Beware the “18/10” Rule When Denying Claims in New York

Timelines for denying (the “18/10 rule”).

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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Greg Lois is the managing partner of LOIS LLC, a 21-attorney law firm dedicated to defending employers and carriers in New York and New Jersey workers' compensation claims. Greg is the author of a popular series of "Handbooks" on workers' compensation, and is the co-author of the 2016 & 2017 Lexis-Nexis New Jersey Workers' Compensation Practice Guide. Greg can be reached at 201-880-7213 or glois@lois-llc.com