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Third Party Claims and Issues in Louisiana Workers Compensation | New Orleans Legal, LLC
Third Party Claims and Issues in Louisiana Workers Compensation
Third-Party Claims and Underlying Personal Injury Claims in Louisiana Workers Compensation
Sometimes, an employee is injured while at work due to the actions of someone other than the employer or co-worker.
In such a situation, the injured employee will likely have a workers compensation claim AND a "third-party claim" against the individual (other than the employer or co-worker) who was responsible for the accident or the injury.
Many times, this "third-party claim" is, in fact, a separate personal injury claim.
And often, this separate personal injury claim is known as an "underlying personal injury claim" because this personal injury claim lies underneath the workers compensation claim.
Under Louisiana's “exclusive remedy rule,” an injured employee is not allowed to sue the employer (or co-workers) for damages such as pain and suffering; an employee may only obtain lost wage benefits and medical benefits for the employer's workers compensation insurance company.
However, an injured employee can sue third parties (individuals and companies besides the employer or its co-workers) for damages such as pain and suffering.
But both the employee, the employer, and the workers compensation insurance company may have valid claims against the third party.
Rights of the Employee against Third-Party Wrongdoers
Under Louisiana law, workers compensation is the "exclusive remedy" between the employer and the employee, meaning that an employee can generally only sue his or her employer through the Louisiana workers compensation system and rules.
However, claims by an injured employee against a third party wrongdoer whose fault brought about the employee's injury are not through the Louisiana workers compensation system and rules.
Louisiana law expressly authorizes the employee to proceed against any third party for damages even though the employee has been awarded workers compensation benefits by his or her employer for the same injury.
Nonetheless, an employer or its insurance company can be reimbursed - which will prevent double recovery by the employee - when the employer or its insurance company intervenes in (or steps into) the employee's lawsuit against the third-party and required that the judgment be in favor of the employer or its insurance company in order to reimburse the employer or its insurance company.
In such a case of intervention by the employer or its insurance company, only the excess recovery goes to the employee; and in some instances, the employer or its insurance company's “recovery” takes the form of a credit against future compensation owed, permitting the suspension of those future payments.
And, the employer or its insurance company may institute its own suit against the third-party wrongdoer, in which case the employee can intervene in order to ensure that the employee recovers a maximum sum.
Last, if the employee institutes suit for workers compensation benefits, and it is determined that his disability was temporary only and has terminated by the time of trial, this finding is not conclusive in the employee's subsequent tort claim against a third party for damages for the same injury.
Ways in Which the Workers Compensation Insurance Company Can Recover in a Third-Party Lawsuit
Generally speaking an employer and its workers compensation insurance company can recover in the following ways in a lawsuit against a third party:
A reimbursement of workers compensation benefits already paid;
A credit against its future workers compensation obligations; and
Judicial interest on the amounts that it recovers.
Concerning the reimbursement of workers compensation benefits that have already been paid, if the employer or its workers compensation insurance company is a party in a lawsuit against a third party, any amounts that are recovered against the third party are apportioned so that the claim of the employer or its workers compensation insurance company for reimbursement of workers compensation benefits actually paid get priority over the claim of the injured employee.
In other words, if the recovery from the third party is only enough to cover the reimbursement of workers compensation benefits already paid, then the employer or its workers compensation insurance company will get paid while the injured employee will get nothing.
This is because Louisiana law provides the employer and its workers compensation insurance company with “first dollar” rights to and a lien upon tort recovery, which means that only after the intervenor has recovered what it is due is any excess apportioned to the plaintiff.
And, the employer and its workers compensation insurance company are entitled to reimbursement out of the total amount of damages awarded, regardless of whether those damages are calculated as weekly lost wage (indemnity) benefits paid to the employee or medical expenses paid on behalf of the employee.
So if the damages awarded in a third-party lawsuit are greater than the amount of the lien of the employer or its workers compensation insurance company, the employer or its workers compensation insurance company is entitled to a credit against its future workers compensation obligation in the amount of the plaintiff's net recovery - which mean the recovery after attorney's fees and court costs are deducted - discounted at 6%.
Social Security Disability Insurance and Louisiana Workers Compensation
Social Security Disability Insurance (SSDI), also known as Social Security Disability (SSD), is insurance through the United States government in case an individual becomes disabled.
Social Security Disability Insurance (SSDI) is available for workers who have paid into the Social Security trust fund through Social Security taxes on their earnings, as well as for certain dependents of disabled workers who have paid into the Social Security trust fund.
Generally speaking, the definition of a disability is a condition where an individual is unable to engage in any substantial gainful activity because of a physical or mental impairment, where is this impairment is demonstrated by medical evidence (such as objective findings by a medical provider, symptoms, laboratory findings, and subjective complaints by the individual).
A person can qualify for Social Security Disability if he or she becomes disabled under the age of 65 or is a qualified family member of a worker who becomes disabled under age 65.
Social Security Disability payments are for disabilities that have lasted or are expected to last for at least 12 months straight or are expected to result in the death of the disabled individual.
In other words, Social Security Disability payments are intended for long-term or permanent conditions, not for temporary conditions (such as where the disabled individual is expected to quickly recover and return to full-duty work).
Once an individual qualifies for Social Security Disability, the actual disability payments will not begin until five months after the date of the onset of the disability.
However, once an individual qualifies for Social Security Disability, that individual will begin receiving health insurance through Medicare beginning 24 months after the five-month waiting period.
The Social Security Disability "Offset"
Under Louisiana workers compensation law and United States federal Social Security law, an injured worker in Louisiana can receive both Louisiana workers compensation lost wage benefits and Social Security Disability Insurance (SSDI) benefits at the same time.
However, when an injured worker in Louisiana is receiving both Louisiana workers compensation lost wage benefits and Social Security Disability Insurance (SSDI) benefits at the same time, this injured worker in Louisiana can not receive a total combined benefit of more than 80% of the gross income that this worker was earning before he or she became disabled.
Additionally, Social Security Disability Insurance (SSDI) benefits can NOT be reduced due to the receipt of social security old-age retirement benefits. So when an injured employee is receiving Louisiana workers compensation lost wage benefits, this employee's social security benefits may be reduced - or "offset" - so that the combined benefits do not exceed 80% of the employee's "average current wage" as calculated by the Social Security Administration (SSA).
The Social Security Administration (SSA) calculates the amount of income that the injured employee was earning before his or her disability as the injured worker's "average current wage," which is the largest amount under the following three options:
The average lifetime earnings of the injured employee;
The average earnings during the five years before the injured employee became disabled; and
The average earnings during the one year before the injured employee became disabled.
But the maximum total amount of combined benefits that an injured worker is allowed to receive is also limited by the total amount of Social Security Disability Insurance (SSDI) benefits received by all of the members of the injured worker's family in the first month that workers compensation is received (otherwise known as the “Total Family Benefit”).
The simplified version of the method for calculating a Social Security Offset is as follows:
The Social Security Administration first calculates the injured employee's average current earnings for the period before the employee became disabled;
The Social Security Administration then calculates the monthly average of the injured employee's average current earnings;
The Social Security Administration then determines how much the injured employee is receiving each month in workers compensation and Social Security Disability Insurance (SSDI) benefits;
The Social Security Administration then determines if the combined income exceeds 80% of the average monthly earnings; and
If the combined benefits do exceed 80% of the employee's average monthly earnings, then the Social Security Administration will reduce the Social Security Disability Insurance (SSDI) benefits by the amount above the 80%.
Additional requirements concerning the Social Security Disability Offset include the following:
The Social Security Disability Offset is only available when the injured worker is receiving Permanent Total Disability (PTD) benefits or Permanent Partial Disability (PPD) benefits;
The amount of the Social Security Disability Offset can be re-calculated by the Social Security Administration every three years, which often reduces the amount of the offset;
The Social Security Disability Offset is NOT available when the injured worker is receiving Supplemental Earnings Benefits (SEBs) or Temporary Total Disability (TTD) benefits;
The Social Security Disability Offset is NOT available for disabilities that arose before September 8, 1978;
The Social Security Disability Offset is NOT available for the receipt of social security old-age retirement benefits;
The Social Security Disability Offset is NOT reduced by any amount of attorney's fees that the worker owes to his or her attorney; and
The Social Security Disability Offset can NOT reduce below the amount to which the employee's total benefits to an amount that is lower than the injured employee's weekly workers compensation rate.
So for example, let's say an injured employee had a monthly average current wage before the disability of $3,000, and the employee is set to receive $1,800 each month in workers compensation benefits and $2,200 each month in SSDI benefits.
Since eighty percent of the monthly average current wage of $3,000 equals $2,400, and the combined total of monthly workers compensation benefits and SSDI benefits equals $3,000, which exceeds the 80% average current wage by $600, the SSDI benefit would, therefore, need to be reduced (or "offset") by $600, meaning the actual monthly SSDI benefit would only be $1,600.
The Social Security "Reverse-Offset"
As stated above, when an injured worker in Louisiana is receiving both Louisiana workers compensation lost wage benefits and Social Security Disability Insurance (SSDI) benefits at the same time, this injured worker in Louisiana can not receive a total combined benefit of more than 80% of the gross income that this worker was earning before he or she became disabled.
So, for this reason, when an injured employee is receiving Louisiana workers compensation lost wage benefits, this employee's social security benefits may be reduced - or "offset" - so that the combined benefits do not exceed 80% of the employee's "average current wage" as calculated by the Social Security Administration (SSA).
But, the workers compensation insurance company can request that the Louisiana workers compensation Court reverse this offset - in other words, claim a social security "reverse-offset" - if the OWC Court concludes that the injured worker is entitled to Permanently Total Disability (PTD) benefits.
So, in all cases where benefits are converted to permanent and total disability benefits, the workers compensation insurance company is entitled to a reverse-offset, lowering what would otherwise be the workers' compensation indemnity payment.
In other words, a social security "reverse-offset" allows the workers compensation insurance company to reduce its lost wage benefits by the excess amount above the 80% of the employee's "average current wage" instead of allowing the Social Security Administration (SSA) to reduce the Social Security Disability Insurance (SSDI) benefits by that amount.
This social security "reverse-offset" exists in Louisiana workers compensation because Louisiana law has decided to give the workers compensation insurance company, rather than the federal government, the benefit of the ceiling placed on both programs by the coordination of benefits.
Settlements and Social Security "Spread" Language
A Social Security Offset can have a tremendous impact on the settlement of a workers compensation claim in Louisiana because receipt of a large lump sum settlement can potentially cause a drastic reduction of an employee's monthly SSDI benefits and might even completely eliminate these monthly SSDI benefits.
Again, this is because an injured worker in Louisiana can not receive a total combined benefit of more than 80% of the gross income that this worker was earning before he or she became disabled.
However, fortunately, specialized "spread" language can be placed into a written settlement agreement that can minimizes or even eliminate the offset altogether.
This "spread" language can minimize or eliminate the Social Security Offset by "spreading" the monthly value of the lump sum settlement over the employee's life span through a formula approved by the Social Security Administration (SSA).
It is this average monthly benefit - the prorated monthly value of the lump sum settlement over the employee's life span - that is then used to calculate any Social Security Offset.
In other words, any potential negative impact of a Social Security Offset can be minimized or eliminated by "spreading" the value of the lump sum settlement over time.
Spread language in a written settlement agreement usually looks something like this:
"Of the $150,000.00 settlement, $30,000 shall be paid as attorney's fees to the attorney for the employee. The $120,000.00 to be paid to the employe, shall be calculated without commutation of interest, but shall represent the negotiated compromise Agreement that the claimant's life expectancy is 22.45 years forward from this date, pursuant to the Annuity Mortality Table for 1949 Ultimate, as established by O.C.G.A. §24-4-45, Appendix, Title 24, and that the settlement herein reached represents the payment of $110.28 per week to the claimant over the balance of the 969.44-week life expectancy of the claimant into the future."
Again, this "spread" language is used to prevent reduction or elimination of Social Security Disability (SSDI) benefits due to the Social Security Offset rule (which provides social security disability benefits will be reduced so that no combination of workers compensation benefits and social security disability benefits can exceed 80% of pre-injury earnings) by projecting the portion of lump-sum disability settlement proceeds over the worker's remaining life expectancy.
Medicare and Louisiana Workers Compensation
Once an individual has received 24 months of Social Security Disability Insurance (SSDI) benefits, he or she automatically qualifies for Medicare.
Medicare is a federal program that provides health coverage for certain individuals who are retired or who have become disabled.
Medicare became intertwined with Louisiana workers compensation in 1981 with the passage of the Medicare Secondary Payer Act (MSPA), which makes Medicare a “secondary payer” in place of third-party obligors (such as workers compensation insurance companies) who are considered “primary payers” under the MSPA.
Critically, in Louisiana workers' compensation, the Medicare Secondary Payer Act (MSPA) prevents cost-shifting from the workers compensation insurance company (who is obligated to pay for medical treatment of the injured worker) to Medicare, which is good public policy since Medicare is funded by taxpayers.
In addition to the MSPA, the Center for Medicare Services (CMS) is authorized by Congress to set forth federal regulations concerning Medicare's rights with respect to workers compensation claims.
Medicare has the two following significant rights under the Medicare Secondary Payer Act (MSPA):
To recover “conditional payments” from the primary payer (such as workers compensation insurance company), which means that if medical treatment is paid for by Medicare, but should be paid by the workers compensation insurance company, then Medicare has the right to recover its payments from the workers compensation insurance company; and
To ensure that the primary payer (such as the workers compensation insurance company) adequately funds the employee's future medical costs in a workers compensation settlement.
So basically, the main point of the Medicare Secondary Payer Act (MSPA) is to “protect Medicare's interest,” which is important because Medicare (and thus the taxpayers) should not have to pay the medical expenses for a work-related injury that are otherwise owed by the workers compensation insurance company.
Medicare will not allow the injured worker simply to settle his or her workers compensation claim, pocket all the money for the future medical expenses, and then have Medicare pay for all the future medical expenses.
To avoid such a scenario, Medicare requires that the workers compensation insurance company "set-aside" a portion of that settlement money so that it can be used for future medical expenses, thereby preventing Medicare from having to pay for those future medical expenses.
This process of "setting-aside" a portion of that settlement money is known as a "Medicare Set-Aside Arrangement" or an "MSA" for short.
In Louisiana workers compensation, a Medicare Set-Aside Arrangement (MSA) is a financial agreement that allocates a portion of a workers' compensation settlement to pay for future medical services related to the workers compensation injury, illness, or disease.
These funds that are "set-aside" in an MSA must be depleted before Medicare will pay for medical treatment related to the workers compensation injury, illness, or disease.
The Center for Medicare Services (CMS), which sets forth federal regulations concerning Medicare's rights with respect to workers compensation claims, states that all parties in a workers' compensation case have “significant responsibilities” to protect Medicare's interests when resolving cases that include future medical expenses.
While there are no laws requiring that an MSA be submitted to CMS for review, the recommended method to protect Medicare's interests is an MSA.
If any party chooses to submit an MSA for review, CMS requests that the party complies with its established policies and procedures.
CMS will only review new MSA proposals when one of the following conditions is met:
The claimant is a Medicare beneficiary, and the total settlement amount is greater than $25,000.00; or
The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date, and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00.
The amount of each MSA is determined on a case-by-case basis.
When to Consider Submitting a Settlement to CMS for Review
There are no legal requirements that any Medicare Set-Aside (MSA) must be sent to the Center for Medicare Services (CMS) for review or approval.
But if a party does choose to use the MSA review process of the Center for Medicare Services (CMS) in order to obtain approval, CMS requires compliance with CMS' established policies and procedures.
CMS reviews proposed MSA amounts in order to determine if the proposed MSA amount is sufficient to cover future medical expenses related to the workers compensation settlement, judgment, or award.
If a proposed MSA total settlement amount meets the "workload review" thresholds, the proposal can be submitted to CMS for approval.
CMS will review a proposed MSA amount when the following workload review thresholds are met:
The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date, and the anticipated total settlement amount for future medical expenses and disability or lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00.
A claimant has a reasonable expectation of Medicare enrollment within 30 months if any of the following apply:
The claimant has applied for Social Security Disability Benefits;
The claimant has been denied Social Security Disability Benefits but anticipates appealing that decision;
The claimant is in the process of appealing and/or re-filing for Social Security Disability benefits;
The claimant is 62 years and six months old; or
The claimant has an End-Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD.
The $25,000 and $250,000 thresholds are determined by considering all parts of a settlement, including indemnity benefits and attorney's fees.
If the workers compensation case settles in conjunction with a tort case, the total amount received by the claimant in the settlement of the tort case (not just the net to the claimant after fees and expenses) is also used to determine if the workload threshold is met.
Medicare's Enforcement Rights in Louisiana Workers Compensation
When a proposed MSA amount is submitted to CMS for review and the claimant obtains CMS' approval, the CMS-approved MSA amount must be appropriately exhausted before Medicare will begin to pay for care related to the beneficiary's settlement, judgment, award, or other payment.
Claimants who receive a workers' compensation settlement, judgment, or award that include an amount for future medical expenses must consider Medicare's interest concerning future medical treatment.
If Medicare's interests are not considered, CMS has a priority right of recovery against any entity that received any portion of a third-party payment either directly or indirectly—a right to recover, or take back, that payment.
Medicare may also refuse to pay for future medical expenses related to the work-related injury until the entire settlement is exhausted.
There are two main situations where Medicare may try to enforce its rights following a Louisiana workers compensation settlement:
When the employee fails to comply with the rules for administering an MSA; and
When the MSA itself (or the lack of an MSA) does not adequately protect the interests of Medicare.
First, when an injured employee fails to comply with the rules for administering an MSA, Medicare will likely require that the employee replace the funds in the MSA, though Medicare may also refuse to pay for related medical treatment until the employee has replaced and exhausted these funds.
Second, if CMS does not approve a settlement, or if a settlement is not even submitted for a CMS for review, CMS has the right to go after the workers compensation insurance company and the employee for a settlement that does not adequately protect Medicare's interests.
Credits and Offsets in Louisiana Workers Compensation
Louisiana provides for the following offsets and credits against the obligation of the workers compensation insurance company to pay workers compensation benefits:
Offsets for Social Security Disability Insurance (SSDI) benefits (in limited situations);
Credits for unemployment benefits;
Credits for disability benefits funded by an employer;
Credits for workers compensation benefits already paid from the obligation to pay SEBs or PPD benefits;
Offsets for certain medical expenses;
Credits for voluntary payments of benefits that were not due and payable when made; and
Credits for certain recoveries in third-party claims.
First, when an injured worker in Louisiana is receiving both Louisiana workers compensation lost wage benefits and Social Security Disability Insurance (SSDI) benefits at the same time, this injured worker in Louisiana can not receive a total combined benefit of more than 80% of the gross income that this worker was earning before he or she became disabled.
Second, no workers compensation benefits (whether for total disability or SEB payments) are payable for any week in which the employee has received unemployment compensation benefits.
Third, an employee's Louisiana compensation benefits are reduced to the extent necessary to limit the employee to two-thirds of his or her average weekly wage at the time of injury, if the employee is receiving payments from benefits under disability benefit plans that are funded by the employer, or other workers compensation benefits already paid from its obligation to pay SEBs or PPD benefits
The workers compensation insurance company can also receive credits for:
Medical expenses in certain situations;
Voluntary payments of benefits that were not due and payable when made; and
Credits for third-party claims.
Concerning medical expenses, payment of any medical bill or expense of an injured employee by any person or entity shall extinguish the claim against the workers compensation insurance company for those medical expenses, unless that other person or entity is:
A relative or friend of the employee;
Any other state medical assistance program.
If the employee or the employee's spouse actually pays premiums for health insurance, either as direct payments or as itemized deductions from their salaries, then this offset will only apply in the same percentage, if any, that the employer of the employee or the employer of his spouse paid the health insurance premiums.
Lastly, Louisiana law does not permit the workers compensation insurance company to take any credits for retirement benefits.
Liens and Subrogation Rights in Louisiana Workers Compensation
A lien is defined as a legal right that an individual or an entity has against the property of another.
Additionally, subrogation is the legal process of allowing an individual or an entity to make a claim against another to recover benefits it has already paid.
In Louisiana workers compensation, liens and subrogation rights can work in a variety of different ways.
Louisiana law does not limit subrogation recovery to just the employer and the workers compensation insurance company; instead, the right of subrogation is extended to all “persons” who have paid OR become obligated to pay Louisiana workers compensation benefits.
Liens in Louisiana workers compensation claims can come into play in a number of ways and need to be handled as part of the settlement process.
Both the employee and the workers compensation insurance company need to feel confident that an agreed-upon settlement is final so that all duties and obligations concerning the claim are completed; for this reason, it is important to account for any liens that are asserted, or that could be asserted, by any third parties and to come to an understanding of who will be responsible for satisfying any such lien.
Health Care Provider Liens and Subrogation Rights
As stated above, liens in Louisiana workers compensation claims can come into play in several ways.
One common way is when a health care provider has unpaid charges for medical treatment that the medical provider rendered to the injured employee so that at the time of settlement there are outstanding medical bills.
Liens for outstanding medical bills can occur when the employee treats with a health care provider that the employer does not know about, and as such the treatment is not approved through the utilization review process.
Under Louisiana law, reimbursement from the workers compensation insurance company for such charges is limited to $750, if the treatment was not emergency care, and any remaining amount above $750.00 cannot be claimed against the employee.
Additionally, all compensable medical expenses incurred before the date of settlement shall be paid by the workers compensation insurance company unless the settlement documents explicitly state otherwise.
Thus, whether or not the $750 cap applies, it is important for the injured employee and the workers compensation insurance company to agree at the time of settlement as to who will pay any outstanding medical bills.
Health Insurance Company Liens and Subrogation Rights
Another common way for a lien to come into play in Louisiana workers compensation is when a health insurance company pays for health care expenses that the workers compensation insurance company is liable.
In such a situation, though, the amount of reimbursement cannot exceed the amount of the workers compensation insurance company's liability for the workers compensation benefit.
In fact, most health insurance policies exclude payment for treatment that is covered under a workers compensation policy, and the health insurance company will have a claim for reimbursement against the employee if their policy pays for such treatment.
Nonetheless, a lien will very likely arise before a workers compensation settlement when an injured employee uses his or her private health insurance to pay for medical treatment, and that lien must be handled before executing the settlement documents.
Also, Louisiana law provides a credit in favor of the employer for any medical expenses paid by another entity, which includes a health insurance company, unless the employee or employee's spouse pays the premiums for such insurance and then the credit is proportional based on payments made by the employee or spouse.
So the general rule is that the employer gets a credit for payments made by a health insurer, but if the employee has a lien letter from his own health insurance company, then deciding who will be responsible for reimbursing the health insurance company can be negotiated in the settlement.
Medicare Liens and Subrogation Rights
Payment of workers compensation medical expenses by Medicare and Medicaid can also result in liens against a workers compensation settlement.
Medicare will want to be paid back most, if not all, of the amount it paid; little to no reduction will be provided on amounts due and owing to Medicare.
Louisiana law specifically provides that payment by Medicare, Medicaid, or other state medical assistance programs does not remove the workers compensation insurance company's obligation to pay for such medical treatment.
Additionally, federal law provides that Medicare's “conditional payments” for workers compensation benefits must be reimbursed.
Medicare conditional payment amounts should be determined before settlement negotiations; for this, most workers compensation insurance companies have contracts with organizations that can perform a conditional payment search.
The workers compensation insurance company will want to know in advance what those conditional payments might be because, generally speaking, paying Medicaid liens and Medicare conditional payments becomes the responsibility of the workers compensation insurance company at the time of settlement.
Third-Party Liens and Subrogation Rights
Under Louisiana law, the employee is entitled to proceed both by claiming workers compensation benefits from the employer and its workers compensation insurance company while at the same time filing a claim or lawsuit for damages against a third-party wrongdoer.
Also, the employer or its workers compensation insurance company may institute its own lawsuit against the third-party wrongdoer (otherwise known as the tortfeasor), in which case the employee is allowed to intervene to ensure that the employee receives the maximum amount of money that the employee may be entitled.
Second Injury Fund Claims in Louisiana Workers Compensation
Louisiana's “Second Injury Fund” or “SIF” is a trust created by state law and administered by the State Second Injury Board (“SIB”) that is funded by payments from workers compensation insurance companies and self-insured employers.
The purpose of the Second Injury Fund is to persuade employers - who otherwise might worry about an increase in workers compensation insurance costs - to hire employees who have pre-existing conditions that constitute "permanent partial disabilities."
The Second Injury Fund accomplishes this by reimbursing some of the workers compensation benefits paid when an employee who has such a pre-existing condition suffers an injury at work and at the same time meets certain legal requirements.
Specifically, the Second Injury Fund legally requires that the workers compensation insurance company prove that:
The employee has a preexisting condition constituting a “permanent partial disability;”
The employer knew about the condition when the employee was hired or hired the employee after learning about the condition; and
The preexisting permanent partial disability combines or merges with a disability caused by a compensable work injury to produce an overall disability that is materially and substantially greater than would have resulted from the work injury alone.
In other words, the Second Injury Fund rewards an employer for employing and retaining people who might otherwise be thought of as a liability risk, and thereby increases the employment opportunities for people with medical conditions that might otherwise discourage hiring and retaining by an employer.
Of course, the workers compensation insurance company that qualifies for reimbursement from the Second Injury Fund is not then relieved of its obligation to the injured worker.
Instead, such a workers compensation insurance company must still pay full workers compensation benefits to the injured worker and then seek reimbursement from the Second Injury Fund for the workers compensation benefits paid to the employee.
The Second Injury Fund is financed by the workers compensation insurance companies, who make annual payments to the Second Injury Fund, according to assessment amounts - which is a percentage of the gross premium received by the insurer for writing workmen's compensation insurance in the preceding calendar year - as determined by the Second Injury Board.
The Louisiana Statutes for Third-Party Claims and Issues in Louisiana Workers Compensation
The primary Louisiana statutes regarding third-party claim in workers compensation are La. R.S. 23:1032, La. R.S. 23:1101, La. R.S. 23:1102, La. R.S. 23:1103, La. R.S. 23:1104, La. R.S. 23:1205, La. R.S. 23:1206, La. R.S. 23:1212, La. R.S. 23:1221, La. R.S. 23:1223, La. R.S. 23:1225, La. R.S. 23:1371, La. R.S. 23:1371.1, La. R.S. 23:1372, La. R.S. 23:1373, La. R.S. 23:1374, La. R.S. 23:1375, La. R.S. 23:1376, La. R.S. 23:1377, and La. R.S. 23:1378, which read as follows:
§1206. Voluntary payments; deductions from benefits
Any voluntary payment or unearned wages paid by the employer or insurer either in money or otherwise, to the employee or dependent, and accepted by the employee, which were not due and payable when made, may be deducted from the payments to be made as compensation.
Amended by Acts 1983, 1st Ex. Sess., No. 1, §1, eff. July 1, 1983.
§1212. Medical expense offset
A. Except as provided in Subsection B, payment by any person or entity, other than a direct payment by the employee, a relative or friend of the employee, or by Medicaid or other state medical assistance programs of medical expenses that are owed under this Chapter, shall extinguish the claim against the employer or insurer for those medical expenses. This Section shall not be regarded as a violation of R.S. 23:1163. If the employee or the employee's spouse actually pays premiums for health insurance, either as direct payments or as itemized deductions from their salaries, then this offset will only apply in the same percentage, if any, that the employer of the employee or the employer of his spouse paid the health insurance premiums.
B. Payments by Medicaid or other state medical assistance programs shall not extinguish these claims and any payments made by such entities shall be subject to recovery by the state against the employer or insurer.
Acts 1989, No. 454, §5, eff. Jan. 1, 1990; Acts 2001, No. 1062, §1.
§1223. Deductions from benefits
A. Except as provided in R.S. 23:1221(4)(s), when compensation has been paid under R.S. 23:1221(1), (2), or (3), the number of weeks of compensation paid shall be deducted from the number of weeks of compensation allowed under R.S. 23:1221(4) or Subpart C of this Part.
B. Except as provided in R.S. 23:1221(4)(s), when compensation has been paid under R.S. 23:1221(1), (2), or (4), the number of weeks of compensation paid shall be deducted from the number of weeks of compensation allowed under R.S. 23:1221(3) or Subpart C of this Part.
Amended by Acts 1983, 1st Ex. Sess., No. 1, §1, eff. July 1, 1983; Acts 1989, No. 454, §6, eff. Jan. 1, 1990; Acts 1996, 1st Ex. Sess., No. 31, §1, eff. May 1, 1996; Acts 1999, No. 126, §1.
A. The benefits provided for in this Subpart for injuries producing permanent total disability shall be reduced when the person receiving benefits under this Chapter is entitled to and receiving benefits under 42 U.S.C. Chapter 7, Subchapter II, entitled Federal Old Age, Survivors, and Disability Insurance Benefits, on the basis of the wages and self-employment income of an individual entitled to and receiving benefits under 42 U.S.C. §423; provided that this reduction shall be made only to the extent that the amount of the combined federal and workers' compensation benefits would otherwise cause or result in a reduction of the benefits payable under the Federal Old-Age, Survivors, and Disability Insurance Act pursuant to 42 U.S.C. §424a, and in no event will the benefits provided in this Subpart, together with those provided under the federal law, exceed those that would have been payable had the benefits provided under the federal law been subject to reduction under 42 U.S.C. §424a. However, there shall be no reduction in benefits provided under this Section for the cost-of-living increases granted under federal law after the date of the employee's injury.
(d) Any other workers' compensation benefits, then compensation benefits under this Chapter shall be reduced, unless there is an agreement to the contrary between the employee and the employer liable for payment of the workers' compensation benefit so that the aggregate remuneration from Subparagraphs (a) through (d) of this Paragraph shall not exceed sixty-six and two-thirds percent of his average weekly wage.
(3) If an employee is receiving both workers' compensation benefits and disability benefits subject to a plan providing for reduction of disability benefits, the reduction of workers' compensation benefits required by Paragraph (1) of this Subsection shall be made by taking into account the full amount of employer-funded disability benefits, pursuant to plan provisions, before any reduction of disability benefits are made.
§1371. Purpose and intent
A. It is the purpose of this Part to:
(1) Encourage the employment, re-employment, or retention of employees who have a permanent, partial disability.
(2) Protect employers, group self-insurance funds, and property and casualty insurers from excess liability for workers' compensation for disability when a subsequent injury to such an employee merges with his preexisting permanent physical disability to cause a greater disability than would have resulted from the subsequent injury alone.
B. Except as provided in R.S. 23:1378(A)(6), this Part shall not be construed to create, provide, diminish, or affect in any way the workers' compensation benefits due to an injured employee. The payment of compensation to an injured employee under this Chapter shall be determined without regard to this Part, and the provisions of this Part shall be considered only in determining whether an employer or his insurer is entitled to reimbursement from the Workers' Compensation Second Injury Fund herein created.
C. As used in this part, the merger of an injury with a preexisting permanent partial disability is limited to the following:
(1) The subsequent injury would not have occurred but for the preexisting permanent partial disability; or
(2) The disability resulting from the subsequent injury in conjunction with the preexisting permanent partial disability is materially and substantially greater than that which would have resulted had the preexisting permanent partial disability not been present, and the employer has been required to pay and has paid additional medical or indemnity benefits for that greater disability.
D. The records of the second injury board shall be confidential as provided in R.S. 23:1293(A).
Added by Acts 1974, No. 165, §1. Amended by Acts 1977, No. 267, §1, eff. Oct. 1, 1977; Acts 1983, 1st Ex. Sess., No. 1, §6; Acts 1995, No. 188, §1, eff. June 12, 1995; Acts 1995, No. 245, §1, eff. June 14, 1995; Acts 2006, No. 453, §1, eff. June 15, 2006; Acts 2010, No. 799, §1, eff. June 30, 2010.
§1371.1. Definitions
As used in this Part, unless the context clearly indicates otherwise, the following terms shall have the meanings ascribed to them in this Section:
(1) "Employer" means any entity who is required to pay and has paid into the fund.
(2) "Hire and fire authority" shall mean the authority of the representative of the employer who plays an integral part in fulfilling the business of the employer with the responsibility to have closely controlled the injured employee regarding his physical conduct and time, as well as providing significant input into the hiring, retention, and firing decisions regarding that employee.
(3) "Permanent partial disability" shall mean any permanent condition, whether congenital or due to injury or disease, of such seriousness as to constitute a hindrance or obstacle to obtaining employment, to retention by an employer, or to obtaining re-employment, if the employee becomes unemployed.
(4) "PPD Employee Registry" shall mean the registry maintained by the Louisiana Workforce Commission of available employees. The listing of an employee on the registry shall serve as proof of knowledge of the employee's preexisting permanent partial disability for the purpose of a Second Injury Board claim.
(5) "Psychiatrist" shall mean an individual licensed to practice medicine by the Louisiana State Board of Medical Examiners or, in the event that the individual is practicing medicine in a jurisdiction other than Louisiana, licensed by the appropriate member board of the Federation of State Medical Boards to practice psychiatry, who has completed a residency in psychiatry, been in clinical practice for at least three years and has training in the evaluation, diagnosis, and treatment of intellectual disabilities.
(6) "Psychologist" shall mean an individual licensed to practice psychology by the Louisiana State Board of Examiners of Psychologists or licensed to practice medical psychology by the Louisiana State Board of Medical Examiners, or, in the event an individual is practicing psychology in a jurisdiction other than Louisiana, licensed by the appropriate member board of the Association of State and Provincial Psychology Boards to practice psychology, who has registered specialty in a relevant clinical area of practice, who has been in clinical practice for at least three years and has training and experience in the evaluation, diagnosis, and treatment of intellectual disabilities.
(7) "Representative" shall include, but not be limited to, third party administrators, attorneys, or adjusting firms of the party filing the claim on behalf of the employer, insurer or group self-insurance fund.
Acts 2006, No. 453, §1, eff. June 15, 2006; Acts 2009, No. 251, §6, eff. Jan. 1, 2010; Acts 2010, No. 799, §1, eff. June 30, 2010; Acts 2014, No. 811, §12, eff. June 23, 2014.
§1372. Louisiana Workers' Compensation Second Injury Board; creation, domicile, membership
The Louisiana Workers' Compensation Second Injury Board, hereinafter referred to as the board, is created. The board, which shall be domiciled in Baton Rouge, Louisiana, shall be composed of five members or their designee, who shall be the secretary of state, the state treasurer, the commissioner of insurance, the secretary of the Department of Children and Family Services, and the assistant secretary of the office of workers' compensation administration.
Acts 1988, No. 997, §1; Acts 2006, No. 453, §1, eff. June 15, 2006.
§1373. Meetings; quorum; officers
A. The board may meet monthly, but in no event shall it meet less than once each three months and at such other times as it may provide by its rules. Three members shall constitute a quorum for the transaction of business. A majority vote of the members present shall be required for all actions of the board. Any member of the board may be represented at any meeting by an alternate designated by the member in writing prior to the commencement of such meeting.
B. The board shall elect a chairman and vice chairman, who shall serve for a two year term; provided that the election be held within thirty days of July 1, of each odd-numbered year.
Added by Acts 1974, No. 165, §1. Amended by Acts 1977, No. 235, §1, eff. July 5, 1977; Acts 2010, No. 799, §1, eff. June 30, 2010.
§1374. Salary; expenses
The members of the board shall receive no salary, but each member shall be reimbursed for necessary travel and other expenses actually incurred while in attendance at meetings of the board or on business for the board.
Added by Acts 1974, No. 165, §1.
§1375. Personnel
A. The board shall appoint, fix the compensation and prescribe the duties of an executive director, who shall be in the unclassified service. The executive director shall devote full time to his duties and may not accept or engage in additional employment of any kind.
B. The executive director shall employ and supervise all such personnel, who shall be in the classified service, necessary for the operation of the business of the board.
Added by Acts 1974, No. 165, §1; Acts 2006, No. 453, §1, eff. June 15, 2006.
§1376. Rule making power; reports
A. The board may conduct such investigations, hold such hearings and adopt such rules and regulations as are necessary and proper to carry out its functions.
B. The board may collect information and compile statistics relevant and pertinent to the administration of the second injury fund. In order to accomplish this purpose, it may require employers and insurers to file reports with it containing such information and details as the board prescribes with respect to occupational accidents and workers' compensation claims.
Added by Acts 1974, No. 165, §1. Acts 1983, 1st Ex. Sess., No. 1, §6.
§1378. Determination of liability of fund
A. An employer operating under the provisions of this Chapter who knowingly employs, re-employs, or retains in his employment an employee who has a permanent partial disability, as defined in R.S. 23:1371.1, shall qualify for reimbursement from the Second Injury Fund, if the employee incurs a subsequent injury arising out of and in the course of his employment resulting in a greater liability due to the merger of the subsequent injury with the preexisting permanent partial disability. The employer or, if insured, his insurer shall pay all benefits provided in this Chapter, but the employer or, if insured, his insurer thereafter shall be reimbursed by the Second Injury Fund for all indemnity and medical benefit payments as follows:
Before July 1, 2004 & on/
after July 1, 2009, but before July 1, 2010
• TTD/SEB/PTD After the first 104 weeks of payment of benefits
• Death benefits after the first 175 weeks of payment of benefits
• 50% of all reasonable and necessary medical expenses actually paid which exceed $5,000.00, but no less than $10,000.00
• 100% of all reasonable and necessary medical expenses actually paid which exceed $10,000.00
On/after July 1, 2004 & before July 1, 2009
• After the first 130 weeks of payment of benefits
• 100% of all reasonable and necessary medical expenses actually paid which exceed $25,000.00
On/after July 1, 2010
• After the first 104 weeks of indemnity
• 100% of all reasonable and necessary medical expenses actually paid which exceed $25,000.00, including reasonable and necessary Vocational Rehabilitation expenses, if such expenses are directly related to services provided in the actual retention or reemployment of employees
(1) Such payments shall be reimbursed provided they are submitted to the board within one year of the approval for reimbursement or within one year of the payment of such weekly compensation payments, whichever occurs later.
(2) No employer or insurer shall be entitled to reimbursement unless it is clearly established that the employer had actual knowledge of the employee's preexisting permanent partial disability prior to the subsequent injury. For injuries occurring after December 31, 2010, actual knowledge shall be established only by any one of the following circumstances:
(a) The employee's preexisting permanent partial disability was caused by a compensable workers' compensation accident or occupational disease while employed by the same employer seeking reimbursement from the Second Injury Fund.
(b) Prior to the second injury, the employee disclosed to the employer the employee's preexisting permanent partial disability on a form promulgated by the office of workers' compensation.
(c) The employer employs, retains, or re-employs employees from the PPD employee registry maintained by the Louisiana Workforce Commission and which is created and maintained in accordance with rules promulgated by the office of workers' compensation.
(d) The employer provides an affidavit, on a form promulgated by the office of workers' compensation, which shall set forth all of the following:
(i) An attestation as to hire and fire authority as defined in R.S. 23:1371.1.
(ii) An attestation as to how and when knowledge was acquired.
(iii) An attestation as to the actual permanent partial disability existing.
(iv) An attestation of how the permanent partial disability, if not a presumed condition as listed in Subsection F of this Section, was a hindrance and obstacle to employment.
(v) An attestation certifying that false statements used in the affidavit may result in penalties pursuant to R.S. 23:1208.
(3) The Second Injury Fund shall be credited or reimbursed for sums recovered by the employer or the insurer from third parties in an amount equal to a pro rata share of the net amount recovered based upon the amounts paid by the fund, and the amounts paid by the self-insurer or insurer which have not been reimbursed by the fund, to or on behalf of the injured employee for medical benefits, workers' compensation indemnity benefits, and vocational rehabilitation services. The employer or the insurer shall advise the board of any subrogation action against third parties on any claim submitted to the board. The failure of the employer or insurer to notify the board of any pending subrogation action prior to receipt of payment from the board shall subject the employer or the insurer to a penalty of twenty percent of the amount otherwise claimed by the employer or insurer as payable from the Second Injury Fund, as well as a return of all amounts paid by the board to the extent these amounts are recovered in the subrogation action. Except as provided in this Subsection the Second Injury Fund shall not be required to reimburse vocational rehabilitation expenses.
(4)(a) The Second Injury Fund shall not be liable for reimbursement or be obligated to give credit for any amounts paid by an employer or carrier as attorney fees, penalties, or interest, nor for any sums paid under the Jones Act or Longshoremen and Harbor Workers Compensation Act.
(b) For settlements occurring after July 1, 2007, the Second Injury Fund shall be liable for reimbursement or be obligated to give credit for attorney fees paid pursuant to R.S. 23:1141, but shall not be liable for reimbursement or be obligated to give credit for attorney fees paid pursuant to R.S. 23:1201 or any other penalty provision provided for in Chapter 10 of this Title.
(5) Upon the board's approval of a claim for reimbursement, and on an annual basis thereafter, the insurer shall report to the board an estimate of the future medical and indemnity liability to the injured employee on a form promulgated by the assistant secretary. The report shall be submitted to the board each year at the same time the annual report required by R.S. 23:1291.1 is submitted to the office of workers' compensation administration.
(a) Upon the board's approval of a claim for reimbursement, the insurer shall immediately certify to the board that the medical reserve and the weekly disability benefits (indemnity) reserve do not exceed the threshold limits provided in the reimbursement schedule set forth in this Subsection. No reimbursement will be made to the insurer unless such insurer complies with the provisions of this Paragraph:
(i) As a prerequisite to reimbursement from the fund, the insurer shall be required to certify that the medical and indemnity reserves have been reduced to the threshold limits of reimbursement and report in accordance with the National Council on Compensation Insurance Workers' Compensation Statistical Plan.
(ii) The Second Injury Fund director shall quarterly submit to the National Council on Compensation Insurance information regarding the Second Injury Fund accepted claims.
(iii) The National Council on Compensation Insurance shall submit a report of any discrepancies pursuant to regulations established by the Department of Insurance. The Department of Insurance is directed to establish regulations concerning Second Injury Fund discrepancies.
(b) The Louisiana Insurance Guaranty Association shall be entitled to reimbursement, but only to the extent of the proportion of the Second Injury Fund assessment paid by insurance companies.
(6)(a)(i) For an accident occurring on or after October 1, 1995, the employer, if self-insured, or the insurer shall obtain written approval from the board of any lump sum or compromise settlement of an approved claim before such settlement is submitted for approval, as provided in Part III of this Chapter.
(ii) If written approval is obtained, an order approving the settlement shall be obtained within one hundred eighty days from the date that approval is issued after which time the written approval shall be null and the self-insurer or insurer must again obtain written approval to settle the claim. The board shall respond to requests for written approval within forty-five days of receipt of the request.
(iii) If an employer, if self-insured, or the insurer seeks authority to enter into a compromise settlement in connection with the settlement of a third-party claim, the board shall respond within three working days unless the settlement contemplates payment by the insurer or self-insurer of additional amounts which exceed fifty thousand dollars. If the settlement contemplates additional amounts which exceed fifty thousand dollars, the board shall respond within forty-five days of receipt of the request.
(iv) If the board does not issue a written response within the time provided in Items (ii) and (iii), the request shall be deemed approved unless the employer or insurer does not comply with rules promulgated pursuant to Item (v) of this Paragraph.
(v) The assistant secretary of the Office of Workers' Compensation Administration shall establish and promulgate, in accordance with the Administrative Procedure Act, such rules and regulations governing the submission of requests for approval as well as response from the board as may be deemed necessary and which are not inconsistent with the laws of this state.
(b)(i) Except in cases of a settlement in connection with the settlement of a third-party claim, if the self-insurer or insurer fails to obtain written approval from the board as provided in Subparagraph (a) of this Paragraph or fails to submit the settlement to the judge for approval as provided in Subparagraph (a) of this Paragraph, the fund shall not reimburse such self-insurer or insurer for the final settlement amount.
(ii) In cases of a settlement in connection with the settlement of a third-party claim, if the self-insurer or insurer fails to obtain written approval from the board as provided in Subparagraph (a) of this Paragraph or fails to submit the settlement to the judge for approval as provided in Subparagraph (a) of this Paragraph, the fund shall not reimburse such self-insurer or insurer for the final settlement amount and twenty-five percent of the unpaid reimbursements due or ten thousand dollars, whichever is greater.
(iii) As used in this Section, "final settlement amount" shall mean only additional funds contemplated to be paid by the insurer or self-insurer.
(c) The board shall not be a party to any lump sum compromise settlement with the employee.
(d) In the event that the board issues a written denial of the settlement, the property or casualty insurer, self-insured employer, or group self-insurance fund may appeal pursuant to Subsection E of this Section. The appeal shall be placed on the preference docket of the appropriate district court and shall be heard on the earliest practicable date.
B.(1) Except as provided in Paragraph (2) of this Subsection, the employer or his insurer, whichever of them makes the payments or becomes liable, shall within one year after the first payment of either compensation or medical benefits, whichever occurs first, notify the board in writing of such facts and furnish such other information as may be required by the board to determine if the employer or his insurer is qualified for reimbursement from the Workers' Compensation Second Injury Fund. Except as provided in Paragraph (2) of this Subsection, no employer, insurer, servicing agent, or self-insured association shall be reimbursed unless the board is notified within one year from the date of the first payment of either compensation or medical benefits whichever occurs first. Employers which are self-insured for workers' compensation benefits, but have not received a certificate of authority from the commissioner of insurance as provided for in R.S. 23:1197 or authorization from the assistant secretary pursuant to R.S. 23:1168(A)(2) or (3) shall not be entitled to reimbursement from the fund.
(2) When R.S. 23:1209(A)(3) is applicable to a claim against an employer, the employer or his insurer, whichever of them makes the payments or becomes liable, shall within one year after the first payment of either compensation or medical benefits, whichever occurs later, notify the board in writing of such facts and furnish such other information as may be required by the board to determine if the employer or his insurer is qualified for reimbursement from the Workers' Compensation Second Injury Fund.
C.(1) Upon receipt of a notice as provided in Subsection B of this Section, the board may conduct an investigation into all phases of the matter and take any and all other actions necessary to permit it to determine whether or not the employer or his insurer is entitled to reimbursement from the Workers' Compensation Second Injury Fund.
(2) The board may call a hearing, and in such case the employer and insurer, if any, shall be notified of the date, time, and place at least ten days before the date set for the hearing. Hearings may be had in the parish wherein the accident occurred or in any other parish that the board determines to be more convenient. The board shall establish rules for the conduct of such hearings. The board may issue subpoenas for witnesses in its behalf or for witnesses deemed necessary to a proper determination of the case. It shall issue subpoenas for witnesses at the request of the employer or insurer. At such hearings, the board shall not make a determination which would create, provide, diminish, or affect any workers' compensation benefits due to an injured employee but shall limit itself to the determination of whether the fund is liable to reimburse the employer, or, if insured, the insurer.
D. If the board finds that the employer or, if insured, his insurer is entitled to reimbursement, as provided in this Part, from the Workers' Compensation Second Injury Fund, the board shall issue its warrant to the state treasurer for payments to be made at such intervals as the board directs from the Workers' Compensation Second Injury Fund to such employer or insurer for the amount provided in Subsection A of this Section. In the event the employer or insurer makes a compromise or a lump-sum payment as provided in R.S. 23:1271 through 1274, the board shall have the discretion of paying in a lump sum or in periodic payments of three-month intervals for the amount that would have been due the employee for that period from the date the compromise or lump-sum settlement agreement is received in the board's office.
E. Written notice of the decision of the board shall be given to all parties to the hearing and the representatives designated by the party on the reimbursement form submitted to the board. The decision of the board shall be final; however, an appeal therefrom may be taken by any of the parties within thirty days after the date of the decision of the board. If an appeal is taken, the board shall be made party defendant, and service and citation shall be made in accordance with applicable law upon the attorney general or one of his assistants. The appeal shall be to the Nineteenth Judicial District Court, parish of East Baton Rouge. All appeals in all such cases shall be tried de novo.
F. Where the employer establishes that he had knowledge of the preexisting permanent partial disability prior to the subsequent injury, and diagnosis of the condition was made by qualified physicians within the scope of their practice or other persons properly licensed and certified to make such a diagnosis, there shall be a presumption that the employer considered the condition to be permanent and to be or likely to be a hindrance or obstacle to employment where the condition is one of the following:
(1) Seizure disorder.
(2) Diabetes mellitus.
(3) Coronary artery disease or congestive heart failure.
(4) Arthritis.
(5) Amputated foot, leg, arm, or hand, or total or partial of at least fifty percent loss of use thereof.
(6) Loss of sight of one or both eyes or legal blindness.
(7) Residual disability from poliomyelitis.
(8) Cerebral palsy.
(9) Multiple sclerosis.
(10) Parkinson's disease.
(11) Cerebral vascular accident.
(12) Tuberculosis.
(13) Pneumoconiosis.
(14) Psychoneurosis or psychosis following treatment in a recognized medical or mental institution.
(15) Bleeding disorder.
(16) Chronic osteomyelitis.
(17) Ankylosis of joints.
(18) Muscular dystrophy.
(19) Arteriosclerosis.
(20) Thrombophlebitis.
(21) Varicose veins.
(22) Heavy metal poisoning.
(23) Ionizing radiation injury.
(24) Compressed air sequelae.
(25) Ruptured or herniated intervertebral disc.
(26) Brain damage.
(27) Spinal surgery including fusion, partial, or total discectomy or microdiscectomy.
(28) Chronic obstructive pulmonary disease (COPD).
(29) Post traumatic stress disorder syndrome (PTSD).
(30) Post concussive syndrome.
(31) Alzheimer's disease.
(32) Sickle cell anemia.
(33) Joint replacement surgery.
(34) Intellectual disability,
(a) Provided the diagnosis of an intellectual disability shall be made on the basis of the following:
(i) Significantly subnormal intellectual functioning, defined as an objective measure of cognitive status which falls at least two standard deviations below the mean of the national standardization sample based on valid results of a recognized individually administered test of intellectual function.
(ii) Objective evidence of concurrent impairment of adaptive functioning in at least two areas of functional behavior as measured by standardized, norm reference measures of adaptive function.
(iii) Evidence of an onset before the age of eighteen years.
(b) It shall not be necessary for the employer to know the employee's actual intelligence quotient or actual relative ranking in relation to the intelligence quotient of the general population.
(c) Diagnosis of an intellectual disability shall be made by a psychiatrist, psychologist, or other person properly licensed and certified to make such a diagnosis.
Acts 1974, No. 165, §1; Acts 1976, No. 267, §2, eff. Oct. 1, 1977; Acts 1976, No. 298, §1; Acts 1976, No. 299, §§1, 2; Acts 1977, No. 267, §§2, 3, eff. Oct. 1, 1977; Acts 1976, No. 50, §1; Acts 1983, 1st Ex. Sess., No. 1, §§1, 6, eff. July 1, 1983; Acts 1985, No. 697, §1, eff. Oct. 1, 1985; Acts 1988, No. 938, §1, eff. July 1, 1989; Acts 1988, No. 997, §1; Acts 1989, No. 23, §1, eff. June 15, 1989; Acts 1989, No. 260, §1, eff. Jan. 1, 1990; Acts 1991, No. 892, §1; Acts 1992, No. 767, §1; Acts 1995, No. 245, §1, eff. June 14, 1995; Acts 2004, No. 227, §1, eff. June 14, 2004; Acts 2004, No. 256, §1, eff. June 15, 2004; Acts 2004, No. 258, §1, eff. June 15, 2004; Acts 2004, No. 293, §1, eff. July 1, 2004; Acts 2005, No. 257, §1; Acts 2006, No. 453, §1, eff. June 15, 2006; Acts 2007, No. 332, §1, eff. July 9, 2007; Acts 2008, No. 220, §8, eff. June 14, 2008; Acts 2010, No. 799, §1, eff. June 30, 2010; Acts 2014, No. 811, §12, eff. June 23, 2014; Acts 2015, No. 254, §1, eff. June 29, 2015.
NOTE: Acts 1991, No. 892, §2 provided R.S. 23:1378(e) shall apply only to decisions of the second injury board issued on or after September 6, 1991.
§1379. Annual report
The board shall make an annual report to the governor and the legislature, which shall contain a statement of the operations of the fund.