Employer Demographics;

b.         Third-Party Administrator (if applicable);

c.         Injured Worker Demographics;

d.         Basis for Request:

i.        Amount and date periods for indemnity, medical, and prescriptions;

ii.       Supporting documentation for all expenses paid; and

iii.     Final determination or claim settlement confirmation.

2. Exception:  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.

 

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 irrevocable.

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 Complaints

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.

 

Ohio Bureau of Workers’ Compensation

Self-Insured Department

30 W. Spring St., L-22

Columbus, Ohio 43215-2256

Email: SIINQ@bwc.state.oh.us

 

B.   The SI employer may file a written appeal of the SI Department’s decision to the Self-Insured Review Panel (SIRP).