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Workers' Compensation Division |
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P.O.
Box 21149 Email: FishFund@labor.state.ak.us |
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Benefits from the Fund are financed from revenue received from each resident and nonresident commercial fisherman's license and permit fee. The Commissioner of Labor and Workforce Development oversees administration of the program with the assistance of the Fishermen's Fund Advisory and Appeals Council. The council is composed of the Commissioner or his designee, who serves as chairman, and five members appointed by the Governor. Fishermen's Fund Advisory District 1 Wrangell and areas south District 2 Areas north of Wrangell to include Yakutat District 3 Areas west of Yakutat to east coast of District 4 Areas west of Alaska Peninsula to District 5 Areas north of Cape Newenham, including
It is the fisherman's responsibility to see that a claim is filed. If the medical provider agrees to file a claim with your insurance company, the Fishermen's Fund, or a federal program such as Medicare, Veterans' Affairs, or the Indian Health Service, it remains the responsibility of the fisherman to see that the claim is complete and filed appropriately. Immediately following an injury or illness:
Fisherman's Report of Injury or
Illness
Fishermens
Fund Fisherman's Report
Please respond completely and promptly. Failure to do any of the above can delay your claim. When do the Fund's benefits kick in? The Fund is an emergency fund payer of last resort, which means that benefits are awarded only after full consideration of other coverage from private health or vessel insurance, and public programs, including Veterans' Affairs or Medicare. (Medicaid is an exception.) Processor Activities and Processor/Tender Vessels A worker whose injury or illness is directly connected to a processing activity does not qualify for Fund benefits, but may be covered under Workers' Compensation. A fisherman on a freezer or troller vessel who becomes injured or ill as a result of processing activities related to freezing the product would generally not be covered. However, a fisherman injured or becoming ill on a tender vessel is usually covered unless the incident was directly connected to processing activities. Withdrawing an Application Withdrawing an application requires a written request from the applicant fisherman and must be reviewed by the Fishermen's Fund Advisory and Appeals Council. If you have medical insurance, the Fund must have a written statementExplanation of Benefits (EOB)verifying you have filed a claim for each of your medical expenses with your health insurance carrier. Vessel or Site P&I (Protection and Indemnity) Insurance If the fisherman applicant does not indicate the P&I deductible on the application, a Report of Vessel or Site Insurance will be requested to verify whether P&I coverage exists, and if so, the amount of the deductible and the name of the vessel owner's insurance carrier or adjuster. If the deductible is unknown, benefits will be limited to $2,500. If expenses exceed, or will be expected to exceed, the deductible under a vessel owner's P&I policy, the fisherman applicant must file with the vessel owner's insurance carrier. These expenses are usually covered under the P&I policy. Expenses not covered should be submitted to the Fishermen's Fund. Otherwise, eligible expenses paid from the Fund which exceed the P&I deductible will be recovered under 8 Alaska Administrative Code (AAC) 055.010 (e) and by exercising subrogation rights under 8 AAC 055.035. The vessel owner's deductible payment to the insurance company is considered a contribution to the insurance liability covered under the policy and is not recoverable from the Fishermen's Fund. A vessel owner who pays for transportation or medical expenses for the injured or ill fisherman may be reimbursed if an agreement exists verifying that the employer advanced the money or paid any medical treatment on their behalf. A crewmember may be reimbursed if there is verification that the employer deducted the payments directly from wages due the injured or ill fisherman. Reimbursement cannot be made without the above supporting information. Alternatively, the injured or ill fisherman and the vessel owner may complete the Vessel OwnerCrewmember Agreement, both signing to attest their understanding that the expenses paid by the owner were paid as a loan to the crewmembers. The wording of the form may be revised to fit the circumstances. There is no assurance this agreement in any way complies with marine law. (Agreement in Appendix C) Indian Health Service (IHS ) Beneficiaries
Fishermen's
Fund Physician's Report Questions 1-4 may be answered by attaching medical records and noting, "See attached chart notes." Questions 5-14 require very little time to complete, and a clerical assistant may answer most of them. Questions 6 and 7 must be answered by the initial treating physician, to confirm that the injury is directly connected with the commercial fishing operations of the fisherman applicant. Chart notes or medical records are required, as an attachment to the Physician's Report, but do not substitute for it. The physician may use the "see attached" notation for numbers 2 & 4 on the Physician's Report if the form is signed and the fishing-related questions are answered. The Physician's Report serves many purposes, such as providing the necessary information in a logical order and concise manner to expedite processing and approvals for payment. When bills are received for the treatment of an injury or illness for which an application has not been filed, the fisherman and all medical providers will be sent a letter informing them no action can be taken until an application has been filed. Council Review When the Fishermen's Fund administrator cannot immediately approve an application for benefits, it must go before the Fishermen's Fund Advisory and Appeals Council for review. The Council meets twice a year, usually in November and March. Common reasons for delays that require the Council's review: 1. No response to an inquiry about items on an application. 2. Failure to seek treatment within 60 days of the onset of the injury or illness. 3. No evidence of a license at the time of injury or illness. 4. Injury or illness unrelated or not directly connected to operations of a commercial fisherman in Alaska. Just Cause The Council may approve benefits when just cause is demonstrated for the delay in the following circumstances:
Just cause for the delay should be explained in writing. Establishing Just Cause for: Not Seeking Treatment within 60 Days of Injury or illness Not Filing within One (1) Year of Initial Treatment Not Responding to an Inquiry within 90 Days. Not Responding to an Inquiry for, or Receiving an Explanation of Benefits (EOB) within 180 Days When a fisherman does not meet the timelines established above, and the Council has determined just cause for the delay exists, the Council may allow the administrator to approve benefits if:
Applications must be sent to the administrator. When a decision indicates, "Your claim cannot be approved by the administrator," it does not mean the fisherman is denied benefits. Often further information is required to enable approval by the administrator, or by law the application requires approval by the Council. Reconsideration or Appeal In the event the administrator cannot approve an application, all parties will be notified in writing of the reason. The application will be reviewed and a final determination made at the next meeting of the Fishermen's Fund Advisory and Appeals Council. Parties will be notified of the time and place of the meeting and may submit written information supporting the application or may appear before the Council. A Notice of the Council's decision will be mailed to all parties, usually within four weeks. A decision may be reconsidered or appealed as noted below. In some cases the Council will deny benefits unless certain conditions are satisfied by a certain time. The fisherman, therefore, must read the Council decision carefully and fulfill all the conditions to assure the best opportunity for approval.
Related costs of transportation, medical care, hospitalization, prescriptions, therapy, and chiropractic care will be paid for an occupational injury or illness if it is "directly connected with operations as a commercial fisherman" in Alaska waters or on shore preparing or dismantling boats or gear used in commercial fishing. Those costs noted above that are necessitated by a cardio-vascular disease may be paid if "attributable, directly or indirectly, to the fishing endeavor" (AS 23.35.080). A fisherman is also entitled to "such assistance after discharge from the hospital during period of convalescence as allowed in consideration of the condition of the Fund" (AS 23.35.090). The total allowance for any one heart attack is $2,500. Covered Injuries or Illnesses. Occupational illnesses or diseases which may be covered include: hernias, varicose veins of the leg; rheumatism, arthritis, musculoskeletal ailments such as bursitis, traumatic sciatica and tenosynovitis; the respiratory diseases bronchitis, pneumonia, and pleurisy caused by or aggravated by the fishing endeavor. With respect to a pre-existing injury, if subsequent aggravation is attributable strictly to that injury, and does not amount to a new injury, then, as with a recurring disability, benefits will not be awarded (AS 23.35.130, Opinion of Attorney General). What is Not Covered? Conditions of Coverage Noncovered Illnesses and Diseases and Other Conditions. Illnesses or diseases and other conditions not covered include strep throat, tonsillitis, the common cold, influenza, ulcers, cancer, appendicitis, insect bites, salmonella, giardia, smoking related conditions, cracked teeth or loose fillings from eating. Sexually transmitted diseases or drug or alcohol related injuries, and those caused by not following good hygiene and health practices, or improper care are not covered. Ear infections caused from diving in a commercial fishery are covered but not when due to a cold. Chronic Conditions. Chronic injuries, although aggravated by the fishing endeavor, may not be covered since they are usually pre-existing and not directly connected to the operations of a fisherman. Three-Month Gap in Treatment. The Council must reassess the treatment of an injury or illness when there is a three-month gap in the treatment. A doctor's statement is required noting how the treatment was directly connected to the prior commercial fishing injury. Fifth Injury Within Eight Years to the Same Area of the Spine. A doctor's statement is required when an application for benefits is received to cover expenses related to the fisherman's fifth injury or illness for the same area of the spine within eight years. The statement is necessary to determine whether it is a new acute injury or illness or if it is a chronic condition, which is not covered. Dental and Eye. Dentures, glasses or contact lenses lost or broken may be replaced or repaired only when lost or broken in activities directly connected to operations as a fisherman. A claim for dental injury without other bodily damage must be supported by a doctor's report that substantiates the injury's direct connection to operations as a fisherman, or an affidavit may be required. Carpal Tunnel. No benefits will be allowed for surgery until all other alternative treatment has been explored. If surgery is required after exploring these alternatives, the Council must review the application to see if the need for surgery is caused by the fishing endeavor. If surgery is required, the fisherman must provide in writing, or present to the Council in person, the following: 1. The extent of alternative treatment pursued; 2. A ten-year history of work experience including the number of years commercially fishing and type of fishing; 3. How the injury or illness has affected the ability to fish; and 4. Any other information considered pertinent. Away from the Boat. An injury or illness occurring away from the boat or fishing site will be covered as long as it is directly connected to operations as a fisherman, such as injuries incurred on a dock while hauling gear to the boat or at home repairing commercial fishing gear. Transportation. Costs are covered to and from the vessel, fishing or gear repair or storage site to the nearest medical facility where appropriate emergency care can be provided. Additional transportation costs to receive specialized or skilled care unavailable at the nearest approved medical facility must be supported by a written statement from the attending physician which clearly defines the specialized medical skill required and the nearest place where it is available. Approval of additional transportation costs may require consideration of the financial condition of the Fund. Costs incurred for transportation after discharge from the hospital during period of convalescence may be approved to return the fisherman to the boat, home or another place that reasonably meets with the fisherman's convenience. (AS 23.35.090-100, 8 AAC 055.010 (d) and AS 23.35.080 & 100.) Benefits will be paid only to the medical provider or to the fisherman to the provider if the bill is outstanding, or to the fisherman if his payment is verified by evidence such as cancelled checks, receipts, or bills or statements from medical providers. A vessel owner who pays a bill can be reimbursed if the Fishermen's Fund administrator receives evidence in writing that there was a prior agreement that the vessel owner would pay any medical expenses, or would advance payment with an agreement to be reimbursed. The fisherman will be reimbursed instead of the vessel owner if the fisherman submits evidence that the vessel owner deducted these expenses from the fisherman's compensation. However, these reimbursements do not imply that such an agreement or understanding is in compliance with marine law. See Appendix C for an example of agreement. Except for compelling reasons, benefits for the care of any one person involving a single injury or disability will not be paid beyond one year from the date of initial allowance, and cannot exceed $2,500. Requests to exceed the benefit limit or the duration of care must be in writing. They must note the "amount of relief" or additional benefits needed, or the "extent of additional time" required. Compelling reasons justifying the request must be specified. The Council must approve all requests. Compelling reasons to exceed $2,500 are not defined in law but must be sufficient to justify the requested benefit or time extension and must include:
Please remember to note: How much additional relief or money is needed in excess of what the fisherman can pay and/or the amount of extended time wanted beyond one year. Alaska
Statutes Title 23 AS 23.35.010. Creation of Fishermen's Fund Advisory and Appeals Council. There is within the Department of Labor and Workforce Development a Fishermen's Fund Advisory and Appeals Council. AS 23.35.020. Appointment and Composition of Council. The council is composed of the commissioner of labor and workforce development or a person designated by the commissioner and five members appointed by the governor for overlapping five year terms. The governor shall appoint one member from each of the following districts: District 1: Wrangell and areas south; District 2: Areas north of Wrangell to include Yakutat; District 3: Areas west of Yakutat to East Coast of Alaska Peninsula, including Prince William Sound, Cook Inlet, and Kodiak; District 4: Areas west of Alaska Peninsula to Cape Newenham, including Bristol Bay; District 5: Areas north of Cape Newenham, including Kuskokwim, Yukon, Kotzebue, and the Arctic. Sec. 23.35.030. Commissioner or designee as chair. The commissioner of labor and workforce development or the person designated by the commissioner serves as the chair of the council. AS 23.35.040. Duties of Commissioner and Council. The commissioner shall consult with the council before the commissioner makes a negative decision on an appeal filed with the commissioner in relation to the care of a sick and disabled fisherman. AS 23.35.050. Regulations. The department may adopt regulations to carry out the purposes of this chapter, including those that are necessary or advisable to protect the fund by limiting or suspending payments from the fund. The regulations must be uniform in application. AS 23.35.060. Creation and Administration of Fishermen's Fund. (a) There is created a fund, designated as the "fishermen's fund." The Department of Revenue is the custodian of the fund and the Department of Labor and Workforce Development shall administer it. The fund shall be composed of 39 percent of the money derived by the state from all commercial fishermen's licenses and money appropriated to carry out the purpose of this chapter. (b) The legislature may appropriate up to 50 percent of the interest income earned by the state on the balance of the fishermen's fund for a grant for statewide marine safety training and education programs. AS 23.35.070. Benefits. A fisherman, upon becoming disabled, is entitled to receive benefits as follows: Immediately after the fisherman sustains an injury or disability arising out of an accident directly connected with operations as a fisherman, either ashore in the state or in Alaska water, or suffers an occupational disease, the fisherman is entitled to emergency treatment, transportation to the nearest place where approved medical facilities are available, medical care, and hospitalization. In this section, "Alaska water" means the inland and territorial water of the state and the fishery conservation zone adjacent to the state established by 16 U.S.C. 1811 (sec. 101, Fisheries Conservation and Management Act of 1976). AS 23.35.080. Emergency Treatment For Cardio-Vascular Diseases. The department may pay the costs, within the maximum limitations, of emergency treatment, transportation, medical care, and hospitalization, necessitated by a cardio-vascular disease, if the department determines that the disease is attributable, directly or indirectly, to the fishing endeavor. AS 23.35.090. Assistance After Discharge. A fisherman is also entitled to such assistance after discharge from the hospital during period of convalescence as the department allows in consideration of the condition of the fund. AS 23.35.100. Transportation, Hospital, Nursing, Medical, and Surgical Expenses. The department may pay out of the fund all reasonable transportation charges incurred under AS 23.35.080 and 23.35.090, including cost of returning the fisherman to the boat or home of the fisherman or to another place that reasonably meets with the fisherman's convenience, and the reasonable hospital, nursing, medical, and surgical expense incurred in the examination, treatment, and care of the fisherman. AS 23.35.110. Contracts For Care. In carrying out this chapter, the department may enter into contracts or other arrangements with hospitals and doctors in the state for furnishing care on an annual basis to persons entitled to benefits. Contracting under this section is governed by AS 36.30 (State Procurement Code) AS 23.35.120. Cooperation With Other Agencies. In providing care the department shall provide the type and quality of treatment that will restore the fisherman to health and productivity, if possible. The department may enter into cooperative arrangements with agencies of the federal government, other states and territories, and private clinics and rehabilitation centers for the care and treatment of fishermen. AS 23.35.130. Duration of Care. Except for compelling reasons, compensation may not be paid for the care of any one person involving a single injury or disability beyond a period of one year from the date of initial allowance. AS 23.35.140. Limitation On Benefits. (a) Except for compelling reasons,
(b) The total allowance for any one heart attack is $2,500. AS 23.35.150. Definitions. In this chapter
Alaska
Administrative Code 8 AAC 055.010. Benefits. (a) To be eligible for benefits from the fund, a person must be a fisherman who, at the time an injury is sustained or illness is contracted, is licensed in his own name by the state to engage in commercial fishing under AS 16.05.480 or AS 16.43, and who is actually so engaged in Alaska water or is occupied in the state preparing or dismantling boats or gear used in commercial fishing. (b) Benefits for respiratory diseases are limited to bronchitis, pleurisy and pneumonia caused by or aggravated by the fishing endeavor. (c) Unless required as a result of accidental bodily injury caused by the fishing endeavor, benefits may not be awarded for the following items:
(d) Transportation to return a fisherman to his home may be allowed to the extent that the costs are in addition to those which the claimant would normally have encountered had he not been injured. (e) Compensation from the fund is limited to medical expenses that are not otherwise covered by public or private insurance. The fund may require information regarding insurance coverage, including an insurance benefits statement, and may hold a claim in abeyance pending the receipt of required information. (Eff. 3/28/74, Register 49; am 4/11/81, Register 78; am 7/28/93, Register 127) Authority: AS 23.35.050, AS 23.35.100, AS 23.35.070, AS 23.35.150(6) 8 AAC 055.020. Pleadings. (a) Proceedings before the council are commenced by filing an application, with the administrator, in writing which consists of the following:
(b) A separate application shall be filed for each separate and independent occupational injury or occupational illness for which benefits are claimed. (c) Benefits may not be awarded unless the following conditions are either met or excused by the council for just cause:
(d) A petition is a request for an extension of duration of care, waiver of benefit limitations, assistance after discharge from a hospital or additional transportation allowances. Petitions for extension of duration of care or waiver of benefit limitations must cite those reasons the petitioner believes justify granting the relief sought. The council may consider the condition of the reserve balance of the fund and the petitioner's insurance coverage relating to the claimed injury in determining whether to grant the petition. Petitions for assistance after discharge from the hospital must include the dates during which hospitalization occurred. Petitions for additional transportation allowances may be considered only for the purpose of providing specialized medical skills which are unavailable at the nearest approved medical facility. The petition must include a written statement from the attending physician which clearly defines the specialized medical skill required for the petitioner and the nearest place where it is available. (e) Petitions under (d) of this section shall be submitted to the council for review and recommendations. (f) The administrator shall notify, in writing, each petitioner or other party of the council's decision on the petition submitted under (d) of this section. The decision of the council is final. (g) Each applicant and petitioner is required to promptly inform the administrator of any changes to the applicant's or petitioner's address. (Eff. 3/28/74, Register 49;am4/11/81, Register 78; am 9/10/98, Register 147) Authority: AS 23.35.050, AS 23.35.130, AS 23.35.100, AS 23.35.140 8 AAC 055.030. Appeals. (a) The administrator shall submit a written notice to each fisherman whose application cannot be accepted based on criteria set out in the law and regulations stating the reason why the payment cannot be made. (b) The council shall review each application which has not been approved for payment by the administrator. Each fisherman who has an application pending before the council shall be notified in writing by the administrator of the time and place of a council session at least 10 days before the session. Each fisherman may submit additional evidence to the council in support of his claim. The evidence may be presented in writing, by personal appearance, or by both methods. (c) The administrator shall notify, in writing, each fisherman and party with an application before the council of the council's decision on the application. (d) A fisherman may appeal the decision of the council. The council's decision is final unless appealed to the commissioner within 45 days after mailing of the notice of the council's decision. The appeal must be in writing and must include a description of the relief sought. The commissioner's decision will be based on a consideration of the whole record and will state the facts relied upon. The decision of the commissioner is final. (Eff. 3/28/74, Register 49; am 4/11/81, Register 78; am 9/10/98, Register 147) Authority: AS 23.35.040, AS 23.35.050 8 AAC 055.035. Right to Subrogation. If the department pays benefits from the fund, the department, to the extent of the value of the benefits, is subrogated to the rights of the fisherman for a claim against a third party arising from an injury, disability, occupational disease, or cardiovascular disease covered by AS 23.35.010 -23.35.150 and this chapter and to the proceeds of an insurance policy covering an injury, disability, occupational disease, or cardiovascular disease covered by AS 23.35.010 - 23.35.150 and this chapter. (Eff. 12/26/86, Register 100) Authority: AS 23.35.050 8 AAC 055.040. Definitions. In this chapter unless the context requires otherwise
Authority: AS 23.35.050
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Last
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June 18, 2001 3:21 PM
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