New Hampshire insurers seeking reimbursement from the Second Injury Fund under RSA 281-A:54 need a physician to certify the medical basis. On WCSIF-1b the examining physician describes the worker's preexisting permanent impairment and its functional limits, the later work-related injury or illness and its limits, and whether the combination causes greater disability than the later injury alone, or in a death case, whether the impairment led to death.
A licensed practicing physician who examined the employee completes the whole two-page form, stating years in practice, office location and examination date, and signs with the date of certification. The insurer fills in the employee, employer, carrier, injury and disability dates and its case number.
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Second Injury Fund Certification by Physician
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It is Form WCSIF-1b, LAB 500 Exhibit Q, which supports an insurance company's claim that a worker with a preexisting permanent impairment suffered a later work-related injury or illness and that the combination results in greater disability. The physician's evaluation helps determine whether the insurer's contentions are valid.
Two sets: the diagnosis of the employee's preexisting permanent impairment with the functional limitations it caused, and the diagnosis of the subsequent work-related injury or illness with the functional limitations that followed. The form asks the physician to be complete in assessing each condition and the combination of the two.
A licensed practicing physician who has examined the employee. The certification states how many years the physician has practiced, the city or town of the office and the examination date, and ends with the physician's signature and date of certification.