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Accident 1/1/12

It all starts with an accident and a claim for benefits

Now what do you do: Investigate* and timely respond.

*Most investigations are similar and include a three point contact:- Contact the claimant as to how the accident happened- Contact the employer as to how the accident happened and- Contact the doctor as to the claimant’s medical status

Once you have properly investigated the claim, and assuming you have coverage for the employer, you must respond timely to the claim. Think like a traffic signal!

Yellow- Take Caution and Investigate! Obtain form C-250 (payroll) and C-11 (lost time) from the employer.

Red- Stop! Controvert the claim with form C-7 *Since the Board has a new process for objecting to claims called the “Rocket Docket” it is best to have your law firm assist you with all the paperwork necessary to properly file the C-7 form. You or the attorney must certify that the controversy is a proper one before you can proceed.

Green- Go! Accept the claim with form C-669

File form C-7Accident 1/1/12

You must file the C-7 on or before the 18th day after disability or within 10 days after employer had knowledge of injury, whichever is greater, or if the first notice of the accident/illness is a notice of indexing. In that instance it is to be filed within 25 days of the indexing date listed on the notice.

TIME LINE-NO RESTRICTIONS MODE



If you accept the claim you must file a C-669. IF PAYMENT HAS BEGUN: on or before 18th day after disability, or within 10 days after employer first had knowledge of injury, whichever is greater.

IF PAYMENT HAS NOT BEGUN: no later than 25 days after the Board issues the Notice of Indexing. However on or before 18th day of disability is customary.



How do I begin payments?

Payments are made based upon medical evidence of disability.If there is no medical evidence of disability, even if the claimant is loosing time from work, no payments should be made.

If the only evidence of disability is the claimant's medical, stating a total disability, then you would pay at a total disability rate. In New York, we pay based upon medical evidence of the degree of disability. *Form C-4 is the medical report from the claimant’s Doctor.

Degrees of Disability

Moderate Disability = 50% of the rate which = $300.00

The Workers Compensation rate is two thirds of the claimant’s AWW (subject to a maximum rate that changes July first of every year). Thus, for our accident date of 1/1/12 the maximum rate that could apply is $772.96. If, for example, the AWW is $900.00 then the Total rate would be $600.00 (as this is 2/3’s of the claimant's AWW and is not above the maximum $772.96).

The medical Dr.’s determine the degree of disability and we pay at the corresponding rate.

No Disability = 0% of the rate which = $0.00

Marked Disability = 75% of the rate which = $450.00Total Disability = 100% of the rate which = $600.00

Mild Disability = 25% of the rate which = $150.00



How do I begin payments?

We would look at the evidence of disability and make our payments at the corresponding rate every two weeks covering a two week period.

The current evidence is Total Disability so we would pay at $600.00 = 100% of the rate.

Clt.’s Dr. filed C-4 = total

First Payment

of $600.00

Second Payment

of $600.00



Clt.’s Dr. filed C-4 = total

First Payment

of $600.00

Second Payment

of $600.00

After paying at the Maximum rate for a period of time, it is proper to be concerned that he claimant has not medically improved or returned to work.What do you do?

Obtain your own evidence of disability.Request an Independent Medical Exam (IME).

Accident 1/1/12


Clt.’s Dr. filed C-4 of total

First Payment

of $600.00

Second Payment

of $600.00

IME filed a report = moderate

Upon the receipt of the IME giving moderate disability you reduce benefits (no restrictions mode) to the corresponding moderate rate of $300.00 and file your C-8/8.6

Payment of $300.00

Accident 1/1/12


File your C-8\8.6

Ct.’s Dr. filed C-4 =

total

Payment of $300.00

Payment of $300.00

You must file your C-8/8.6 within 16 days after the date on which benefit payments were stopped or modified (reduced).

Accident 1/1/12


File your C-8\8.6


total

Payment of $300.00

Payment of $300.00

After paying at the Moderate rate for a period of time it is proper to be concerned that the claimant has not medically improved or returned to work.

What do you do?

Once again, obtain your own evidence of disability. Request an IME.

Accident 1/1/12


IME filed a report = mild

Payment of

$150.00

Upon the receipt of the IME giving mild disability you reduce benefits (no restrictions mode) to the corresponding mild rate of $150.00 and file your C-8/8.6.

File your C-

8/8.6

Payment of

$150.00RAF-1

Accident 1/1/12


IME filed a report = mild

Payment of

$150.00

File your C-

8/8.6

Payment of

$150.00RAF-1

Claimants will react to the reduction in benefits by requesting a hearing (RFA-1) if they have not returned to work. Their position will be that they are totally disabled and the carrier has unfairly reduced them to a mild disability.

Accident 1/1/12

TIME LINE- RESTRICTIONS MODE

Once you reach the Board for a hearing usually one of two things happens. You either work out a rate or you set the case down for trial.

*Early in a case you usually work out a rate rather than the expense of a trial.

Accident 1/1/12


In our case the claimant’s attorney will argue for a $600.00 rate as found by their Doctor. We will argue for the $150.00 rate as found by our IME. For this example, assume we agreed to a temporary $300.00 benefit rate. The Judge will issue a decision stating that the Carrier must Continue Payments (CCP) at the agreed to $300.00 rate. The award must be paid within 10 calendar days of the date the decision was duly filed.

Payment of $150.00

Law Judge decision

Payment of $300.00

Accident 1/1/12


Payment of $300.00


total

Payment of $300.00

You are concerned that the claimant still has not returned to work and still is not improving medically. So, you obtain another IME.

Accident 1/1/12


Payment of $300.00

IME filed a report=No disability

Payment of $300.00

Now you must request a hearing (RFA-2).

RFA-2

Accident 1/1/12


Payment of $300.00

Payment of $300.00

Now that we are in front of the Judge a second time, we are much less likely to compromise. The Claimant's attorney will argue for a $600.00 rate based upon their medical of total and we will argue for no payments based upon our IME of no disability. We will insist on a suspension of benefits awaiting the outcome of a trial on the issue of no disability vs. total disability.

No Payments

Accident 1/1/12


Trials are usually performed by depositions of the doctors. Then the transcripts and written and oral summations are submitted to the law Judge. Sometimes disputes are not medical but factual so there may be employer witness testimony which is usually conducted before the Law Judge.

Accident 1/1/12


After the evidence is submitted to the law Judge a decision is rendered. You can appeal the decision if you file your appeal within 30 calendar days of the date the decision was duly filed.

Decision of the law

judge

Decision of $150.00

Payment of $150.00

Payment of $150.00

Accident 1/1/12


Decision of the law

judge

Decision of $150.00

Payment of $150.00

Payment of $150.00

The process begins all over again if you remain concerned with the continuing rate.

Accident 1/1/12


Settlement Payment of $150.00 MMI Payment

of $150.00

At any time you can settle the case. The settlement must be on Board form S-32 and must be approved by the Board.

Eventually you will attempt to obtain a finding of Maximum Medical Improvement (MMI). This is a medical finding by your IME or even by the claimant’s doctor that the claimant has permanency and active treatment is not necessary.

Accident 1/1/12


MMI

Once MMI has been found a case can go in the direction of either a Permanent Partial Disability (PPD) or Permanent Total Disability (PTD) upon Classification or a permanent partial disability with a Schedule Loss of Use (SLU) finding.

Classification

SLU

Accident 1/1/12


Classification

A Classification case is for cases where the injury is to the trunk of the body or head and is not a cite of injury covered under the SLU statute. The benefit culminates with a payment, if the claimant is not working, based upon the claimant’s loss of wage earning capacity (physical and vocational factors). This benefit is limited in duration ( 225-525 weeks) if the claimant is PPD but is lifetime if the claimant is a PTD.

Accident 1/1/12


SLU

SLU is for injuries to the extremities for example: toes, feet, legs, fingers, hands, arms, hearing, vision and facial disfigurement. Payment ends with one final payment based upon the degree of loss of function (medical evidence) of the body part. Payment is made even if the claimant is working.

Please review our power point on the disability guidelines and the treatment guidelines for a more comprehensive look at defending your workers compensation claims.

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Self Improvement