Fundamentals of filing a claim

State of Georgia
Subsequent Injury Trust Fund
Fundamentals of Filing a Claim

Marquis II Tower, Suite 1250 285 Peachtree Center Ave. NE Atlanta, GA 30303-1229

Tel: (404) 656-7000 Fax: (404) 656-7100 http://sitf.georgia.gov

CONTENTS
Introduction Staff Contact The Claims Process
Executive Legal Authority Rules & Regulations
Administration Notice of Claim
Pending Employer Knowledge Permanent Impairment Presumed Conditions Merger Causal Merger Greater Than Merger Combined Effects Merger Return to Work Reimbursement Agreement Denied Claims Pending Checklist
Reimbursement Reserve Reduction Request for Reimbursement Indemnity Expenses Medical Expenses
Settlement Requirements Granting Authority Delays SITF Claim Acceptance Settlement Checklist
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INTRODUCTION
Our Mission
The Subsequent Injury Trust Fund provides reimbursements and information to employers, insurers, and their agents, in those Workers' Compensation claims involving individuals with a preexisting permanent impairment.
Our Vision
The Board of Trustees and staff of the Subsequent Injury Trust Fund commit to bringing awareness of the financial benefits available to employers, insurers, and their agents, by continuing our efforts to build positive relations in the risk management arena.
Our Goals
1. Work with clients and parties at interest on how to properly present claims.
2. Increase agency visibility among insurance agents and risk managers.
3. Build alliances with state agencies that provide employer-related services.
4. Empower all levels of staff with agency-related knowledge.
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STAFF CONTACT

EXECUTIVE/ADMINISTRATION STAFF
Administrator, Mike Coan 404-656-7013 mcoan@sitf.ga.gov
Deputy Administrator, Allan Payne 404-656-7062 apayne@sitf.ga.gov
Executive Assistant, Ann Dixon 404-656-7017 adixon@sitf.ga.gov
Fiscal Officer, Evon Strickland 404-656-7016 estrickland@sitf.ga.gov
Director of Administrative Services, Kathy Cannon 404-656-7022 kcannon@sitf.ga.gov
Administrative Unit Assistant, Chris Perea 404-656-7027 cperea@sitf.ga.gov
Administrative Unit Assistant, Kerry Griffin 404-656-7030 kgriffin@sitf.ga.gov

REIMBURSEMENT UNIT
Specialist, Bob Fisher 404-656-7069 btfisher@sitf.ga.gov
Specialist, Marsha Jones 404-656-7079 mjones@sitf.ga.gov
Specialist, Nettie Rothstein 404-656-7081 nrothstein@sitf.ga.gov
Specialist, Cynthia Sims 404-656-7082 csims@sitf.ga.gov Specialist, Steve Howe 404-656-7083 showe@sitf.ga.gov Reimbursement Unit Assistant, Beth Moser 404-656-7008 bwolf@sitf.ga.gov

PENDING CLAIMS UNIT
Supervisor, Bob Cato, CSP 404-656-7033 bcato@sitf.ga.gov
Supervisor, Barbara DeVeaux 404-656-7032 bdeveaux@sitf.ga.gov WC Specialist, Mary Benjamin 404-656-7039 mbenjamin@sitf.ga.gov
WC Specialist, Tara Henslee 404-656-7046 thenslee@sitf.ga.gov
WC Specialist, Tressie Matthews 404-656-7056 tmatthews@sitf.ga.gov WC Specialist, Bishop Tinsley 404-656-7060 btinsley@sitf.ga.gov Claims Unit Assistant, Sharon McClure 404-656-7008 smcclure@sitf.ga.gov

SETTLEMENT UNIT
Supervisor, Reecie Jones 404-206-6379 rjones@sitf.ga.gov WC Specialist, Derrick Turner 404-656-7051 dturner@sitf.ga.gov
WC Specialist, Phyllis Holt 404-656-7108 pholt@sitf.ga.gov WC Specialist, Alethea Watt 404-656-7110 awatt@sitf.ga.gov Settlement Unit Assistant, Isha McGhee 404-656-7116 imcghee@sitf.ga.gov

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THE CLAIMS PROCESS

Notice of Claim
ADMINISTRATION

PENDING
Employer Knowledge Permanent Impairment
Merger

EXECUTIVE
Claim acceptance, denial, compromise

REIMBURSEMENT
Reimbursement Request

SETTLEMENT
Settlement Authority Mediation

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EXECUTIVE

Board of Trustees John Fervier James F. Braswell E. Pauline Hale John L. Quinn

Mike Coan, Administrator Allan Payne, Deputy Administrator

SITF Board Decisions Litigation Stipulation Agreements

Rule Changes Final Claim Approval Policy Standards

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LEGAL AUTHORITY
The legal authority for the Fund established by the General Assembly is published in Title 34, Chapter/Article 9 of the Official Code of Georgia.
http://www.legis.state.ga.us
34-9-350 Purpose 34-9-351 Definitions 34-9-351.1. Authorized Self-Insurer 34-9-352 Office of Treasury and Fiscal Services 34-9-353 Surety Bond 34-9-354 Board of Trustees 34-9-355 Appointment of Administrator 34-9-356 Expenses 34-9-357 Budget 34-9-358 Assessments 34-9-359 Penalties and Fees 34-9-360 Deductibles 34-9-361 Presumed Permanent Impairment 34-9-362 Notice of Claim 34-9-363 State Board Approval 34-9-363.1 Settlement 34-9-364 Apportionment 34-9-365 Effective Date of Injury 34-9-366 Not a Party, Not Bound 34-9-367 Attorney Fees 34-9-368 Dissolution of the Fund
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RULES & REGULATIONS
The Board of Trustees is authorized to amend SITF Rules and Regulations when appropriate. The Rules are designed to inform insurance carriers, self-insurers, employers and employees about the Georgia Subsequent Injury Trust Fund (SITF) and to define the prerequisites and proper procedures for filing a claim with the fund.
622-1-.01 Board of Trustees 622-1-.02 Cost of Administration; Budget 622-1-.03 (1) Payment of Non-dependency Benefits into the SITF 622-1-.03 (2) Payment of Assessments to the Fund by Insurers
and Self-Insurers 622-1-.03 (3) Reports by Employers of Compensation and Benefits Paid;
Failure to Pay Assessments 622-1-.04 Filing Claims Against the Subsequent Injury Trust Fund 622-1-.05 Employer's Knowledge Statement 622-1-.06 Procedures for Payment of Reimbursement Benefits by the Fund 622-1-.07 Settlements Subsequent to Reimbursement Agreements 622-1-.08 Fund not Bound as to Certain Matters.
Visit our Website http://sitf.georgia.gov
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ADMINISTRATION
Notice of Claim Auto-notification of claims filed
Incoming mail Claims database Open records requests Claim status information Reimbursement checks Assessment collection
ADMINISTRATION STAFF Kathy Cannon 404-656-7022
kcannon@sitf.ga.gov Chris Perea
404-656-7027 cperea@sitf.ga.gov
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NOTICE OF CLAIM
To reduce paper handling, SITF has made available an Online Notice of Claim Form. Receipt notification of online filing is provided to the employer/insurer or servicing agent. If you prefer to submit a claim form on paper, the form can be downloaded from the SITF website http://sitf.georgia.gov The employer/insurer should notify the Fund as soon as practicable of a possible claim, but no later than: - payment of 78 weeks of income or death benefits, or - within 78 calendar weeks from the date of injury whichever occurs later. Also: - the claim must be filed prior to final settlement.
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FILE ONLINE http://sitf.georgia.gov
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PENDING

PENDING CLAIMS UNIT
Bob Cato, CSP Supervisor 404-656-7033 bcato@sitf.ga.gov
Tressie Matthews 404-656-7056 tmatthews@sitf.ga.gov
Bishop Tinsley 404-656-7060 btinsley@sitf.ga.gov

Barbara DeVeaux Supervisor 404-656-7032 bdeveaux@sitf.ga.gov
Mary Benjamin 404-656-7039 mbenjamin@sitf.ga.gov
Tara Henslee 404-656-7046 thenslee@sitf.ga.gov
Sharon McClure Claims Unit Assistant 404-656-7008 smcclure@sitf.ga.gov

Assigns activated claims to Specialist Review claim for proper documentation Verifies Employer Knowledge Verifies pre-existing permanent impairment Verifies merger Based on findings, recommends acceptance or denial of claim Evaluates claim value
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EMPLOYER KNOWLEDGE
The affiant must be someone who has firsthand knowledge of the injured worker's pre-existing condition such as an individual in an executive, personnel, or personnel-advisory capacity, or, if an employer is subject to the Americans With Disabilities Act, the designated custodian of (medical) records.
Attach any documentation or records that were in the employer's possession prior to the subsequent injury. If you attach documents, these must be accompanied by certification on employer's letterhead that states "documents were contained in employer's files". Any reports specifically referred to in the affidavit must be attached and certified.
The employer should identify the actual date of knowledge of the prior impairment.
The employer, if possible, should list any individuals (along with their address and telephone number) either currently or formerly working for the employer who may have firsthand knowledge of the employee's pre-existing disability.
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PERMANENT IMPAIRMENT
DEFINITION
Any permanent condition due to previous injury, disease, or disorder which is, or is likely to be, a hindrance or obstacle to employment or to obtaining reemployment if the employee should become unemployed.
DOCUMENTATION
Prior Medical Reports Employee Personnel File Prior WC Injury Information Physical Evaluation File Pre-employment Physical Exam
Documents Health Questionnaire
KNOWLEDGE
The EMPLOYER must reach an informed conclusion the the pre-existing condition is:
Permanent in nature; Is likely to be a hindrance to employment; and Provide a letter certifying that information was in the employer's
file PRIOR to the date of the subsequent injury.
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PRESUMED CONDITIONS
There are 23 presumed conditions that are considered by law to be permanent and likely a hindrance to employment.

1. Epilepsy

16. Sickle cell anemia

2. Hyperinsulism

17. Multiple sclerosis

3. Diabetes

18. Chronic osteomyelitis

4. Tuberculosis

19. Cardiovascular disorders

5. Hemophilia

20. Mental retardation

6. Cerebral palsy

21. Parkinson's disease

7. Muscular dystrophy

22. Compressed air sequelae

8. Psychoneurotic disability

23. Ruptured intervertebral disc

9. Amputated foot, leg, arm, or hand

10. Residual disability from poliomyelitis

11. Ankylosis of major weight bearing joints

12. Total occupational loss of hearing (as defined in OCGA 34-9264

13. Arthritis which is an obstacle or hindrance to employment

14. Loss of sight of one or both eyes or a partial loss of uncorrected vision of more than 75% bilaterally

15. Any permanent condition which, prior to the occurrence of the subsequent injury, constitutes a 20% impairment of a foot, leg, hand, arm, or the body as a hole.

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MERGER
MERGER CONDITIONS Had the pre-existing permanent impairment not been present, the subsequent injury would not have occurred. The disability resulting from the subsequent injury (in conjunction with the pre-existing permanent impairment) is materially, substantially, and cumulative greater than that which would have resulted had the pre-existing permanent impairment not been present, and the employer has been required to pay and has paid compensation for that greater disability; or Death would not have been accelerated had the preexisting permanent impairment not been present.
The Employer/Insurer must provide medical evidence supporting merger between the
subsequent injury and the prior impairment.
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CAUSAL MERGER
Had the pre-existing permanent impairment not been present, the subsequent injury would not have occurred. EXAMPLE: Injured worker has epilepsy, she has a seizure, loses consciousness, falls and hits her head incurring severe head trauma. If the employee had not had the permanent impairment, she would not have suffered the subsequent injury. EXAMPLE: Injured worker has had a prior herniated disc at L4-5 with discectomy. While performing his normal job as a mechanic (routine twisting, turning, etc.), he experiences back pain. He is diagnosed with a "recurrent" herniated disc. Because he had a permanent impairment, and did not have a specific event that caused the injury, this would still be considered a causal merger.
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GREATER THAN MERGER
The disability resulting from the subsequent injury, in conjunction with, the pre-existing permanent impairment is materially, substantially, and cumulatively greater than that which would have resulted had the pre-existing permanent impairment not been present; and the employer, during the subsequent injury, must have paid compensation for that greater disability (not medical expenses).
EXAMPLE: The injured worker has diabetes. He/she steps on a nail and incurs a puncture wound to the foot. He/she subsequently develops osteomyelitis/infection and has to have several debridements or possibly a partial amputation.
The employer/insurer is required to pay or has paid for the greater disability which was the consequence of the claimant's pre-existing diabetes and the impact of the diabetes on the subsequent injury. If the claimant did not have the pre-existing diabetes, with the same injury and no complications, there would be no greater than merger.
NOTE: The permanency rating from the prior injury cannot be added to the permanency rating of the subsequent injury to create a greater disability.
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COMBINED EFFECTS MERGER
COMBINED EFFECTS
This occurs only when the injured worker is totally unable to reenter the workforce. The fund established this type merger in an effort to provide greater reimbursement possibilities.
The merger occurs when two separate impairments or areas of the anatomy do not directly "merge", but when combined, cause permanent and total disability to the injured worker.
EXAMPLE: An employee is totally blind in the left eye. He/she sustains an injury to the cervical spine and requires fusion. The employer has no work available for this person the employee cannot do his/her regular job because of the cervical spine and cannot do "desk" work because of the blindness in the left eye. Therefore, because of the two separate impairments, the employee is totally and permanently disabled from the job resulting from the combined effects.
In the instance of a combined effects merger, all medical expenses will be apportioned (not paid). Only indemnity expenses, after proper deductibles are met, will be reimbursed.
REMEMBER: Merger must be substantiated by medical evidence.
The examples presented within this document are for illustrative purposes only; they are not case specific.
Each SITF claim is reviewed on its own merits.
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RETURN TO WORK
NO NEW DEDUCTIBLE APPLICATION When a claim is accepted by the Fund and the injured
worker returns to work with the same employer (with no break in service), the employer is not subject to additional indemnity or medical deductions if the employee suffers a new accident that merges with the same prior impairment. The Fund operates as a tool to assist in the rehabilitation process and provides for reimbursement of allowable rehabilitation expenses.
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REIMBURSEMENT AGREEMENT
1. The Reimbursement Agreement is a legally binding document and must be signed (on behalf of the employer and insurer) by someone with management or supervising authority.
2. Third party administrators cannot sign the Reimbursement Agreement.
3. Attorneys for the employer/insurer can sign the document.
4. The Fund creates, signs, and forwards the Reimbursement Agreement to the claim handler for signature by the insurer. Once the agreement is signed by both parties, the Fund forwards the document to the State Board of Workers' Compensation for approval. A copy of the Board approved Agreement is returned to the Fund and a copy is mailed to the claim handler.
5. A Board approved Agreement (identifying the proper payee) MUST be on file prior to payment on a SITF claim.
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DENIED CLAIMS
The Fund will notify the employer/insurer if it is determined that a claim does not qualify for reimbursement.
When a claim is denied by the Fund, the employer/insurer must request a hearing with the State Board of Worker's Compensation Form WC-14. The form must be submitted within 90 days of receipt of the denial notice and a copy must be forwarded to the Fund. This notice to the Board need not be a request for an immediate hearing, but meets statutory requirements and protects the employer/insurer's claim.
The Fund makes every attempt to resolve differences with the employer/insurer prior to a hearing date.
Many times the Fund reconsiders a denial decision when proper documentation is subsequently provided.
A denial decision can be avoided when all requested documentation is submitted to the Fund.
If the employer/insurer fails to file the Form WC-14 with the State Board of Workers' Compensation within 90 days of receipt of the formal denial notice from the Fund, the employer/insurer is barred from recovery on the claim.
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EMPLOYER'S KNOWLEDGE AFFIDAVIT (EKA)

Original notarized Employer's Knowledge Affidavit's S.I.-"H".

1.

If verbal knowledge is used or factual statements given, a verifying statement

from the employee will expedite evaluation.

2.

Legible documents contained in employer's files prior to the subsequent injury.

3.

Employer's certification letter (SEE REVERSE SIDE OF EKA).

WORKERS' COMPENSATION BOARD FORMS

1.

LEGIBLE copy of front and back of First Report of Injury.

2.

All board forms, including WC-2, WC-3, WC-4, WC-6, and WC-104, where

applicable.

3.

Current work status: __TO ___TPD ___RTW __WITH __WITHOUT

RESTRICTIONS __REG ___LGHT

PRIOR IMPAIRMENT INJURY MEDICAL REPORTS

LEGIBLE medical narratives supporting prior permanent impairment.

SUBSEQUENT INJURY MEDICAL REPORTS

1.

LEGIBLE medical narratives supporting subsequent injury. (Up-to-date from Date

of Accident).

2.

All rehabilitation reports if applicable.

3.

Please do not submit reimbursement requests or bills at this time.

MERGER: O.C.G.A 34-9-351(1)

1.

Merger requires medical narratives or a statement from the treating physician

that clearly establishes merger as defined in Code Section 34-9-351(1).

2.

Please keep in mind that the prior impairment must be the principal factor that

materially, substantially and cumulatively aggravated the (subsequent) condition

so as to synergize a greater degree of disability when considered together.

LITIGATION

1.

Is there any current or past litigation? ___Yes ___No.

2.

Claimant's attorney: NAME, ADDRESS, PHONE.

3.

Please briefly describe the nature of the litigation and include all awards as

applicable.

4.

Are there settlement negotiations in progress? ___Yes ___No. If yes, please

advise amount of demand and amount of counter offer.

5.

If settled, please submit a copy of the board-approved stipulation.

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REIMBURSEMENT

Assigns reimbursement requests to Specialist.

Reviews reimbursement requests.

Verifies Reimbursement Agreement on file.

Verifies Reserve Reduction Certificate on file.

REIMBURSEMENT UNIT



Allan Payne, Deputy Administrator

404-206-6370

apayne@sitf.ga.gov


Bob Fisher

Marsha Jones

404-656-7069

404-656-7079

btfisher@sitf.ga.gov

mjones@sitf.ga.gov

Verifies required SBWC forms submitted.
Audits medical, indemnity, and rehabilitation documents and narratives.

Nettie Rothstein 404-656-7081 nrothstein@sitf.ga.gov
Steve Howe 404-656-7083 showe@sitf.ga.gov

Cynthia Sims Based upon verified data,

404-656-7082 csims@sitf.ga.gov

authorizes reimbursement of

allowable charges.

Initiates payment process.

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RESERVE REDUCTION
In accordance with OCGA 34-9-360(c) "the insurer shall be required to certify that the medical and indemnity reserves have been reduced to the threshold limits of reimbursement."
A third party administrator cannot certify reserves without prior authorization by the insurer. The TPA must provide the Fund with an authorization document and will not be required to submit a Reserve Reduction Letter.
Self-insured employers are not required to certify reduction of reserves.
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REQUEST FOR REIMBURSEMENT
1. A completed Reimbursement Request must be returned to the Fund for EACH request.
2. Both indemnity and medical expenses can be included on the form.
3. An itemized list of all medical expenses must accompany the medical Reimbursement Request.
4. A certified counterpart of the Employer or Insurer's computergenerated pay document may be substituted for the itemized list. It must include: payment date, service provider, diagnosis codes, CPT codes, amount paid, and any reductions per fee schedule.
5. Medical narratives and rehabilitation reports must accompany a request for medical expense reimbursement.
6. Funeral benefits, penalty fees, administrative costs, and legal costs are NOT reimbursable by the Fund.
7. No reimbursement will be made unless a Reimbursement Request form is completed and signed by the claiming party.
8. The employer/insurer is required to attest to their efforts to assure that the injured employee is entitled to receive, or to continue to receive workers' compensation benefits. Failure to comply with this regulation may subject the claim to a denial of reimbursement benefits.
9. After the initial fund payment, reimbursement requests may be made in 13-week intervals.
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INDEMNITY EXPENSES

Total Disability
A copy of the WC-2 and WC-4 forms must accompany the initial and the final request for indemnity expense reimbursement. The forms must also be submitted annually for the life of the reimbursement claim.
Additionally, if another losttime/return to work period occurs, please submit a copy of the WC-2 form.
For accidents occurring after July 1, 1992, a copy of the WC104 must be submitted. This is necessary when the comp rate is expected to be reduced from the TTD to the TPD rate.

Temporary Partial Disability
Attach a list breaking down weekly payments if such payment amounts were less than the maximum allowance under OCGA 34-9-262. (See examples)
The Fund reserves the right to request a copy of the actual payment record.

Indemnity Deductible This deductible is equal to 104 weeks times the comp rate.
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Example: Weekly Payments

FROM 7-28-83 2-02-87 5-10-89

TOTAL DISABILITY

THRU

# WEEKS AMOUNT

3-04-86

135.8 18,333.00

3-10-88

57.8 7,803.00

5-23-89

2.0

270.00

$26,406.00

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Example: Weekly Payments

PAY PERIOD ENDING 2-16-89
2-23-89
3-02-89
3-09-89
3-16-89
3-23-89
3-30-89
4-06-89

TEMPORARY PARTIAL DISABILITY

PRE INJURY WAGE

POST INJURY WAGE

288.71 - 188.50

= 100.21 X

.66667

288.71 - 192.00

=

96.71 X

.66667

288.71 - 192.00

=

96.71 X

.66667

288.71 - 192.00

=

96.71 X

.66667

288.71 - 233.76

=

54.95 X

.66667

288.71 - 260.00

=

28.71 X

.66667

288.71 - 192.00

=

96.71 X

.66667

288.71 - 192.00

=

96.71 X

.66667

=

66.81

=

64.47

=

64.47

=

64.47

=

36.63

=

19.41

=

64.47

=

64.47

$444.93

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MEDICAL EXPENSES

$7,500 Deductible The first $5,000 in allowable expenses is not reimbursable. Amounts over $5,000 (up to $10,000) will be reimbursed at 50%.

EXAMPLE:

Expenses Less Deductible
Reimbursed Amount

$7,000 5,000
$2,000 x 50% $1,000

Allowable charges incurred after the $7,500 medical threshold limit is reached are reimbursed at 100%.
-- - No New Deductibles - - When the employee returns to work with the same
employer and no break in service. (See Page 21)
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SETTLEMENT

SETTLEMENT UNIT
Reecie Jones, Supervisor 404-206-6379 rjones@sitf.ga.gov
Alethea Watt 404-656-7110 awatt@sitf.ga.gov

Assigns Specialist to claims where settlement authority is requested.

Evaluates settlement demand amount and conditions.

Reviews disability award.

Calculates value of lifetime claims.

Negotiate settlement amounts and conditions.

Attends WCB mediation hearings.

Based on verified data, recommends authority or denial of settlement claims.

Phyllis Holt 404-656-7018 pholt@sitf.ga.gov

Derrick Turner 404-656-7116 dturner@sitf.ga.gov

Isha McGhee Settlement Unit Assistant 404-656-7116 imcghee@sitf.ga.gov

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REQUIREMENTS
Agreements
The employer/insurer shall obtain the approval of the Fund on all settlements entered into with the injured worker.
After the Reimbursement Agreement is approved by the State Board of Workers' Compensation, the employer/insurer shall keep the Fund informed of any settlement discussion with the injured worker.
Demand
Prior to reaching a settlement agreement with the employee, the employer/insurer must submit a settlement demand in writing to the Fund. The employer/insurer must keep the Fund apprised of progress and changes in settlement negotiations.
Mediation
Mediation is NOT a requirement to obtain settlement authority. The Fund encourages efforts to extend settlement authority prior to the mediation date in hopes of reaching an agreement. For cases that must go to mediation, the Fund must have a complete document package no later than 21 days prior to the mediation date.
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GRANTING AUTHORITY
1. The Fund will grant settlement authority to the employer/insurer based on investigations by the Workers' Compensation Specialists in the Settlement unit. Usually, this process takes approximately four to six weeks.
2. The Fund does not negotiate settlement with the attorney for the injured worker.
3. Settlement will not be reimbursed if the injured worker returns to work.
4. In the instance where a claim is settled prior to acceptance by the Fund, the Fund is not bound by those settlement terms.
5. Any settlement advances are deducted from the settlement authority granted by the Fund.
6. The Fund should be notified within 30 days of negotiations; sooner on capped claims. Authority granted is only good for 30 days because benefits decrease weekly.
7. Once settlement is agreed upon between the employer/insurer and the injured worker, the Fund should be included as a party of interest. A draft Stipulation Agreement can be faxed to the Fund for review prior to signature by all parties.
8. If an agreement cannot be reached, notify the Fund and the authority request will be returned. The settlement portion of the claim will be closed. Reimbursement will continue as agreed between the Fund and the employer/insurer.
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DELAYS
1. Employer/insurer does not provide a settlement recommendation.
2. No demand from the injured worker's attorney. 3. No recent reimbursement request is on file and no
updated medical narratives are received. 4. Maximum medical improvement is not reached. 5. Confirmation of SSDI is not received. Applicable
for injuries occurring after 7/1/92. 6. Confirmation of current work status. 7. Confirmation of permanent partial disability.
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SITF CLAIM ACCEPTANCE

Settlement Prior to Acceptance
When the Fund is not a party to the settlement, it is not bound to the terms of the settlement agreement; however, the fund will review the claim.
Any stipulated settlement agreement must be a "liability" agreement.
Any "no liability" settlement agreement will result in a denial, as the Fund can only reimburse indemnity, medical, and rehabilitation expenses the employer/insurer is legally obligated to pay to the injured worker. (OCGA 34-9-360)

Settlement After Acceptance
The Fund must be apprised of settlement negotiations and approve the settlement agreement.
Without the Fund's approval, the reimbursement agreement between the Fund and the Employer/Insurer becomes null and void.

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Employer/Insurer's Subsequent Injury Trust Fund Settlement Authority Request Checklist

DEMAND & EVALUATION

1.

Employer/Insurer's settlement evaluation.

2.

Demand from the claimant and his/her attorney, if represented.

3.

Are there settlement negotiations already in progress? ___yes ___no

4.

If yes, please provide amount of demand and counter offer, including provision for open

medical expenses.

5.

Is a Medicare set-aside provision being considered? ___yes ___no

WORKERS' COMPENSATION BOARD FORMS

1.

Board forms, including WC-2, WC-3, WC-4, WC-104, WC-243, WC-240, where applicable.

2.

Board awards and advances, if any.

3.

Current work status: ___TD ___TPD ___RTW ___WITH ___WITHOUT

RESTRICTIONS ___REGULAR ___LIGHT

4.

If released to light duty, is there a job available?

5.

Have you filed a WC-104 with the Board?

SUBSEQUENT INJURY MEDICAL REPORTS

1.

Legible medical narratives for the past 12 months or from the last reimbursement

request.

2.

Does the injury qualify for a permanent impairment rating? If so, please submit copy.

3.

Recent surveillance reports, if any.

4.

Rehabilitation reports, if applicable.

5.

Copy of Social Security Disability Award, if applicable for claims with accident dates after

7/1/92.

6.

Is the case catastrophic or has the employee filed for this designation with the State

Board?

LITIGATION

1.

Is there any pending litigation? ___yes ___no

2.

If yes, please submit copy of WC-14 and describe the nature of the litigation.

TOTALS PAID TO DATE

1.

Indemnity $____________

2.

Medical $___________

SITF cannot grant settlement authority unless all of the above information and materials are in our possession.

If settlement mediation is imminent, the complete package must reach SIT at least 21 days prior to mediation date.

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VISIT OUR OFFICE
Marquis Two Tower, Suite 1250, 285 Peachtree Center Avenue NE, Atlanta, GA 30303 Main Tel: (404) 656-7000 Interstate 75 /85- exit at Courtland Street. Public garage parking is available at Courtland and Harris Street. A walkway to the Tower is available at Courtland Street Garage 7th Floor. From Downtown Atlanta: I-75/85 North. Exit at Andrew International Blvd. Turn left on International, cross Piedmont Road, turn right on Peachtree Center Ave. Public parking is available at Peachtree Center Ave and Harris Street(LAZ Parking). Public parking is also available at the Courtland Garage. The Marquis Two Tower is on the corner of Peachtree Center Ave and Baker Street.
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