The Board is now instructing carriers that when lost time does not exceed seven days, the claim administrator should file the FROI accepting liability for the medical portion of the claim. Why seven days? That is the “waiting period” for indemnity benefits in New York. Although the Board initially instructed carriers that the FROI-PD form was accepted (for a “partial denial” medical-only filing) the Board rescinded this guidance and now states that a FROI-00 should be filed; the claim administrator may later file a denial if lost time is claimed (SROI-04). This can also be used when there is no evidence regarding the claim.
A decision by the carrier to deny the compensability of an alleged injury (other than “minor injuries”) must be reported to the Board and insurance carrier by filing an eClaims form.
There are two different timelines that apply. Th Board will allow for the greater of:
18 days: On or before the 18th day after lost time (“the disability event”); or
10 days: within 10 days after the employer has knowledge of the lost time (“disability event”).
How does the Board know if a denial was filed “timely”?
The Compliance Unit is measuring Timeliness of Controversy on only lost time claims. The timelines they are checking are (a) 18 days from Date of Accident, (b) 10 days from Date Employer had Knowledge of Injury, and/or (c) 10 days from Initial Date of Disability, whichever period is greater.
To determine he date that the employer had knowledge the Board will use the earliest date of “Date Employer Had Knowledge of the Injury” (DN0040), “Date Employer Had Knowledge of Disability” (DN0281), Board’s Assembly Notice Date, and/or the Indexing Notice Date.
To determine the initial Date Disability Began/Current Date Disability Began the Board will look to the filings to see Initial Date Disability Began (DN0056) and Current Date Disability Began (DN0144) are present, and the Initial Return to Work Date (DN0068) is less than or equal to 7 days then Current Date of Disability (DN0041) is used.
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Here is the post-webinar video from our most recent presentation, “Defending Occupationals” from our New Jersey workers’ compensation webinar training series. The complete archive of prior presentations is here.
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Subject: New Jersey, Workers’ Compensation Law, Occupational Exposure, Repetitive Stress Injuries
Date Presented: September 26, 2016
Presenter(s): Greg Lois, Esq.
Run time: 19:07
The “Second Injury Fund” (“Fund”) refers to a special fund established by the Workers’ Compensation Act allowing the Department of Labor to collects a surcharge on all workers compensation policies issued in New Jersey. N.J.S.A. 34:15-95. The collected monies create a fund to reduce the costs of “second injuries” on New Jersey’s employers, in order to encourage employers to hire previously-disabled workers. The Law creating the Fund was enacted in 1923, before the Americans with Disabilities Act made it impermissible to discriminate in the hiring of previously-disabled workers. See 42 U.S.C. 126.
The Fund used to be called the “2% Fund” because the surcharge was originally set at 2%. Now the surcharge is 6.76%. As of January 1, 2013. (http://www.njcrib.com/circulars/NJ1849.pdf) As of January 2017, all rating information is available only online. Practitioners use the terms “Second Injury Fund” and “2% Fund” interchangeably. Continue reading What is New Jersey’s Second Injury Fund?→
New York Workers’ Compensation Law §110 states that an accident must be reported when it:
“will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident occurred, or which has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid.”
In order to be reportable, the injury must:
Cause the worker to lose one day of work in addition to the date of loss; OR