When Does the Subsequent Injuries Fund Pay On a Claim?

California law requires that the majority of employers carry workers’ compensation insurance to provide for their workers in the event that they sustain a work-related injury during the course and scope of their employment.  Unfortunately, some employers either do not carry this insurance or even do not realize that they are required to do so.  California Labor Code § 3351 defines “employee,” and the definition is broader than most people realize, including even workers such as handymen, nannies, and minors.  In the event an employee sustains an injury, the Uninsured Employers Benefit Trust Fund (UEBTF) may provide funding for the employee.  If the employer is illegally uninsured and fails to pay the compensation awarded to the employee by the Workers’ Compensation Appeals Board, the employee may submit a claim to the UEBTF for payment of his or her claims.

The Subsequent Injuries Benefits Trust Fund (SIBTF) is another source of compensation for injured workers.  Under California Labor Code § 4751, employees who had a previous permanent disability or impairment at the time he or she sustained another injury in the work place can apply to the SIBTF for compensation.  To be eligible for compensation from the SIBTF, the injury from the current employment combined with the previous disability or employment must have the combined effect of at least a seventy percent permanent disability for the worker.  Moreover, the new injury must cause at least thirty-five percent of the permanent disability.

Note that an employer does not have to be illegally uninsured for an injured employee to be eligible to receive benefits through the SIBTF.  The SIBTF is meant to help pay a portion of the permanent disability compensation for permanently disabled workers for qualifying workers, as described above.  If an employee qualifies to receive benefits through the SIBTF, the employer will pay only the portion of permanent disability that is attributable to the injury received through the current employer.  The SIBTF will pay the remainder of the benefits owed to the employee.  The purpose of the SIBTF is to encourage employers to hire workers who are already permanently disabled without fear that they will be held responsible to pay benefits that are attributable to a permanent disability incurred through previous employment.

We have extensive experience in assisting our clients understand the repercussions of all types of workers’ compensation claims on their business.  Call us today so we can talk with you about your business and its responsibilities.

Medically Required Equipment

Workers’ compensation is a system established to help provide fair reparation and payment to employees who have sustained work-related injuries.  The variety of injuries meant to be covered under this system is broad, although not without some limitations.  In addition, the treatments covered by the workers’ compensation system range from physical therapy to acupuncture to prescription medication.  The type of treatment that is covered will depend heavily on what is prescribed by the employee’s treatment physician.  In some cases, a physician may determine an employee’s injury requires medical equipment to treat.

There are important differences between medical equipment and medical supplies.  The workers’ compensation system has borrowed the definition of “durable medical equipment” from the Medicare system.  Durable medical equipment means medical equipment that is reusable, and necessary for treatment of the employee in his or her home.  Note that this means certain items such as latex gloves or hypodermic needles would not qualify as DME, as they are not reusable.  Moreover, an electric scooter that the employee never uses in the home, but rather simply uses to get around the local grocery store also probably would not qualify.  Note that not all Medicare rules have been adopted by California in this area.

Under the workers’ compensation system, a physician may bill for and be reimbursed for dispensing medically necessary durable medical equipment.  The rate to be billed and reimbursed is capped at a particular rate established by California Labor Code 5307.1.  However, there is an exception for this if the DME device is a “dangerous device.”  A “dangerous device” is defined by California statute, and typically will be a piece of equipment that can only be dispensed with a prescription from a physician licensed in that particular field.  For dangerous devices, there is a different fee schedule or formula established by statute.

Employers should be wary, as unscrupulous individuals have exploited the provisions for DME billing.  For example, in 2014, several men were charged with many felony counts of conspiracy and submitting fraudulent claims after renting out DME in the workers’ compensation system, double billing and billing far above the actual value.  The men faced over fifty years in prison.

 

Durable medical equipment is covered under workers’ compensation, but you should consult an attorney to make sure you understand the obligations of your business.  Call us today at (714) 516-8188 if you have questions regarding Durable Medical Equipment.

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