In New York, when an individual suffers an accident or illness arising out of and in the course of employment, workers’ compensation becomes the primary source of wage replacement and medical benefits. It is important to understand how workers’ compensation benefits affect or are affected by other available benefit programs. Some of these additional benefit programs duplicate workers’ compensation benefits, some supplement workers’ compensation benefits, and others are paid instead of workers’ compensation benefits.
Private Long Term Disability Benefits: Some employers voluntarily provide employees with long term disability benefits. Individuals can also obtain these policies on their own. Long term disability benefits are typically available for periods of disability which extend beyond an ‘elimination period.’ These policies issue indemnity benefits to policyholders who are disabled and unable to work beyond a set period of time, i.e. six months, 26 weeks, or another set period of time specified in the long term disability policy.
The Workers’ Compensation Board does not have jurisdiction over private long term disability benefit plans. As there is no jurisdiction, the Board has no legal authority to direct reimbursement for a duplication of benefits. Therefore, a claimant can receive both workers’ compensation indemnity benefits and benefits from their long term disability policy at the same time and even receive more from the two than their normal weekly wage while working. However, most long term disability policies contain provisions that require reimbursement to the long term disability carrier or take an offset for any workers’ compensation benefits. These reimbursements and offsets are to be determined in accordance with the terms of the long term disability policy. Continue reading How an Award of Workers’ Compensation Benefits Impacts Other Disability Benefits→
The New York Workers’ Compensation Board will schedule hearings on its own initiative. Every hearing will have a “goal” and will result in the entry of an Order. The goal of every hearing is transmitted to the parties of interest on Form EC-16.1. Initial hearings are held to address the establishment of a case: parties must be prepared to discuss the particular facts of the accident, notice, and the causal relationship of the alleged injuries to the employment.
In an admitted case, defense counsel will rely on handling instructions, the Form C-2F (if any), the FROI/SROI screens, the return-to-work information available, and the wage information contained in the FROI. Statements contained in the filings (particularly in the Form C-2F) may be considered stipulations and binding (on the part of the employer).
Prior to any regularly-scheduled hearing (particularly in an established case) the issues facing the carrier/employer should be well understood. Hearing notices are prepared and mailed to all parties by the Board approximately 21 days prior to the date of hearing. Defense counsel should supply the employer with an action plan for upcoming hearings and request any necessary documents/information in preparation for the listing.
Any party can request a hearing as per WCL §20, which states:
[The Board] upon application of either party, shall order a hearing, and within thirty days after a claim for compensation is submitted under this section, or such hearing closed, shall make or deny an award, determining such claim for compensation, and file the same in the office of the chair. Immediately after such filing the chair shall send to the parties a copy of the decision. Upon a hearing pursuant to this section either party may present evidence and be represented by counsel.
A carrier requests a hearing by filing a Form RFA-2 (“Request for Further Action by Carrier/Employer”). The most common Request for Further Action filed by employers is a request to stop or reduce benefits in a case where ongoing benefits have been ordered by the Court. A carrier/employer can not simply stop paying benefits because an IME physician says the claimant has reached “MMI” or has a reduced level of disability – there is no “self help” allowed and the case must be heard by a Law Judge before benefits can be stopped or reduced. Continue reading Field Guide to New York Workers’ Compensation Hearings→
Here is the post-webinar video from our most recent presentation, “Getting the Most from your IMEs in New York” from our New York webinar training series. The complete archive of prior presentations is here.
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Recently, we posted an article detailing the most common defenses that are used in denied New York Workers’ Compensation claims, that article can be found here.
Controverting a claim in the state of New York also requires that the carrier and/or self-insured and the defense counsel submit very specific forms in a statutorily defined time frame in order to raise and maintain those defenses. In most cases, if these aforementioned forms are not submitted in a timely fashion or are defective, the carrier and/or self-insured may waive all of its defenses and may have to accept the claim as compensable.
Initial Considerations in Controverted Claims
The process to controvert or deny a workers’ compensation claim in the state of New York is initiated when the carrier or self-insured files the electronic First Report of Injury – Denial Type 04 (FROI-04) which can be viewed here or a Subsequent Report of Injury – Denial Type 04 (SROI-04) form which can be viewed here. These forms now replace the Form C-7 or Notice that Right to Compensation is Controverted form, which used to be the forms upon which a claim was controverted. To view the obsolete form you can click here.
N.J.S.A. 34:15-40 (“Section 40”) governs the credit due a respondent for any third-party recovery by the petitioner and provides in part:
. . . out of that part of any amount about to be paid in release or in judgment by such third person or his insurance carrier on account of his or its liability to the injured employee or his dependents, the employer or his insurance carrier shall be entitled to receive from such third person or his insurance carrier so much thereof as may be due the employer or insurance carrier pursuant to subparagraph (b) or (c) of this section. Such sum shall be deducted by such third person or his insurance carrier from the sum to be paid in release or in judgment to the injured employee or his dependents and shall be paid by such third person or his insurance carrier to the employer or his insurance carrier. Service of notice, hereinbefore required to be made by the employer or his insurance carrier upon such third person or his insurance carrier, shall be by registered mail, return receipt and in cases other than an individual shall be mailed to the registered office of such other third person or his insurance carrier.
The Appellate Division has recently held that where an individual settles an intentional tort suit against an employer, the workers’ compensation carrier is entitled to assert its N.J.S.A. 34:15-40 lien with respect to the settlement amount. Specifically, the court found that the tort litigation is equivalent to a third party action and that without the lien the petitioner might receive a double recovery for the injuries.
How to assert a workers’ compensation lien under N.J.S.A. 34:15-40.
Serve notice upon the liable third person or that person’s insurance carrier that compensation has been applied for by the injured employee (or his dependents). As a practical matter, it is a good idea to serve a notice letter upon the plaintiff/worker, as well as the plaintiff’s attorney, usually the same attorney representing the worker in the compensation matter. Continue reading Reimbursement from Third-Party Recoveries in New Jersey→
To deny a workers’ compensation claim in New York, the carrier/self insured employer must file an electronic denial. The electronic denial form is mandated by the EDI/eClaims process and designated a “FROI-02” (where the denial is the first document filed by the carrier or self-insured employer) or a SROI-04 (where the carrier/self insured employer has already filed an electronic claim form).
When denying a claim, the carrier/self-insured employer must designate a, EDI denial code (“MTC code”) which is specific to the legal defense raised. For example, the legal defense of “No Accident Arising Out of and In the Course of Employment” is coded as “1A: No Compensable Accident.” It is general practice for the risk professional handling the claim to contact counsel in advance of filing a denial pleading to confirm the legal defenses to be raised and the denial codes to be used.
After the Board notifies the employer (or its insurance carrier) that a workers’ compensation case has been indexed against the employer, the employer may file a notice of controversy (FROI-04) within 25 days from the date of mailing of the notice of indexing. Failure to file the notice of controversy within the prescribed 25 day time limit could bar the employer and its carrier from pleading certain defenses to the claim. WCL § 25(2)(b). Continue reading Denying Claims in New York→