New York created the Workers’ Compensation Law in 1914 as a compromise between workers and employers.  As part of the compromise, workers gave up the right to sue the employers for negligence that caused an injury.  In return, workers were promised payment for lost wages and medical bills for work-related injuries, without regard to fault.  An injured worker’s entitlement to compensation and the amount of compensation are the same, regardless of whether the accident was the fault of the worker, the employer or someone else.

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WHAT IS COVERED...

To receive workers’ compensation benefits, a worker must prove that they were involved in an accident while they were working and because of the work, that the employer was notified, and that the accident caused or contributed to an injury.  The legal definitions of what “working” and “because of the work” are very broad, and protect workers when they are on, entering or leaving the employer’s property, and sometimes when they are traveling.  The employer must usually be notified within 30 days of the accident, unless the late notice is excused by the Workers’ Compensation Board.  A separate claim must also be filed with the Workers’ Compensation Board within two years of the accident.  

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Occupational diseases are also covered by workers’ compensation.  An occupational disease is a condition that develops over a period of time because of the type of work a person does.  For example, a person who performs a data entry job may develop a problem with their hands or wrists.  If a doctor feels that the cause of the problem is the person’s job, involving repetitive use of the hands, this may qualify as an occupational disease under the law.

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AMOUNT OF WORKERS’ COMPENSATION...

The amount of compensation that an injured worker receives while out of work depends on three things.  One is their average weekly wage, which is how much the person earned while working for that employer in the 52 weeks before the accident.  In general, the most that a worker can receive in workers’ compensation is two-thirds of their average weekly wage up to the maximum compensation rate for the date of accident. 

The second factor is the date of the accident.  The maximum weekly benefit range changes on July 1 of each year and applies to accidents that occur between July 1 and June 30 of that year.  Over the years the maximum weekly benefit rate has steadily increased and is now over $1,100 per week.

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The third factor that plays a role in how much a person is paid by workers’ compensation is their “degree of disability.”  A person may be either totally or partially disabled. Total disability is an inability to do any work of any kind.  Partial disability means that a person can do some type of work, even if they cannot do the type of work they were doing at the time of the accident. 

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A worker who is partially disabled may receive compensation in an amount less than the maximum rate.  There are different degrees of partial disability, and the precise rate a person receives depends on their degree of their disability.  There are also time limitations that apply to temporary disability and permanent partial disability.  How these time limits apply in any particular case can be a complicated question and depend on when the worker reached “maximum medical improvement” and the type and degree of their permanent disability.

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MEDICAL TREATMENT…

Once a compensation case is accepted by the insurance company or established by the Workers’ Compensation Board, medical expenses related to the case are covered.  Only medical providers who are coded by the Board may treat compensation patients.  This includes doctors, chiropractors, nurse practitioners, physician’s assistants, physical therapists, psychologists, social workers, and others.  Medical providers are not allowed to bill a compensation patient directly but must send their bills and reports to the insurance company and the Board.  If there is a dispute regarding a medical bill, the insurance company must file a form with the Board advising it of the dispute.  The bill will then be addressed by the Board.

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Most medical treatment in the workers’ compensation system is covered by the Workers’ Compensation Board’s Medical Treatment Guidelines.  The Guidelines pre-approve many tests and treatments, but limit others.  In most cases, even if a test is approved under the Guidelines, the insurance company can require you to use a facility they choose to have the test performed.  The Board has created a “Medical Portal” through which health care providers can submit requests for authorization of specific kinds of treatment and prescription medication.  There is a three-step process in the Portal that providers must usually complete before a hearing can be requested to address a medical dispute.

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WHAT A WORKERS’ COMPENSATION CLIENT SHOULD DO...

–  If your disability prevents you from working, you must see a doctor at least once every three months.  The doctor must then file medical reports certifying that you are disabled.  The insurance company does not have to pay you for any time period in which you do not have medical proof of disability.

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–  You should keep track of your out-of-pocket expenses.  You are entitled to be reimbursed for mileage for travel to and from doctors, therapists, etc, as well as for items like bandages.

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–   If your injury involves an arm, leg, hand, foot, fingers, toes, hearing loss, vision loss, or facial scar you may be entitled to a money award even if you do not miss time from work.  It is unlikely that either the insurance company or the Workers’ Compensation Board will take steps to make sure that you receive your award.  You should consult Grey & Grey to make certain that you receive your proper award.

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–   If you return to work after an accident and you are making less money due to your disability, you must continue to see the doctor on a regular basis and you must keep a careful record of your earnings.  You should keep all of your pay stubs in an envelope and make extra copies of your tax documents.  You may be entitled to workers’ compensation benefits for the loss of earnings.

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–  HOWEVER, YOU MUST NOTIFY THE INSURANCE COMPANY AND GREY & GREY IF YOU RETURN TO ANY KIND OF WORK FOR ANY PERIOD OF TIME AFTER AN ACCIDENT.  FAILURE TO REPORT WORK WHILE COLLECTING WORKERS’ COMPENSATION BENEFITS IS ILLEGAL AND MAY RESULT IN LOSS OF WORKERS’ COMPENSATION BENEFITS AND CRIMINAL PROSECUTION.

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– Insurance companies often send out questionnaires, rehabilitation nurses, and investigators to ask questions and interfere with medical treatment.  You may fill out these questionnaires and speak to these individuals only to confirm your address and your work status.  You should tell them that you are represented by Grey & Grey and to contact our office if they want any other information.  (We will probably tell them that they are not entitled to any other information).

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– Whenever the Workers’ Compensation Board schedules a hearing in your case you must make sure to have current medical evidence for the hearing.

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–  If you are out of work for more than six months, you should call our office to find out if you are eligible for Social Security Disability benefits.

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– If your doctor feels you can do some work, even if you cannot return to your own job, you must look for work to protect your compensation benefits.  The best way to do this is to call ACCES-VR for retraining or go to a One-Stop Career Center operated by the Department of Labor.

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WHAT GREY & GREY DOES...

 –  We will provide you with all the forms you need to file your claim, and we will file the claim for you after the paperwork is complete.

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–  The insurance company is not defenseless.  It can and often will arrange examinations with medical consultants to obtain opinions about whether you are disabled or need medical treatment.  After such an exam, you may be notified that your payments have been suspended or reduced or that the insurance company is denying further medical treatment.  If you let us know that this is happening, we will request a hearing for you.

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–  When the Compensation Board schedules a hearing in your case, we will appear on your behalf and present your claim to the Judge.  You should also be present in case questions come up that we need you to answer.

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–  Not all problems can be resolved at a regular hearing.  Sometimes a trial or deposition testimony is needed from you, the doctors, or other witnesses.  If a trial is necessary, we will try your case to the best of our ability and take whatever testimony is needed to help you win your case.

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–  We want to obtain the best possible result for you in your workers’ compensation claim.  We will track your claim from beginning to end, explain your rights under the law and what is needed to win your case, and work with you to get the necessary documents or evidence.  Our goal is for you to receive the benefits to which you are entitled.

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For more information, contact us.