Under the New York State Workers’ Compensation Board’s Medical Treatment Guidelines a physician must file form C-4AUTH if a recommended surgical procedure is not consistent with the Board’s Medical Treatment Guidelines.

In the vast majority of cases, form C-4AUTH is denied by the insurance carrier. However, many times the carrier has not properly filed their denial.

First, the carrier must approve or deny the requested procedure within 30 days of receipt of the request. This is done by simple checking off the “Granted” or “Denied” box on the C-4AUTH form. In most instances, the insurance carrier will formally deny the procedure within the 30-day timeframe. However, Board Rule 300.23(d) requires that within 5 days after this denial the carrier must file for C-8.1 Part A and attach thereto a medical report demonstrating its basis for denial. This is where many insurance carriers fail to comply with the rules. They don’t file for C-8.1A within 5 days and/or fail to attach a conflicting 2nd opinion. This failure will render their denial defective.

If your physician has requested approval for surgery and it has been denied, make sure that you determine whether or not the denial was properly filed. If not, your surgery may automatically be approved.

Form C-4.3, created by the Workers’ Compensation Board in January 2012, represents somewhat drastic changes in the way that physicians document permanent impairments in New York State Workers’ Compensation claims.

The new form has been modified to accommodate the 2012 permanency guidelines.

In classifiable cases the physician must document whether or not maximum medical improvement has been reached and specifically identify the function capacities and exertional abilities of the patient. Section F of the form requires the doctor to quantify the limitations caused by the injury in 15 different categories such as lifting, kneeling, and driving a vehicle.

Physicians are also required to document the body part affected by the injury, impairment table reference, and severity ranking.

Without question, a physician who properly completes the form will spend a significant period of time doing so. However, if the form is completed in its entirety the physician will be entitled to payment under level 5 consultation code in order to compensate the professional for his or her efforts.

If you have been injured in a work related accident in the Albany, NY area and believe that you have suffered a permanent impairment, please feel free to contact our firm.

If you have received a notice to attend a Workers’ Compensation hearing in New York State it is important to take action. There are many reasons that the Workers’ Compensation Board has scheduled a hearing. They can involve suspension of benefits, permanency awards, or disputes regarding your medical care.

If you are not sure why a hearing has been scheduled it is probably time to have an attorney review your case. Failing to appear at a hearing could result in adverse findings. There are circumstances where you may not have to appear at your hearing, if you are represented by counsel.

If you received a hearing notice and would like to find out what is means to you, feel free to contact our firm for a free consultation.

Before the implementation of the Medical Treatment Guidelines, patients in New York State Workers’ Compensation cases were often afforded lumbar fusion surgery. However, since the Guidelines became effective, it is much more difficult to get lumbar fusion surgery approved.

Under A.14 a lumbar fusion is listed as one of the specific medical procedures requiring pre-authorization. Unfortunately, most insurance carriers will deny authorization for lumbar fusion surgery and will secure a medical opinion from their paid consultant. That opinion usually recommends against the surgery and begins a spiral of litigation.

Following the litigation process, which can take anywhere from two to nine months, or longer, an Administrative Law Judge will make a ruling as to whether the fusion surgery must be covered or not. The litigation process often includes deposition testimony from the requesting physician as well as the independent medical examiner.

If you need a lumbar fusion as a result of a work related injury and are not sure what steps to take, feel free to contact our firm.

Insurance adjusters love unrepresented claimants. This is because they know more than you do. They may lead you to believe that your case is worthless and offer you a nuisance value settlement. You should never accept their first offer.

In many cases, the injuries are not severe enough to warrant a significant settlement. However, you should be sure to allow enough time to lapse in order to make sure that a more significant injury does not develop.

In our office, we cannot take every case but we are always happy to explain our assessment of the value of your case. There is usually more money after the insurance company makes their initial offer to you.

Having practiced Workers’ Compensation Law for 20 years, one of the most common questions a client will ask me once they receive a notice to appear at a hearing is whether or not they will have to talk. The answer to that question depends on why the hearing has been scheduled.

Obviously, an unrepresented claimant would have to do all of the talking with the presiding Law Judge and the insurance company’s attorney.

Some hearings are scheduled for testimony to be taken from the claimant, lay witnesses, or even medical experts. If the case is scheduled for testimony, the claimant will be questioned in detail regarding the circumstances surrounding the issue at hand.

If the case is not scheduled for testimony, the claimant will likely not have to speak at the hearing. Instead his or her attorney will do most, if not all, of the talking.

It is our practice to meet with clients before their hearing in order to fully prepare them for what to expect at the hearing.

If you are 55 years old or older and have been denied Social Security Disability benefits, there is a good chance that you may win your case on appeal. This is because special rules apply to claimant’s 55 years old and older.

If you are unable to perform the type of work that you have done during the past 15 years, have a limited education level and can only do light or desk work, it will be presumed that you will not be able to learn a different type of work. This is a significant presumption.

If you are age 55 or older and received a denial from Social Security, do not be discouraged. You should have your case evaluated by a Social Security Disability Attorney.

For claimants, older cases can be transferred from the liable insurance carrier to a State agency known as the Special Funds Conservation Committee. Section 25A of the Workers’ Compensation Law outlines which cases may be transferred and under what circumstances this may occur.

Many times a claimant will receive a notice for a hearing many years after the injury has become inactive. The notice of hearing may indicate “Question of Section 25 liability.” In such circumstances, it is advisable for the claimant to appear at the hearing although the findings will usually not have any direct impact on the claimant’s entitlement to benefits. Instead, the hearing will usually revolve around whether the insurance company retains liability or the case is transferred to the Special Funds Conservation Committee for handling.

If you have questions regarding your New York State Workers’ Compensation claim, feel free to contact our office.

Spoliation is the destruction of evidence so that it will not be available to a person during a lawsuit. Spoliation is most common in medical malpractice cases because in these cases the evidence that is most useful to the patient is in the possession of the doctor, that is a patient who wants to sue a doctor for negligence must use the medical records written by the doctor they are suing. It is very easy for a doctor to either destroy or alter these records before turning them over to a patient.

Currently in New York one cannot sue a person who destroys evidence and there is a lot of debate in the legal community as to whether or not this is right. There is some relief for people who are the victims of spoliation. Generally at trial if evidence is not available because it has been destroyed, the Judge will instruct the jury to assume that the destroyed evidence would have worked against the case of the person who destroyed the evidence.

In most Social Security claims, the crucial issue in granting or denying benefits involves how severally your medical or psychological conditions affect your ability to function in a work place.

In our opinion, the best way to secure specific information regarding exactly how you have been affected by your disability is to have your doctor or psychiatrist complete what is known as a medical source statement. This is a very useful form completed by the health care provider that specifically states what he or she believes your functional capacity is.

Unfortunately, many doctors are not willing to complete this information on your behalf. In those circumstances it is even more important that you provide specific examples of how your medical or psychological conditions affect your life on a day-to-day basis. At the time of each evaluation, be sure to tell your doctor exactly which types of activities you are having difficulty performing or dealing with. This way the doctor may reference these situations in his reports which can be extremely beneficial to your Social Security claim.

If you have questions regarding your Social Security Disability matter, please feel free to contact our firm.

Alexa Site Info