- Claimant denies having gainful employment while collecting temporary disability benefits. He actually started up a small business, but the business lost money.
- Claimant says he applied for jobs at 34 different businesses while seeking benefits. The employer performed its own follow-up search and learned he applied for only two (2) jobs.
- Claimant lying about his physical restrictions to our IME doctor
- Concealing volunteer work while “too disabled” to do your regular job?
- Caught selling street drugs while collecting workers’ compensation benefits?
- Claimant first admits to working, but her attorneys later state she isn’t. Claimant later found working seasonally while collecting benefits.
Continue reading Is this Workers’ Compensation Claim Fraud in New York?
In New York, pursuant to Workers’ Compensation Law § 114-a (1), a claimant may be disqualified from receiving workers’ compensation benefits “[i]f for the purpose of obtaining compensation . . . or for the purpose of influencing any determination regarding any such payment, [he or she] knowingly makes a false statement or representation as to a material fact.” A fact is “material” if it is “significant or essential to the issue or matter at hand,” and it need not be demonstrated here that claimant received compensation to which he was not otherwise entitled or that he did not sustain a compensable injury (Matter of Losurdo v Asbestos Free, 1 NY3d 258, 265 .
Recently the Third Department of the New York Appellate Division entertained an appeal in which the claimant was disqualified from receiving future benefits and forced to pay back past benefits as a result of violating Workers’ Compensation Law § 114-a, therefore committing fraud. The case, Matter of Poupore v Clinton County Highway Dept. 2016 NY Slip Op 03037 was decided on April 21, 2016. In this case, the penalty imposed by the Law Judge and the Board Panel was upheld on appeal.
Under New Yorker’s Workers’ Compensation Law § 120, an employer may not fire or otherwise discriminate against an employee who has claimed or attempted to claim workers’ compensation benefits. If there is an allegation that an employer discriminated against an employee because he/she has attempted to claim compensation benefits, they must file two copies of a Discharge or Discrimination Complaint (Form DC-120 ) with the Workers’ Compensation Discrimination Unit. Any complaint alleging an unlawful discriminatory practice must be filed within two years of the commission of such practice.
The Discrimination Unit will notify the employer of the Complaint by issuing a “Notice to Employer and Request for Information Regarding Discharge or Discrimination Complaint” (Form DC-130). The DC-130 Form must be completed by the employer and returned to the Discrimination Unity within 30 days of receipt. A trial will ultimately be scheduled by the Board to address the Discrimination action. Continue reading Defending New York Workers’ Compensation Discrimination Cases
Completing the FROI-04 (denying the claim).
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
This post provides a general overview of how traumatic, specific accident claims are generally handled.
At the time of the accident:
First, the worker gets medical treatment and notifies her supervisor about the accident and how it occurred.
The employee notifies the employer of the accident in writing, as soon as possible, but within 30 days. The Board may excuse the lack of notice if notice could not be given (for example: the claimant was taken to the hospital and could not inform her employer), the employer had knowledge, or if the employer is not harmed by lack of notice. WCL § 18.
The employee may file a claim with the Board by filing a Form C-3. This must be done within two years of the accident or within two years after the employee knew, or should have known, that the injury was related to employment. WCL § 28. Continue reading New York Claim Path: Reporting, Filing, and Appearing.
When Injury Reporting is Required.
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
- Require more than ordinary first aid; OR
- Require at least three “first aid” visits.
The Workers’ Compensation Board has an official form for reporting injuries (Form C-2F “Employer’s Report of Work-Related Injury/Illness“). The form must be provided to the injured worker upon request and has to be maintained (held) by the employer for at least 18 years.
The C-2F report must be filed with the Workers’ Compensation Board within 10 days after the occurrence of the accident.
Failure to file the report subjects the employer to potential misdemeanor criminal liability, punishable by a fine of not more than $1000. A second penalty – not to exceed $2500 – can be imposed by the Board. Continue reading Practical Advice on Injury Reporting in New York