Treatment Authorization Requests: Ensuring Proper Compliance with 12 NYCRR 325-1.4

Workers’ Compensation Law Section 13 establishes the obligation of the employer to “promptly provide for an injured employee such medical surgical, optometric or other attendance or treatment… for such period as the nature of the injury or the process of recovery may require.”

When requesting authorization for treatment, the provider submits a Board form titled, “Attending Doctor’s Request for Authorization and Insurer’s Response.”  The Board code for the form is shortened to C-4AUTH. Unlike a variance request, a request for authorization in a C-4AUTH is …

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How To Ensure Your IME is Compliant with Section 137

In order for an Independent Medical Examination (IME) report to be compliant with Section 137 of the Workers’ Compensation Law, a copy of each report must be submitted by the practitioner on the same day and to the Board, the insurance carrier, the claimant’s attending physician or practitioner, the claimant’s representatives, and the claimant themselves in the same manner (WCL Section 137(1)(a)). “If a practitioner who has performed or will be performing an independent medical examination of a claimant receives a request for …

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Concurrent Employment – Limiting and Litigating Average Weekly Wage

Claimants may have more than one job at the time of their work incident. Pursuant to New York Workers’ Compensation Law Section 14(6), the average weekly wage can be increased if the claimant has two or more jobs at the time of the work injury. Therefore, this issue of concurrent employment is raised by a claimant, and not a carrier, because it can mean more indemnity benefits to the claimant. When concurrent employment is raised, the claimant should provide written documentary proof of concurrent employment, …

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New Attachment for Schedule Loss of Use Stipulations

There are two types of permanency evaluations:

  1. Schedule awards for the impairment of extremities, vision loss, hearing loss, or facial disfigurement
  2. Non-schedule classification as a permanent partial or total disability.

On October 4, 2019, in subject number 046-1211, the Board issued specific circumstances where a new attachment must be used when stipulating to schedule loss of use and non-schedule sites are also involved.

The new stipulation must be used in three situations:

  1. When there is no medical report from either party regarding the established non-schedule
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A Quick Guide on How to Navigate Claims That Occur Outside of North Carolina

Whether the North Carolina Industrial Commission has jurisdiction to adjudicate a workers’ compensation claim can be critical to a claim’s defense. A scenario where this issue commonly arises is when an employee is injured outside of the state of North Carolina, yet chooses to file a North Carolina claim.

N.C. Gen. Stat. Section 97-36 is the statute governing the North Carolina Industrial Commission’s jurisdiction over claims arising from accidents occurring outside of the state. Of particular importance, the North Carolina Court of Appeals has held …

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When Does an Injury at Work Actually Arise Out of Employment in New Jersey?

For a work-related injury to arise out of employment, there must be a causal relationship between the employee’s injury and their employment. Simple concept, right? Well, maybe not. Consider the following hypothetical scenarios:

  • A worker faints while sitting at their desk
  • A worker is walking and, for no explicit reason, their lower back locks
  • A worker suffers a stroke while making coffee in the office kitchen

The above scenarios are all unlikely to have risen out of employment within purview of the court. Why? It …

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You Down With 13(d)? Yeah, You Know Me: Responding to Health Insurer Reimbursement Requests

Occasionally, when a workers’ compensation claim is initiated, medical bills are paid by the claimant’s private health insurance. If this happens, you may receive correspondence from the health insurer asking for reimbursement. What should you do in that situation?

The short answer is that you have no obligation to respond to a direct demand for reimbursement. However, there is a process for reimbursement. This is where the Health Insurer Match Program (HIMP) comes into play.

Per the Board, “health insurers may submit information regarding payments …

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Using Labor Market Surveys to Rebut Disability

An issue that is frequently encountered in workers’ compensation claims is whether a claimant can prove disability — i.e., whether the claimant can show that they are incapable of earning their pre-injury wages at the same or any other employment as a result of their work-related injury.

One tool that employers can use to rebut evidence of disability is a labor market survey prepared by a vocational rehabilitation expert. To enhance their evidentiary value, labor market surveys should be specifically tailored to the claimant’s individual …

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Candy Cane Catastrophe: A Brief Look at Workers’ Compensation Defenses in New Jersey

With the holidays quickly approaching, it is important to keep in mind a number of issues that may arise when co-workers gather to celebrate. Many employers host year-end holiday parties to recognize another year gone by and to celebrate the many successes of the company. In the unfortunate event that an employee is injured during the most wonderful time of the year, it is important to remember the guiding principle of workers’ compensation: the employer is responsible for an injury that occurs in the course …

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Incarceration Upon Conviction of a Felony and its Effects on Attachment to the Labor Market

Attachment to the labor market is an important issue among employers and carriers. By pushing this issue, we can attempt to reduce indemnity costs and aid in the claimant’s return to work. Generally, a claimant who is temporarily partially disabled must show that he or she is attached to the labor market to be entitled to workers’ compensation benefits. The claimant need only seek employment within his or her restrictions, provided by the treating physician, and for a position for which he or she is …

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