Workers compensation insurance payments address lost wages and medical bills related to a work injury. Because the effects of that work injury can last a lifetime, so too can the associated benefits. The New York Workers Compensation Board outlines what is covered, what the payments will be, and the criteria for adjusting or ending benefits.
With that in mind, most of the time you will not be surprised by your benefits payment. But there are some cases in which injured workers in New York State will see workers compensation payments unexpectedly reduced or even halted before they feel they are ready to return to work. If you are caught off guard, you should know that you have the right to representation from an experienced workers compensation attorney.
The two ways you may see benefits be different than expected are if your initial claim was denied, or the insurer believes the ongoing benefit should be adjusted.
Denying an Initial Claim
Once you suffer a work-related injury and file a related report, the clock begins ticking for the insurer. After loss time exceeds seven days, the insurer must begin paying benefits. If the insurer chooses to contest a claim, they must do it within 18 days from the date of an accident, or 10 days from learning about the accident.
If your claim is disputed, the New York State Workers Compensation Board will attempt to resolve the issue internally. Failing that, a hearing before a workers comp law judge will determine what, if anything, will be paid.
A series of appeals are available to either side following the hearing, all the way up through the Appellate Division, Third Department, Supreme Court of the State of New York.
You have a right to legal representation of your choosing throughout the process. It should be noted that while you wait for benefit payments to begin, your attorney is not permitted to charge you for their services. Any legal fees charged must be approved by the Workers Compensation Board and will be deducted from your benefits payment.
Changing Ongoing Workers Compensation Payments
Once benefits are established, payment comes every two weeks and should not change without new information. But the law requires you to be examined every 45 days by a doctor, who reports on your recovery to the Workers Compensation Board.
Based on the doctor’s report, the insurer may determine that your benefits should change or that it will not pay for certain past or future medical treatment. If this happens, the insurer must file the appropriate forms with the Workers Compensation Board and share a copy with you or your representative.
There are various reasons why an insurer may decline to pay for future treatment. They include:
- Conflicting medical reports
- Your failure to attend an independent medical examination (IME)
- A medical appliance or program used in treatment is not covered by the worker’s comp law
- The treatment is not for your established condition
An IME can be requested by the insurance company and is with a doctor of their choosing. If you are requested to attend an IME, it’s advisable to contact the Paul Giannetti Law Firm to discuss your rights and options.
Insurers may also try to decline to pay for treatment already received. The insurer may cite any number of reasons, including:
- Prior authorization was not granted for treatment over $1,000
- Treatment was not causally related to the injury
- Provider was not authorized under the worker’s comp law
When an insurer declines to pay for treatment or seeks to adjust your workers compensation payments, you may appeal the decision via the same channels as if the initial claim had been denied.
Section 32 Agreement
Another way workers compensation payments can end is with a Section 32 agreement, but this won’t change your payments without notice. A Section 32 is a negotiated agreement that results in a lump sum or annuity in lieu of ongoing payments. You may be approached by your employer or insurer to negotiate this agreement, and the negotiations will not affect your ongoing payments.
If the New York State Workers Compensation Board accepts the agreement, the case is closed and no other claims can be made. A Section 32 agreement can cover only medical benefits, only indemnity, or both. Negotiating a Section 32 agreement is voluntary, and you should seek qualified representation to obtain the best settlement for you.
Contact my firm today for a free consultation so you can eliminate surprises and receive all the workers compensation benefits to which you are entitled.