The Players In A Workers’ Compensation Claim

Before we talk about how to file your claim, it is important to understand who the “players” are in the Workers’ Compensation system.

The Claimant

As the injured worker, you are referred to as “the claimant” in the system. As the claimant, you have the burden to prove your case. The evidence required is typically your testimony as to how the injury occurred or occupational disease arose, as well as medical evidence to support the link between your physical infirmity and your work. The medical evidence is also used to determine your degree of temporary and permanent impairment. Sometimes additional witness or physical evidence is also offered when proving the case.

Your Employer

Your Employer is obligated to carry Workers’ Compensation insurance. The Employer may also commence your claim by filing Form C-2. Sometimes, your Employer’s insurance company will initiate the claim after the Employer informs them of the injury or illness. Your Employer is also supposed to file various forms, so as to allow calculation of your Average Weekly Wage and an accurate account of your lost time.

The Carrier

Typically, an Employer purchases a policy of Workers’ Compensation insurance from an insurance company. The Insurance Company is referred to as “the Carrier.” Some large Employers are self-insured while others employ a third-party administrator to handle the day-to-day aspects of the Workers’ Compensation cases. Again, the third party administrator is often referred to as “the Carrier.”

The Carrier must meet certain deadlines as set forth in the statute regarding whether to accept or deny your case initially. Generally, the Carrier has 25 days from formal knowledge of the claim to make that determination. The Carrier will also administer the claim and make payments from beginning to end.

Medical Providers

Your medical providers include the treating doctors, chiropractors, physical therapists, physicians’ assistants, nurse practitioners, nurses, and those associated with them.

The medical providers play an essential role in your case. Not only do medical providers treat your injuries and facilitate your return to work, but the medical reports constitute the evidence in your case.

The New York Workers’ Compensation Board

The New York State Workers’ Compensation Board is a NYS agency charged with administering the claims that are made. The Board is made up of a Chairperson and Commissioners. The Commissioners sit in panels of three and hear the first level of appeals. The Workers’ Compensation Board employs judges who handle the hearings. In some cases, a hearing is not held and the decisions are made administratively under the judge’s review.

The New York Workers’ Compensation Board has established a set of forms that the medical providers should use in reporting their findings and opinions. These forms are referred to as “the Family of C-4 Forms.” The forms can be found on the New York State Workers’ Compensation Board’s website. At MCV Law, we encourage injured workers to be familiar with the forms so as to understand what the doctors must report and how that affects the money benefits payable.

Additionally, the New York State Workers’ Compensation Board has established Medical Treatment Guidelines for various body sites and injuries. It is important that your medical provider follow the Guidelines and use the forms to seek authorization for treatments that vary from the Guidelines, as well as certain surgical procedures and requests.

Now that you understand who the players are, let’s move on to the step-by-step process.