Conn. Agencies Regs. § 31-354-9

Current through August 9, 2024

Section 31-354-9 - Procedures under section 31-349 of the general statutes

(a)Compensation for Second Liability

(1) If an employee with a permanent physical impairment incurs a second compensable injury either by accident or by disease, and both conditions result in a permanent disability which is materially and substantially greater than the disability which would have resulted from the second injury alone, he shall receive compensation for the entire amount of disability.

(2) As a condition precedent to the liability of the Second Injury Fund, the employer or his insurance carrier shall, after the expiration of 52 weeks of disability and ninety days prior to the expiration of the 104 week period of disability notify the custodian of the Second Injury Fund of this pending case.

(3) With timely notice, i.e. notice to the custodian of the Second Injury Fund of the pending case 90 days prior to the expiration of the 104 week period of disability, an employer or compensation carrier may transfer its liability to the Second Injury Fund.

(b)Notice

(1) Notice to the Fund shall:

(A) Be sent to the custodian of the fund or his designee;

(B) Be accompanied by a voluntary agreement or finding and award. If there is no voluntary agreement or finding and award, the claim may be rejected unless it is being contested as to compensability. The employer or insurance carrier shall provide the Fund with a copy of its notice of contest and shall request that the Fund be made a party of interest in the contested claim.

(C) Be accompanied by copies of all supporting medical reports; and

(D) Contain a statement outlining the claim, type and amount of benefits paid to date or other proof of disability.

(2) If notice is untimely or a voluntary agreement is not approved within the statutory time period, the Fund may reject the claim.

(c)Transfer Agreement

(1) If the claim is voluntarily accepted by the Fund, the employer or its carrier shall prepare a transfer agreement.

(2) Clearly stated within the body of the transfer agreement shall be:

(A) An accounting and calculation of benefits paid toward the 104 weeks and the type of benefits paid; temporary total, temporary partial, and/or permanent partial disability.

(B) The claimant's present disability status and copies of all medical data substantiating such status.

(C) A reimbursement request for all compensation benefits paid and medical costs incurred subsequent to the date of fund liability.

(3) If more than one body part is injured, the Fund shall only accept transfer of the body parts statutorily eligible for transfer. Each body part may transfer upon payment of 104 weeks of disability attributable to that body part.

(4) The claimant's signature may be required by the fund.

(d)Claimant's Process and Procedures

(1) A change of address shall be forwarded to the Fund immediately.

(2) A change of the authorized attending physician requires prior approval from the Fund or the commissioner.

(3) A medical report shall be sent to the Fund from your authorized attending physician i.e. after each visit.

(4) Prior to the scheduling of any non-emergency surgery, a second opinion from another physician may be required. Upon notification, the Fund may schedule the evaluation appointment.

(5) All medical and pharmaceutical bills forwarded to the Fund for payment shall be itemized originals; "balance forward" bills are not acceptable.

(6) Changes in circumstances affecting a claim, including but not limited to the following, shall be reported to the Fund:

(A) Marital Status - divorce; living apart; spousal death;

(B) Dependency - attaining majority; emancipation; student status;

(C) Legal Representation - a change in attorneys; a termination of client relationship;

(D) Medical Treatment - a change in attending physician; medical referrals;

(E) Benefit Payments - errors; overpayment; and

(F) Employment - date returned to work.

(7) Failure to notify the Fund in writing of any changes in circumstance could result in the discontinuation of benefits and possible litigation.

(8) send all correspondence to:

Second Injury Fund

Claims Department

P. O. Box 668

10 Griffin Road North

Windsor, CT 06095-0668

(e)Obligations of Authorized Attending Physicians

Such regular progress reports as may be required by the Second Injury Fund shall be sent to the Fund by the attending physician.

(f)Transfer of Liability under Subsection (f) of Section 31-349 of the General Statutes

(1) No hearing, informal or formal, shall be assigned or held for the purpose of transferring liability to the Second Injury Fund under the provisions of subsection (f) of Section 31-349 of the General Statutes, unless and until the claimant or his representative has certified in writing to the Second Injury Fund the following information:

(A) The date the claimant's employer removed all or substantially all of its industrial or commercial operations to a location outside the state of Connecticut, or the date the claimant's employer permanently shut down all of its operations within a business facility located in the state, and thereafter failed to comply with the provisions of section 31-284b of the General Statutes;

(B) The name and address of the claimant; the claimant's employer; the claimant's compensation carrier; and the claimant's group health carrier;

(C) A copy of the voluntary agreement or the finding and award approved and signed by a compensation commissioner;

(D) A statement indicating that the claimant is currently receiving compensation benefits and shall notify the Fund every 30 days that he/she is still receiving compensation benefits; and

(E) A description of the health plan in force on the date of injury, including whether or not a contribution was made by the claimant to the cost of premium.

(2)Liability

The Fund's liability for the costs of the coverage shall begin 15 days after the custodian is so notified and shall continue so long as the individual receives compensation pursuant to this chapter; and enrollment into a group program shall be deemed to be equivalent coverage.

(3)Notice

The Fund shall not be liable for any costs incurred (1) prior to the date the notice is received or (2) during the 15 days after the notice is received if the custodian determines during that period that the individual is ineligible. Failure to comply with any of the foregoing provisions during the fifteen day period after the notice has been received by the Fund may render the claimant ineligible.

(4)Jurisdiction

A commissioner having jurisdiction may, when in the opinion of that commissioner sufficient cause exists, assign for an informal or formal hearing a case involving a request of transfer of liability of the Fund pursuant to subsection (f) of section 31-349 of the General Statutes.

Conn. Agencies Regs. § 31-354-9

Effective July 21, 1994