Eligibility Guidelines For Second Injury Rehab Benefits {WCR-7}

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS ELIGIBILITY GUIDELINES FOR PHYSICAL REHABILITATION BENEFITS THROUGH THE SECOND INJURY FUND 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC Program Goal: The goal of the rehabilitation program "is to restore the injured person as soon as possible and as nearly as possible to a condition of self-support and maintenance as an able bodied worker through physical rehabilitation" pursuant to §287.141, RSMo, and the applicable rule thereto. Scope of Benefits: §287.141 (7) RSMo defines the term "physical rehabilitation" to include medical, surgical, and hospital treatment in the same manner as the employer is required to provide to the employee under §287.140 (1) RSMo. Physical rehabilitation shall include medical, physical, and occupational therapy provided on an inpatient or outpatient basis, and it shall not include vocational rehabilitation as defined by §287.141 through §287.148, RSMo. Eligibility Criteria: · The employee must be seriously injured as determined by a treating physician, or as determined by the Missouri Division of Workers' Compensation (DWC) based on a review of all of the evidence. It is the seriousness of the injury rather than the type of treatment that determines the employee's eligibility for benefits. · Generally, a serious injury demonstrates a marked decrease in mobility and/or function of any body part and requires physical rehabilitation for restoration of function. The DWC offers the following as examples of serious injuries: ­ Amputation of hand, arm, foot, or leg ­ Crushing injuries ­ Head injuries ­ Back injuries not amenable alone to recognized medical and surgical procedures ­ Atrophy due to nerve injuries or nonuse ­ Debilitating burns ­ Multiple traumas ­ Quadriplegia ­ Paraplegia ­ Other injuries in the DWC's discretion that may constitute a significant impairment. · Therapy must be provided by a facility certified by the DWC. · Injured employees must comply with physical rehabilitation as ordered by the treating physician. · Failure of the injured employee to participate in prescribed therapy will result in the denial or termination of benefits. · Approval of benefits may be authorized by the DWC for no greater than twenty (20) weeks. However, if the need for physical rehabilitation is shown to the satisfaction of the DWC to require a period greater than twenty (20) weeks, the DWC shall issue a special order for such additional period upon review of the relevant information. · A request for consideration of eligibility may be initiated by the DWC, a health care provider, party to the case, or his or her attorney of record. · It is intended that the injured employee receive the Second Injury Fund benefits during the course of the rehabilitation treatment. · The DWC recognizes that there may be times, due to disputes and/or lack of notice to the DWC regarding the eligibility of the injured employee, that the injured employee will have completed the course of treatment prior to the payments being processed. If payment is made after the treatment is completed, the payments will only cover the timeframe that the injured employee actively participated in therapy. · During rehabilitation treatment, the injured employee must be making continued progress toward rehabilitation goals. This program is not designed to be a maintenance program. · The DWC must have jurisdiction over the underlying workers' compensation case. · The burden of proof regarding eligibility is on the injured employee. If there is no response from the healthcare provider regarding treatment, the injured employee or his or her attorney must provide medical records and/or other relevant documentation to the DWC that substantiates eligibility for the physical rehabilitation benefit. · If the injured worker is denied benefits, he or she may submit a written request for a hearing to the DWC director. If the seriously injured does not appear to qualify, but you feel they may meet the required guidelines, please make the referral or call 573-526-3876. WCR-7 (10-11) AI American LegalNet, Inc. www.FormsWorkFlow.com