Workers’ Compensation, or “Workers’ Comp”, is a form of insurance which provides injured workers with coverage needed for medical treatment (medical benefits) and lost wages (indemnity benefits) arising out of a work-related accident. These medical and lost wage benefits come directly out of an insurance policy which is paid for by the employer, and come at no cost to the employee. All Workers’ Comp cases in New York are handled by the Workers’ Compensation Board (WCB), an organization dedicated to overseeing such cases. A majority of our patients will have regular hearings at the WCB. Please note that when it comes to receiving Workers’ Comp benefits, fault is irrelevant (i.e. you do not have to prove that the injury was your employer’s fault to receive benefits).
- HISTORY (click to open content)
In the past, if an employee was injured at work, they were normally required to prove that the employer was at fault for the injury (i.e. they were negligent) and would have to have the issue resolved in a lawsuit. This was a costly and time-consuming process which usually meant that an injured worker either couldn’t receive necessary medical care, or had to pay for it out of their own pocket, until the worker could get money out of a lawsuit (if they won). In 1910, New York State enacted its first Workers’ Compensation law. This law started a practice which is still in use to this day – an employee can receive compensation regardless of whose fault the injury was, as long as the injury happened at work, while they were performing their regular work duties. This was advantageous to both employees and employers. Employees could receive benefits they needed rather quickly, without having to wait years for a lawsuit to finish. Employers benefited from this, because generally the benefits received through Workers’ Compensation would be much less than they may have had to pay out if they lost a lawsuit.
On March 24, 1911, the New York Court of Appeals rejected the law on the grounds that it was unconstitutional. The very next day, the worst industrial disaster of the 20th century occurred in the Triangle Shirtwaist Factory of New York. This incident took the lives of 146 workers (123 women and 23 men). The high death count was largely attributed to the fact that one of the two doors to the factory were locked from the inside as an effort to curb stealing of fabric and other materials. This kick-started New York’s Workers’ Compensation system as it made it clear that workers needed protection. Six years later (1917), the United States Supreme Court upheld New York’s Workers’ Compensation Law as constitutional. In the meantime, in 1914, the Workmen’s Compensation Commission was established to oversee Workers’ Compensation claims in New York State. In 1945, the Commission changed its name to the Workers’ Compensation Board, which is the name is uses to this day.
TERMS AND COMMON FORMS
The below list of terms and forms is by no means inclusive. It is a rundown of the more important information for a case.
- Workers’ Compensation Board
WCB – Workers’ Compensation Board. The state agency which oversees all Workers’ Comp claims in the state of New York. Most patients will have hearings regularly at the WCB to determine payments that are to be made by the insurance carrier to either the patient for lost wages or to their medical provider (doctor) for medical bills, along with any other outstanding issues that their case may have. For more information about the WCB as well as general Workers’ Compensation information, please visit their website at http://www.wcb.ny.gov/
- Insurance Carrier
This is the company that pays the injured worker any compensation they are entitled to, such as lost wages and medical costs. It is an insurance policy that the employer pays into.
- MTG – Medical Treatment Guidelines.
This is used as the standard of care for treatment of work-related injuries in the State of New York. They are a set of documents that clearly outline what forms of treatment are allowed for specific injuries, including the frequency and duration of treatment. The Guidelines are used as a standard for both medical providers to know what treatment they can provide and for Workers’ Compensation insurance carriers to know what treatments they must reimburse. There are currently only guidelines for: the knee, shoulder, neck, mid and low back, and Carpal Tunnel Syndrome. There are also guidelines for non-acute pain.
- Established Sites
These are parts of the body (e.g. arm, leg, neck) which the WCB determined sustained injuries as a result of the claimed work-related accident. These are parts that a medical provider is allowed to treat and they are also parts eligible for a Schedule Loss of Use or Classification.
Compare this to Accepted Sites: Accepted sites are those parts of the body which the insurance carrier voluntarily agreed to pay for the treatment of.
Occupational Disease – Work-related injuries arising not out of a specific incident or accident, but over time.
-Lung conditions as a result of working with asbestos.
-Carpal Tunnel Syndrome in the wrist as a result of repetitive typing.
-Shoulder injury as a result of repetitive heavy lifting.
- Controverted Case
A controverted case is one in which the insurance carrier is refusing to cover a Workers’ Comp claim. There are various reasons an insurance carrier may do this, such as: the accident was not reported on time, the employer did not have a policy with that insurance carrier at the time of the accident, the worker did not injure the body parts they claim to have injured, or the accident never happened, among other reasons. The insurance carrier usually indicates that it is controverting a case on form FROI. Normally, when a case is controverted, no payments will be made to either the patient or the doctors until the issue is resolved by the WCB. The WCB normally reviews the facts of the claim and decides whether the insurance company is actually supposed to cover the claim or not.
- FROI Form
First Report of Injury. This is the form filed by an insurance company (carrier) that indicates whether they will be covering a specific accident or if they are controverting the claim (please see definition of “Controverted Case”).
- C-3 Form
Employee Claim form. This is generally the form that will be used by employees to open a case with the WCB. The form can either be filled out by the employee (injured worker / patient), or by their legal representative, if they have one. An injured worker general has two years to file this form. In the case of an occupational disease, they have two years from the day they knew or should have known that their injuries were caused by their job duties.
- C-4 Form
Doctor’s Initial Report. This is the form that a medical provider (doctor) will have to fill out after the first time they see an injured worker (patient). It is used as a billing form for the first time a doctor sees the patient for a Workers’ Comp case. Aside from billing information, it includes information such as how and when the injury happened, what body parts were injured, and if the patient missed any work due to the injury. This is a very important form that will be used to try to prove that a worker/patient sustained injuries as a result of their accident.
- C-4.2 Form
Doctor’s Progress Report. This is the form that doctors use to bill anything after an initial visit (including follow-up visits as well as treatment such as physical therapy). Aside from billing information, this form contains data such as if the patient can currently work, if they are currently working, and if they have any work restrictions. A C-4.2 form should be submitted every 45 days, and no less frequently than every 90 days.
- C-4.3 Form
Doctor’s Report of MMI/Permanent Impairment. This is a form filed by a doctor stating that: a. The patient has reached MMI and b. The patient has a permanent impairment. A permanent impairment means that the patient’s problems will likely last for the rest of their lives. It is standard to wait a year after the accident or after the patient has had surgery to file such a form. However, the form may be filed as little as six (6) months from the date of accident or surgery. This form can also be used to state that a patient did not reach MMI if a judge orders a doctor to submit this form
- C-4.1 Form
Continuation To Carrier/Employer Billing Portion Of Forms C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4. This is not a standalone form and cannot be used on its own. It is used if there are too many treatment codes to fit on any of the other billing forms. It would be attached to these other forms.
Maximum Medical Improvement. It is a term that is used to indicate that a patient’s condition will not improve with any additional treatment (usually physical therapy). In other words, the patient has recovered as much as he or she will ever recover. MMI can be determined either by the patient’s treating doctor or by an IME doctor.
Independent Medical Examination. This is a medical examination performed by a doctor that has a relationship with the insurance carrier. They can either be an employee of the carrier or they may be under contract with them and paid per case. This is something akin to a second opinion. It is done to ensure that the treatment the patient’s doctor is providing or requesting is necessary. A majority of Workers’ Comp patients will be asked by the insurance carrier to undergo one or more IMEs. You must attend the IMEs or else your benefits may be cut off. The patient will normally be informed in writing that they must attend an IME. An IME doctor would state whether they believe a patient requires additional treatment or not. If your doctor states you need further treatment but the IME doctor states that you do not, the issue then needs to be resolved by the WCB (either at hearings or in a deposition).
This is a process in which attorneys from both sides (the patient and the insurance carrier) can ask the treating doctor and/or the IME doctor any questions they may have in regards to a patient’s treatment. It is a chance for the doctor to provide sworn testimony that will be used as evidence by both sides for the patient’s case. It can be done in a courtroom, but is usually done over the phone. A deposition is normally requested if there is a dispute in a case, such as the IME doctor stating no more treatment is necessary while we claim it is necessary, or if it is unclear how a particular body part was injured in the accident. Dr. Malakov provides excellent outcomes in his depositions, due to extensive preparation for each case.
- MG-2 Form
Attending Doctor’s Request For Approval Of Variance And Carrier’s Response. The Medical Treatment Guidelines allow for certain timeframes for physical therapy and other treatments. If a doctor wants to provide treatment past the time frames allotted in the MTG, they must file an MG-2 form. This is similar to prior authorization that is required for regular health insurance. The insurance carrier can deny or grant this treatment. If it is denied, the provider can request that the Workers’ Compensation Board review the denial.
- C-8.1 Form
Notice Of Treatment Issue(S)/Disputed Bill Issue(S). This is a form the insurance carrier files to deny a medical bill. The denial is then reviewed by the WCB.
- Section 32 Settlement Agreement
This is normally an agreement that closes a patient’s Workers’ Compensation claim. It is a settlement that is agreed upon by the patient (and/or their attorney) and the employer (and/or their insurance carrier). While part of the agreement is usually that the insurance carrier will no longer pay for any medical treatment (“closed medicals”), an agreement may be signed that includes continued medical care (“open medicals”). A lump-sum award may also be part of this agreement. The agreement may also allow for continued reimbursement of lost wages or other annuity instead of a lump sum award. The agreement is normally not final until it has been approved by the WCB.
Schedule Loss of Use. This is a lump sum award given to an injured worker if they sustain permanent damage to an extremity (e.g. arm, hand, leg, foot). It can also be given if the worker suffers permanent damage to their eyesight or hearing. The amount of the award is usually determined by the percentage of the disability that a doctor indicates on the C-4.3 form as well as the injured worker’s average weekly wage.
- Non-SLU (classification)
Non-schedule Loss of Use. A non-SLU is also known as a “classification.” This is similar to an SLU award in the sense that it is awarded to workers that sustain permanent injury to their body. It is also similar in the sense that it is determined by the information supplied on a C-4.3 from by a doctor as well as the worker’s wages. One of the differences is that it is awarded for permanent injuries to any part of the body other than extremity. The most common non-SLU award is for injuries to the spine (neck, low back, mid-back). However, it can also be awarded to injuries involving areas such as the pelvis, heart, lungs, and brain. The other main difference is that instead of a lump sum award like with an SLU, a non-SLU/classification award is usually paid out at set regular intervals (similar to the lost wages a worker can receive when they first open the claim).
- Uninsured Employers Fund
If an employer does not have Workers’ Compensation insurance, the injured worker can still receive Workers’ Comp benefits through this Fund. Payments from the fund are made by the No Insurance Unit (a division of the WCB). The WCB then normally fines the employer for not having proper coverage.
RELEVANT INFORMATION AND TIMEFRAMES
- 1RELEVANT INFORMATION AND TIMEFRAMES
-Injured workers have 30 days to report an accident to their employer in writing.
-Injured workers have two years to file a case with the Workers’ Compensation Board (WCB). This is done on a C-3 form. If it is an occupational disease case, the worker has two years from the day they knew, or should have known, that their injuries were a result of their job duties.
-If a patient cannot work due to their work-related accident, they will usually receive weekly cash benefits for lost wages in the amount of two-thirds of their weekly wage (but no more than the weekly maximum rate, which is $864.32 through June 30, 2017)
-A medical provider cannot bill a patient directly for a Workers’ Compensation claim except for a small set of specific instances. We frequently find that patients see that certain medical bills or requests for medical treatment are denied and fear that they will receive a bill from us. Rest assured that we are legally not allowed to bill you, the patient. The only instances we can go after the patient for unpaid bills is if: the Workers’ Compensation Board disallows a claim in its entirety; if a patient does not pursue the claim (they do not file the necessary paperwork, do not attend hearing, etc.); or if the patient settles their case.
-When it comes to receiving Workers’ Comp benefits, fault is irrelevant (i.e. you do not have to prove that the injury was your employer’s fault to receive benefits). For an accident to be covered by Workers’ Compensation, all that is required is that the incident happened “in and out of the course of employment.” In other words, the accident had to have happened while you were working and because you were working.
-If your employer does not have Workers’ Compensation insurance, you can still receive Workers’ Comp benefits through the Uninsured Employers Fund. You can even receive benefits even if you are an undocumented immigrant or get paid cash/off-the-books.
-While an attorney is not required, having one can often help to guide you through the process and make sure all forms are filed correctly. They are especially important if you have a complicated case and there is some disagreement between you and your insurance. They can also help ensure you receive the appropriate compensation. If your case ends up having hearings, the WCB will often advise you to seek legal representation. Please note that an attorney is not allowed to charge you directly. Their fee comes out of the compensation you may receive.
- 2STEPS TO TAKE AFTER BEING INJURED ON THE JOB
- Receive required medical treatment. Unless it is an emergency, the provider must be authorized by the WCB. All providers in Rego Rehab are WCB-authorized.
- Notify your employer/supervisor of the injury in writing.