New York Workers’ Compensation

The Basics About Workers’ Compensation in New York

The New York Workers’ Compensation System is complex. It’s often said, “the devil is in the details”, and this rings true here. While it’s meant to help workers smoothly move from getting hurt to getting better, it can sometimes feel more like a complicated maze of rules and paperwork than a simple process.

Contrary to popular belief, workers’ compensation isn’t a lawsuit, but a claim for insurance benefits. If the insurance company fails to deliver the necessary assistance, the Workers’ Compensation Board steps in to make decisions approving or denying the treatment or lost wages claimed by the injured worker. 

What Is a Workers’ Compensation Claim?

Have you ever thought, “Today, I’d love to get injured at work and then sort everything out!”? Most likely not. If you do get hurt at work, would you know what to do? Like most people, you probably wouldn’t. 

That’s why we have something called workers’ compensation insurance. It’s a legal way an injured worker can ask for help, and it’s available in all fifty states.

In simple terms, it’s a request for benefits from an insurance policy that every boss must get for their workers. It doesn’t matter who’s at fault for your injury, you can get help from this insurance.

Many people think they’re suing their boss if they file a workers’ compensation claim. That’s not true. When you file a workers’ compensation claim, it’s like making an insurance claim, not a lawsuit. Your boss gets this insurance so they don’t get sued by their workers – you can’t sue your boss, but you can make a workers’ compensation claim.

Workers’ Compensation insurance provides two basic benefits:

1. Indemnity – this is a payment for lost wages. You could get a weekly payment and maybe a cash settlement at the end, depending on your injury.
2. Medical benefits – the workers’ compensation insurance company is supposed to pay for any medical care you need to get better.

Key Participants in the Workers’ Compensation System:

1. You, the injured worker
2. The Insurance company, which represents itself and your employer. Some self-insured employers use external firms to oversee the program
3. The Workers’ Compensation Board, the ‘judicial’ body that adjudicates disputes between you and the insurance company

Additional Participants:

1. Your legal representative (an attorney or licensed representative)
2. The defense attorney, representing the insurance company and your employer
3. Your healthcare provider(s)
4. The insurance company’s healthcare providers, also known as Independent Medical Examiners (an unfortunately misleading term)
5. Lay witnesses, such as colleagues or other individuals who may be called to testify at the Workers’ Compensation Board if the insurance company contests your case

Understanding the Claim Process:

The term “claim” represents your case within the system. If you’re injured at work, you will have to file a claim for benefits. Here are some typical steps at the start of the claim:

– As an injured worker, you’re required to inform your employer, file a C3 claim form with the New York workers’ compensation Board, and consult a healthcare provider

– Employers are obligated to inform their insurance provider, file an injury report, and respond to information requests from the insurance company and the workers’ compensation board

– The insurance company has a specific timeline to initiate investigation, commence payment of the claim (covering medical and lost wages), or dispute the claim

Crucial Timelines:

Notification: Inform your employer immediately about the accident. Legally, you have up to 30 days to do so in writing, but there are exceptions if you miss this deadline

Claim Filing: You have up to two years from the date of your accident to submit a claim to the NY Workers’ Compensation Board

Insurance Company Response: Upon learning about the claim, the insurance company begins their investigation. Strict regulations dictate their response time and the consequences of any delay.

Workers’ Compensation Board Administrative Process:

The initial phase of the claim is often amicable, but disputes may arise once the initial cordiality fades. If there is a dispute about getting lost wages (such as how much you are being paid) or obtaining medical care (getting authorization for tests and surgery) then the injured worker turns to the Workers’ Compensation Board and asks for a hearing before a Workers’ Compensation Law Judge. Unfortunately, even the Workers’ Compensation Board makes it difficult for you to get what you need and has many ‘bureaucratic’ roadblocks.

Consider these examples:

1. An injured worker awaiting treatment: 

A retail worker has injured her knee and is awaiting an MRI scan. Despite her doctor’s recommendation, the insurance company seeks a second opinion that denies the need for the test. The worker or her attorney must request a hearing before the WCB, which could take months.

2. An injured worker returning to work:

If the same worker recovers and resumes work after six weeks, the system will assess whether her injury is ‘permanent’ one year post-accident. If the medical opinions differ, a negotiation or a court hearing may ensue.

3. An injured worker unable to return to work:

In some unfortunate cases, a worker might suffer a permanent injury that prevents him from returning to work. Once the doctors declare that the worker has reached “Maximum Medical Improvement” (MMI), several legal steps determine the extent of the permanent injury and the corresponding future lost wages.

4. An injured worker’s doctor requests a specific type of treatment

The Workers’ Compensation Board requires ALL doctors to use the electronic medical portal to request various courses of treatment from physical therapy to medication. There is a strict and confusing process that the doctor must follow and the injured worker cannot even get a hearing before a Judge until the doctor finishes the process. A process that could take weeks or months! 

Navigating the New York workers’ compensation system can be complex, but understanding the process and its key players can empower you on your journey from injury to recovery.

Medical Care and Medical Treatment – Getting the Medical Care You Need

You might think that getting medical care after a work-related injury is simple. Unfortunately, it’s not always straightforward.

Imagine you’re sitting in my office, telling me about your work injury. One of the first things I’ll ask is if you’ve received medical treatment. Many people delay getting treatment, but without a doctor verifying your injury is work-related, your claim could stall.

You’d think getting the care you need would be easy – I’m hurt, I need treatment. But in the world of workers’ compensation, it’s not that simple. 

Medical care in workers’ compensation is strictly controlled and can be limited. It often seems more about saving insurance companies money than helping injured workers get better.

There are guidelines written by the workers’ compensation board that doctors use to treat you. These guidelines can be complex, running into thousands of pages, and may not always line up with the best treatment your doctor recommends. So, it’s essential to find a doctor who knows these guidelines well.

For instance, if you hurt your lower back lifting a box, the guidelines allow for treatment and physical therapy at first. But once you hit a limit (usually 12-18 sessions), there are strict rules about how your doctor must ask for more treatment, provide proof of improvement, and more.

There are some key terms you’ll hear:

Medical Treatment Guidelines – these refer to specific body areas you might hurt and need treatment for (e.g., Back, Neck, Head, Carpal Tunnel, Shoulder).

Prior Authorization Request (variances/drug formulary) – this is when a doctor asks for certain treatments, surgeries, therapies, or medications that need approval beforehand. 

Prima Facie Medical Evidence – a basic medical report from a doctor that states you had a work injury and diagnoses a specific condition related to your work. 

Degree of Disability/Impairment – a measure of how your medical condition affects your ability to work.

Maximum Medical Improvement – the point when a doctor believes you won’t get any better or worse. 

Permanency – once you reach maximum medical improvement, doctors must provide more evidence about whether your condition is permanent.

All of these medical issues significantly impact the benefits you can receive and the money you’re entitled to.

Here are three steps to get the medical care you need:

Step 1 Find a doctor who knows how to fill out the necessary forms and request the benefits you need. They need to be approved by the Workers’ Compensation Board to treat injured workers (except in emergencies).

Step 2 If you’re not working due to your injury, see your doctor every 6 to 12 weeks to determine if you have an ongoing medical disability. If you don’t get medical treatment but don’t return to work, you could lose your benefits.

Step 3 Ask questions so you understand your situation. If you have a lawyer, you can better communicate with them about your case. Remember, doctors don’t know everything – you need to take charge of your care!

Settling Your New York Workers’ Compensation Claim

When you’re stuck in a legal process or need a lawyer, it’s normal to wonder, “What’s the benefit? Why am I doing this?” Besides getting medical help and some money for missed work, is there anything else you can get?

Good question. Well, it depends. Workers’ compensation insurance is meant to help you get better and get back to work by covering medical bills and giving you some money when you can’t work. But, what if your injury lasts forever or stops you from working again?

At this point, we need to look at the details (like what part of your body is injured, how long you couldn’t work, how old you are, etc.) to see what kind of ‘settlement’ you might get.

Here are some common settlements in New York Workers’ Compensation claims:

1. Permanent Partial Disability (PPD) – If you can’t go back to work, you might be labeled as having a permanent partial disability. The Workers’ Compensation Board will see how bad your injury is and will give you money for a certain number of weeks based on that. After that, you’ll only get money for medical care.

For example, if they say you have lost 15% of your ability to earn money, you’ll get extra money for 225 weeks. But, there are exceptions!

2. Scheduled Loss of Use – This is a common way to get extra money. There’s actually a list of body parts and how much money they’re worth.

For example, if you lose 10% use of your right arm, that’s equal to 31.2 weeks of money (312 x 10%). If you get $800 a week, you’ll receive 31.2 weeks x $800 = $24,960 minus any money you already got.

3. Section 32 Waiver Agreement – This part of the Workers’ Compensation law lets you and the insurance company agree on a settlement. The Workers’ Compensation Board has to approve it. This is often used if your case could become a PPD case or if there are disagreements in the case.

For example, a carpenter was supposed to get $35,000 a year for at least 7 more years and had a chance of needing more back surgery. Considering his age and these details, the insurance company agreed to a one-time payment of $175,000 plus $22,000 for future treatment, totaling $197,000. This was on top of what he already received.

Remember, what you can get depends on a lot of things. If you’re injured at work, it’s smart to watch your money, know that you might not get as much as you hope, and understand that many details affect what you end up with.