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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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