Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 450 - WORKERS' COMPENSATION INSURANCE - EXPERIENCE RATING
Section 031-450-6 - Aggravation of Prior Work-Related Injuries

Universal Citation: 02 ME Code Rules ยง 031-450-6

Current through 2024-13, March 27, 2024

A. Definitions. For purposes of this Section:

(1) "Subsequent injury" means an injury giving rise to a claim for which benefits have been paid pursuant to 39-A M.R.S.A. §212 or § 213, with the exception of any injury that was subsequently determined by the Workers' Compensation Board not to be compensable.

(2) "Prior lost-time work-related injury" means an injury to a claimant for which benefits have been paid before the date of the subsequent injury pursuant to 39-A M.R.S.A. §212 or § 213, with the exception of any injury that was subsequently determined by the Workers' Compensation Board not to be compensable.

(3) "Aggravates or combines with a prior lost-time work-related injury to produce incapacity": A subsequent injury, as defined in Paragraph 1 above, aggravates or combines with a prior lost-time work-related injury, as defined in Paragraph 2 above, to produce incapacity, when the insurer or self-insurer covering the prior injury has reimbursed the insurer or self-insurer covering the subsequent injury for compensation benefits paid pursuant to 39-A M.R.S.A. §212 or § 213, unless the subsequent injury claim was subsequently determined by the Workers' Compensation Board not to be apportionable to the prior carrier. For purposes of this Paragraph, reimbursement includes internal fund transfers or accounting recognition if the same carrier is on the risk for both injuries.

B. Reporting of subsequent injuries. When reporting incurred losses to the designated advisory organization, an insurer shall separately identify all claims attributable to lost-time work-related injuries that aggravate or combine with any prior lost-time work-related injury to produce incapacity.

C. Exclusion from incurred loss experience. The designated advisory organization shall exclude all claims reported under this Section from an employer's loss experience when calculating the employer's experience modification factor, and shall make appropriate corresponding adjustments to aggregate loss experience when determining employers' expected losses for experience rating purposes. The designated advisory organization shall develop and implement an appropriate coding mechanism. This Section does not restrict the use of such information for ratemaking purposes.

D. Apportionment after reporting date. If a claim is included in an employer's incurred loss experience, but a payment or decree made after the loss report was filed establishes that the injury aggravates or combines with a prior lost-time work-related injury, then the exclusion of the claim from the employer's incurred loss experience shall be retroactive only if the employer is entitled to a correction of the relevant loss report pursuant to Section 5.

E. Merit rating plan. If the employer is not subject to experience rating, claims reported under this Section shall be excluded from the employer's loss experience in determining the number of claims within the rating period and in determining the employer's loss ratio for purposes of the merit rating plan established pursuant to 24-A M.R.S.A. §2382-D(3).

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