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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

ELIGIBILITY GUIDELINES FOR PHYSICAL REHABILITATION BENEFITS THROUGH THE SECOND INJURY FUND
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 (hereinafter referred to as "Division") 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 Division 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 Division's discretion that may constitute a significant impairment. · Therapy must be provided by a facility certified by the Division. · 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 Division for no greater than twenty (20) weeks. However, if the need for physical rehabilitation is shown to the satisfaction of the Division to require a period greater than twenty (20) weeks, the Division 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 Division, 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 Division recognizes that there may be times, due to disputes and/or lack of notice to the Division 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 Division 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 Division 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 Division 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.
www.dolir.mo.gov/wc WCR-7 (12-03) AI