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§ 116.12. Subsequent Injury Fund Payment/Reimbursement Schedule

(a) Claims against the Subsequent Injury Fund (SIF) shall be paid in the following priority:

(1) claims by insurance carriers for reimbursement made pursuant to Labor Code § 403.007 and § 132.10(g) of this title (relating to Payment of Death Benefits to the Subsequent Injury Fund);

(2) claims by injured employees for lifetime benefits, as provided by Labor Code § 408.162;

(3) claims by insurance carriers for reimbursement, made pursuant to Labor Code §§ 408.0041, 410.209, and 413.055 and § 116.11 of this title (relating to Request for Reimbursement from the Subsequent Injury Fund); and

(4) claims by insurance carriers for reimbursement made pursuant to Labor Code § 408.042(g) relating to multiple employment and those in accordance with division rule(s) adopted pursuant to Labor Code § 413.0141.

(b) The SIF uses the fiscal year September 1 through August 31.

(c) Claims described in subsection (a) of this section should be reviewed and, if appropriate, paid in the fiscal quarter following the quarter in which the request was submitted and no later than one year following the submission.

(d) In accordance with Labor Code § 403.006(d), if the commissioner determines that partial payments of the claims described in subsection (a)(4) of this section are necessary, partial payments shall be calculated in the following manner:

(1) The total amount of completed eligible requests for reimbursement submitted under subsection (a)(4) of this section that are received during the previous fiscal year will be used to establish a baseline amount.

(2) The baseline amount will be divided by the total amount of SIF funding available as determined in accordance with the Labor Code.

(3) The resulting fraction will be equally applied to all claims submitted under subsection (a)(4) of this section to determine the partial reimbursement amount.

(4) If reimbursement requests are paid with partial payments, no further future recovery is available from the SIF for the non-reimbursed portion of that particular request.

(e) If reimbursement requests are paid with partial payments, the SIF administrator shall, no later than October 30 of the following fiscal year, enter appropriate orders for claims described in subsection (a)(4) of this section. The order shall specify the amount the SIF shall pay to the insurance carrier.

(f) The SIF administrator will refrain from acting on an insurance carrier’s request for reimbursement from the SIF until final resolution of all disputes affecting the request for reimbursement.

The provisions of this §116.12 adopted to be effective February 11, 1992, 17 TexReg 689; amended to be effective March 13, 2000, 25 TexReg 2090; amended to be effective August 15, 2002, 27 TexReg 7123; amended to be effective January 7, 2010, 35 TexReg 100.

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At a Glance:

Title:

§ 116.12. Subsequent Injury Fund Payment/Reimbursement Schedule

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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