This article provides a general overview of how traumatic, specific accident claims are generally handled.
At the time of the accident:
First, the worker gets medical treatment and notifies her supervisor about the accident and how it occurred.
The employee notifies the employer of the accident in writing, as soon as possible, but within 30 days. The Board may excuse the lack of notice if notice could not be given (for example: the claimant was taken to the hospital and could not inform her employer), the employer had knowledge, or if the employer is not harmed by lack of notice. WCL § 18.
The employee may file a claim with the Board by filing a Form C-3. This must be done within two years of the accident or within two years after the employee knew, or should have known, that the injury was related to employment. WCL § 28.
Within 48 hours of the first medical treatment:
The doctor completes a preliminary medical report on a Form C-4 and mails it to the appropriate District Office. Copies of the Form C-4 must also be sent to the employer or its insurance carrier, the injured worker, and her representative (if any). WCL § 13-(a)(4)(a).
Within 10 days of the accident:
The employer or its third party designee reports the injury to the Board and the insurance company with a Form C-2F. WCL § 110 (2).
Within 14 days of receipt of Form C-2F:
The insurer provides the injured worker with a written statement of his/her rights under the law (Form C-430S). This must be done within 14 days after receipt of the C-2F from the employer or with the first check, whichever is earlier. WCL § 110 (2). If the insurer requires the injured worker to use a provider within a network for diagnostic tests, it must provide the injured worker with the name and contact information for the network. WCL § 13-a(7)(b).
Within 15 days of initial treatment:
The doctor completes a 15-day report of the injury and treatment on a Form C-4 and mails it to the District Office of the WCB. WCL § 13-a(4)(a).
Within 18 days after the first day of disability, or 10 days after the employer first has knowledge of the alleged accident, or within 10 days after the carrier receives the Form C-2F:
The insurer begins the payment of benefits if lost time exceeds seven days. If the claim is being disputed, the insurer must inform the Workers’ Compensation Board (and the claimant and his/her representative, if any) by filing an electronic data interchange form FROI-04. If the claim is not disputed, but payment is not being made for specific reasons stated on the notice (e.g., that there is no lost time or that the duration of the disability is less than the 7-day waiting period), the insurer must also notify all of the parties. WCL § 25 (1) and 12 NYCRR § 300.22.
The insurer files a FROI-00 or FROI-04 with the Board indicating either that payment has begun or the reasons why payments are not being made. A copy of the FROI must be transmitted to the claimant and his/her attorney/licensed representative, if any, within one business day of the electronic filing with the Board.9 If the employee does not timely notify the employer, this notice may be filed within 10 days after the employer learns of the accident.
Now is the time to controvert!
A case may be disputed because:
- The employer alleges that proper notice was not timely given; or
- The claim was not properly filed; or
- A lack of causal connection is alleged between the alleged injury and the accident; or
- The employer-employee relationship is denied; or
- The accident is alleged not to have occurred at work; or
- Any other reason for denying the claim.
All of these grounds are discussed at length in my Handbook – See Chapter 2 (“Fighting Frivolous Claims”) and Chapter 5 (“Defenses”). A dispute will create an adversarial proceeding. The forum will be the Workers’ Compensation Board, and a Workers’ Compensation Law Judge will hear the dispute.
Timelines for denials.
As per Workers’ Compensation Law Section 25-2(a), a denial must be filed “on or before the eighteenth day after disability or within ten days after it has knowledge of the accident, whichever period is greater.” Failure to file a denial within this time period can result in a $300 penalty assessed against the carrier (but defenses are not stripped). Under Section 25-2(b), a denial may be filed “within 25 days from the date of mailing of a notice that the case has been indexed.” If the denial is not filed (by filing FROI-04 or SROI-04), then all defenses (substantive or legal) are barred.
In practice, the Board rarely assesses the $300 penalty for late filing under Section 25-2(a) and instead rigorously enforces the preclusionary Section 25-2(b).