SECTION V TABULATION OF EXPERIENCE

The experience used for purposes of the Merit Rating Plan shall be the individual risk experience valued at least three months prior to the RED and reported in accordance with the provisions of the Pennsylvania Workers’ Compensation Statistical Plan. It shall include voluntary compensation insurance but shall exclude maritime employments and employments under the Federal Employees’ Liability Act.

To determine the Merit Rating Plan adjustment the prescribed experience shall be tabulated by the PCRB on approved Merit Rating Plan forms.

The audited payrolls or other exposures for each classification for the experience period shall be tabulated by policy years.

Incurred losses or claims reported for all policy periods considered in qualifying a risk for the Merit Rating Plan shall be tabulated in the following manner:

1. 1. Claims having no indemnity benefit payment or case reserve for indemnity benefit payment shall be excluded from the experience tabulation for purposes of the Merit Rating Plan. Losses as reported (indemnity, medical and total) shall be shown for each policy year. Losses incurred shall be on a gross basis, before the application of the deductible when such coverage is provided.
   2. All claims not excluded from the experience tabulation for purposes of the Merit Rating Plan by virtue of sections (a) above shall be listed in the experience tabulation with the following information:
      • Policy number
      • Policy effective date
      • Claim number or number of claims
      • Indemnity loss amount
      • Date of loss

All claims reported with Catastrophe Code No. 48 shall be excluded from merit rating calculations.

All claims reported with Catastrophe Code No. 12 shall be excluded from merit rating calculations.

No loss shall be excluded from the experience of a risk on the ground that the employer was not morally responsible for the accident that caused such loss.

It shall not be permissible to revise values because of department or judicial decision or because of developments in the nature of injury between two valuation dates. Provided, however, that

1. 1. in cases where loss values are included or excluded through mistake other than error of judgment
   2. where a claim is declared non-compensable (see note below)
   3. where the claimant or carrier has recovered in an action against a third party
   4. where a claim should have been reported with Catastrophe Code No. 48, or
   5. where a claim or a portion of a claim is ruled or officially declared fraudulent, or
   6. where a claim should have been reported with Catastrophe Code No. 12.

In the above circumstances, revised statistical report(s) are required to be submitted in accordance with the approved Statistical Plan. When a change to a claim value due to the above circumstances is known to the insurer with certainty within 48 months of the expiration of a Merit Rating Plan adjustment which included loss values for that claim, such revised statistical report(s) shall be used to adjust that merit rating.  Such adjustments to merit ratings shall be made regardless of when the correction report(s) reflecting the cited event(s) is/are submitted to or received by the PCRB.

Note: For purposes of this rule, the term “non-compensable” refers to:

1. 1. 1. an official ruling  specifically  holding  that  a  claim  is  not  entitled  to  benefits  under  the  provisions  of  the Pennsylvania Workers Compensation or Occupational Disease Act.
      2. a case where  no  claim  was  filed  during  the  period  of  limitation  provided  by  the  Pennsylvania  Workers Compensation or Occupational Disease Act for the filing of such claim and the carrier therefore closes the case.
      3. a case where the carrier contends prior to the evaluation date that a claimant is not entitled to benefits under the Pennsylvania Workers Compensation or Occupational Disease Act and the claim is officially closed because of the claimant’s failure to prosecute his claim.