If you are injured on the job, workers’ compensation benefits are a vital resource to offset you lost wages and medical expenses. However, individuals applying for workers’ compensation benefits in New York State face an abundance of rules and stringent deadlines, as well as opposition from employers and insurance companies. All of these obstacles can prevent you from obtaining benefits.
Lipsitz Green Scime Cambria’s experienced workers’ compensation team will help you successfully navigate through the complicated workers’ compensation process and fight on your behalf to ensure you get all the compensation you are entitled to.
Information on Workers’ Compensation Claims Process
This page provides information on various aspects of the process injured workers have to follow when filing a claim to obtain workers’ compensation benefits in New York State. Click any of the following topics for information on:
- Who is eligible for New York State workers’ compensation benefits;
- Steps to follow when filing a workers’ compensation claim;
- How to appeal the decision when your claim has been denied
- Medical forms that must be filled out and filed properly; and
- Reaching a settlement for your workers’ compensation claim.
If you have questions on any of the information found on this page or if you would like to discuss your workers’ compensation claim, contact Lipsitz Green Scime Cambria today.
New York State Workers’ Compensation Eligibility
Almost all employers in New York State are required to provide workers’ compensation for their employees. In order to find out if you are eligible for New York State workers’ compensation, be sure to check with your employer. Most employees in New York are eligible for workers’ compensation, including:
- All for-profit employees
- County or municipality employees engaged in “hazardous” work
- Public school teachers
- New York State employees
- Farm workers who are paid at least $1,200 over the course of a year
- Most nonprofit workers, and
- Any other workers who are determined to be employees and who are not excluded under the law.
The Claims Process
Filing a Workers’ Compensation Claim
If you are injured on the job, there is a series of actions you should take to make sure that your workers’ compensation claim is filed and processed properly. It is important to observe the various deadlines for filing so that you are able to receive your benefits. An experienced workers’ compensation attorney will be able to assist you with filing your claim and navigating the complex system of deadlines and potential appeals.
Immediately after the accident, you should:
- Obtain the necessary medical treatment
- Notify your supervisor about what happened and how the accident occurred
- Notify your employer in writing about the accident as soon as possible within 30 days
- File a claim with the Workers’ Compensation Board on the Form Employee Claim (C-3 Form) by mailing the form to the correct Workers’ Compensation Board District Office. The C-3 Form can also be filled out online. If you choose this option, you may either submit the form electronically or print out the completed version and mail it. The claim must be filed within two years of the accident or within two years of when you knew or should reasonably have known that the injury was related to your employment.
Within 48 hours of your accident, have your doctor complete the preliminary medical report (C-4 Form) and send it to the appropriate Workers’ Compensation Board District Office. A copy must also be sent to your employer/insurance carrier, you as the injured worker, and your representative.
10 Days after Notifying Your Employer
10 days after your accident, your employer must report the injury to the Workers’ Compensation Board and the employer’s insurance company.
14 Days after Receiving Your Employer’s Report
Within 14 days of receiving your employer’s report, the insurer must provide you with a written statement of your rights under the law. This notice can also be sent to you with your first compensation check if that check is sent before the 14 day limit. If your employer’s insurance company requires you to use a network it has contracted with for your diagnostic tests, you as the claimant must be notified of the names and contact information of the health care providers in that network when you are sent your statement of rights or as soon as possible if that statement has already been sent to you.
18 Days after Receiving Your Employer’s Report
With 18 days of receiving your employer’s report, the insurance company must begin paying your benefits if your lost time exceeds seven days. If the claim is being disputed and your payments are being withheld, the insurer must inform the Workers’ Compensation Board, you, and your representative. The insurance company must also notify the Workers’ Compensation Board either indicating that payment has begun or explaining why payment is being withheld. If you do not notify your employer of your injury in a timely manner, the insurance company’s notice may be filed within 10 days of learning of the incident.
Every Two Weeks
After the initial process is completed, the insurance company should continue to make your benefits payments every two weeks. If your compensation is stopped or modified, the insurance carrier must notify the Workers’ Compensation Board. Your doctor must submit progress reports to the Workers’ Compensation Board every 45 days and, after 12 weeks, the insurance company will consider whether or not rehabilitation is necessary in your case.
Workers’ Compensation Claim Denials and Appeals
The workers’ compensation claims process is complex and difficult to navigate. These complexities are only magnified if your claim is denied and you decide to appeal your case. An experienced workers’ compensation attorney will be able to help you through the difficult and often confusing workers’ compensation claims and appeals process in order to ensure that you receive the workers’ compensation benefits to which you are entitled.
Workers’ Compensation Claim Denials
Your claim will be paid if your employer or their insurance carrier agree that your injury or illness was directly caused by work. However, your employer or their insurance company may also deny your claim. If this happens, you do not receive benefits until a judge rules on your case. If you do not receive workers’ compensation benefits due to a dispute with your employer or their insurance company, you may still be eligible for disability benefits, but these payments will be subtracted from future workers’ compensation payments.
There are several reasons why a workers’ compensation claim might be denied, including:
- Missing deadlines to file the various forms necessary
- Disputes about whether the injury sustained was actually work-related
- Claiming a condition that does not meet New York State guidelines for receiving workers’ compensation
- Filing a claim after you have left the job at which you sustained the injury
- Discrepancies between your accident report and your medical records
- Failing to promptly seek medical attention
If the injury is a result of the intent to harm yourself or someone else, or if you were intoxicated at the time of the accident, your claim may also be denied.
When the Workers’ Compensation Board receives notice that a claim is being denied, a pre-hearing conference will be scheduled. Separate hearings and separate depositions will be scheduled for each party to the claim.
Appeals Process: Board Panel Review
If the judge denies your claim, you may be able to appeal the decision. A review of the denial can be requested within thirty days of the initial decision being filed. The first stage of the appeals process is an application for the denial to be reviewed by the Workers’ Compensation Board. This application is made when a party disagrees with the decision to deny the claim at a hearing level. The Application for Board Review must be filed within thirty days of the date the decision was filed and the respondent, usually your employer’s insurance company, has thirty days to file a rebuttal. An appeal to the Workers’ Compensation Board pauses the insurance company’s obligation to pay your benefits until a decision is reached. It is an administrative appeal that is considered by a three-member panel of the Workers’ Compensation Board whose decision, known as the Board Panel Decision, can affirm, modify, or reverse the prior decision. A decision by the Board Panel is subject to appeal to the full Workers’ Compensation Board within 30 days and additional appeal may be filed with the Third Department of the Appellate Division.
Most workers’ compensation decisions are subject to an appeal. It is important to note that the claimant is not the only party able to appeal a decision; employers and insurance companies can also make appeals. Several different elements of the decision can be appealed, including medical benefits, wages lost, the type of medical treatment received, and whether the claimant qualifies for permanent disability.
Important Medical Forms
As you begin medical treatment, it is vital that your physician submit the correct forms in a timely fashion. Certain common forms and timelines are listed below.
- Doctor’s Initial Report (Form C-4): must be filed within 48 hours of your first treatment. To report continued treatment, Form C-4.2 must be used. To report permanent impairment, Form C-4.3 must be used.
- Attending Doctor’s Request for Approval of Variance and Carrier’s Response (Form MG-2): used to request treatment or testing that is outside the Medical Treatment Guidelines.
- Attending Doctor’s Request for Authorization and Carrier’s Response (Form C-4AUTH): used to confirm a telephone request for written authorization for special service(s) costing over $1,000 in a non-emergency situation.
- Attending Ophthalmologist’s Report (Form C-5): must be filed within 48 hours of your first treatment. Another report on your progress must be filed in 15 days and then every 90 days while treatment continues.
- Record of Percentage Hearing Loss (Form C-72.1): must be filed when your hearing test is completed.
- Practitioner’s Report of Functional Capacity Evaluation (Form FCE-4): must be filed by a physical or occupational therapist according to the specifications listed on the form.
- Provider’s Request for Judgment of Award (Form HP-J1): must be filed by an authorized workers’ compensation health provider at least 30 days after your administrative award or arbitration decision has been issued (if decision was made on or after March 13, 2007). Waiting 60 days is often recommended.
In order to be sure that your prescription coverage or coverage for other medical treatments will not be denied, it is essential to be treated by a doctor with extensive workers’ compensation experience. These experienced physicians will be more equipped to submit the appropriate forms within the correct timelines to ensure that you receive the coverage and reimbursements to which you are entitled. Lipsitz Green Scime Cambria’s Workers’ Compensation Department has attorneys and paralegals who are dedicated to making sure that your prescription coverage is not denied and that you are provided with the medications you need to effectively manage the symptoms from your work injury or illness.
Settling a Workers’ Compensation Claim
A Section 32 Waiver Agreement is negotiated between the injured worker and an insurance carrier to settle the payments for lost wages, also called indemnity, and/or medical benefits on a workers’ compensation claim. You may choose to settle either indemnity or medical benefits or you can choose to settle both matters. If an injured worker agrees to the settlement, the worker waives the right to future workers’ compensation payments in exchange for either a lump sum payment immediately or an annual payment. Both the injured worker and the insurance company must agree to settle the claim. If agreed upon and approved by the Workers’ Compensation Board, the settled issue is closed forever and the insurance company is no longer responsible for that portion of the claim. The waiver agreement is not binding until it is approved by the Workers’ Compensation Board. In some cases, the Board will use a desk review process to review and approve or disapprove the agreement. The circumstances under which a desk review might occur include cases that settle indemnity only where the worker is represented by an attorney or cases where all parties request a desk review.
Required Settlement Forms
The forms required for a Section 32 Waiver Agreement are:
- Form C-32: required for all Section 32 Waiver Agreements. Form C-32 provides consent for desk review.
- Form C-32.1: required for all Section 32 Waiver Agreements. In Form C-32.1, the attorney for the worker attests that the agreement has been reviewed with the worker and the worker understands the terms laid out within the agreement.
- Form 32-I: required for indemnity-only settlements in addition to Forms C-32 and C-32.1.
Settling Lost Wages
When negotiating a Section 32 settlement, you may choose to settle indemnity (lost wages), medical benefits, or both. If you settle indemnity, you will stop receiving regular workers’ compensation payments for lost wages and you will instead receive an amount agreed upon by you as the injured worker, your lawyer, and the insurance company. The amount is subject to negotiation and, like all workers’ compensation payments, is tax free. You may choose to receive a lump sum upfront or to receive annual payments.
Settling Medical Benefits
If you choose to settle your medical benefits, you will stop receiving regular payments for medical care. The insurance company will give you a lump sum payment in an agreed-upon amount. It is important to note that health insurance does not cover the cost of work-related conditions, so it will not cover the cost of your care even if it was purchased through a state or federal program. You are not required to settle the medical portion of your claim; if you choose to keep it open, the insurance company will continue to pay for your medical care.
When opting to settle your medical benefits, it is important to take Medicare interests into account. This is most often done by setting up a Medicare set-aside account out of the proceeds from your settlement. This account can then be used to pay for your medical treatment. Failure to do this may result in Medicare refusing to pay for your treatment. Medicare is federal, so the Workers’ Compensation Board has no jurisdiction over it. To be eligible to receive Medicare, you must either meet the age requirement of 65 or older or you must be a Social Security Disability recipient.
The Settlement Process
In order to settle a workers’ compensation claim, either your lawyer will approach the insurance company or the insurance company will approach your lawyer to begin the process. Usually, the insurance company will draw up an agreement. Once all parties—you, your lawyer, and the insurance company—agree on the terms, the Workers’ Compensation Board will review the agreement. Until the Board reviews and approves it, the agreement is not final and binding. You and the insurance company will have 10 days from the date you submitted the agreement for approval to withdraw. This date, however, depends on whether or not you have a Section 32 hearing. If you do have a hearing, the date of submission is the hearing date. If the law judge approves the agreement at the hearing and none of the parties withdraw in writing within the 10 day period, the Workers’ Compensation Board will mail you the final decision, which is known as the Notice of Approval. The Notice of Approval will not be sent until after the withdrawal period ends.
If there is no hearing and the Board has approved your agreement, you will be sent the proposed—but not the final—decision, which is known as the Proposed Notice of Approval. The Proposed Notice of Approval will include the submission date on it and all parties involved will have 10 days from that date to withdraw from the agreement in writing. The Proposed Notice of Approval will also include the specific date the decision becomes final if none of the parties withdraw within the 10 day period. The insurance carrier is required to pay the settlement amount within 10 days of this date.
Prescription Coverage Denial
Lipsitz Green Scime Cambria works quickly to reinstate your insurance coverage of prescriptions after a sudden denial of coverage.
Labor Market Attachment
Lipsitz Green Scime Cambria will provide you guidance on maintaining labor market attachment to help ensure you maintain your benefits.