Meggesto, Crossett & Valerino, LLP

Yes – you can collect both NYS Unemployment Insurance benefits and Workers’ Compensation benefits at the same time. Your eligibility for both benefits will generally occur if you are being paid at a partial disability rate from Workers’ Compensation and are deemed ready, willing, and able to work by the Unemployment office. Alternatively, if your doctor’s opine you to be totally disabled and you are receiving Workers’ Compensation benefits at the total rate, you are likely not eligible for Unemployment benefits.
Can I Collect NYS Unemployment Insurance Benefits and Workers’ Compensation?
While you can collect both benefits at the same time, you cannot collect more than your Average Weekly Wage from both benefits. For example, if your Average Weekly Wage is set at $500.00 per week, your unemployment benefits will go down if you are collecting more than this from both Workers’ Compensation and Unemployment. Your Workers’ Compensation is set first and your Unemployment benefits are adjusted accordingly. Therefore, you must report your Workers’ Compensation earnings to the Unemployment office.
William Crossett IV
Partner

Email: crossett@mcvlaw.com

Phone: 315-471-1664

William Crossett concentrates his practice in the representation of Injured Workers. Since 1982, he has appeared before the Workers’ Compensation Board and the Courts of New York. As an advocate for the Injured Worker, he has testified before the New York State Senate and has presents Continuing Legal Education programs.


It is a fact of life in the world of New York State Workers’ Compensation that getting medication is not as easy as your everyday trip to the pharmacy to pick up a prescription. One of the main reasons for this is the number of parties involved, and the regulatory structure under which those parties do business.

We tend to think of the medications which we take as a private business between our doctors and ourselves. Although we are aware that our private health insurance has a say in what will and will not be paid for, the Doctor is well aware of those particular restrictions, and will prescribe accordingly, keeping the prescription machine flowing smoothly enough that being able to obtain a prescription is relatively easy.

For compensation claimants, there are not only more parties that stand between you and your medication, there is the additional regulatory filter of the New York State Medical Treatment Guidelines. These are guidelines that all parties involved must adhere to.

For the Workers’ Compensation claimant it may be better to think of a prescription as a request, rather than Doctor’s Orders. It is a request that has to pass through all parties involved in order to be granted.

Here is an overview of the general process:

  1. Claimant sees the doctor and medications are prescribed.
    The claimant has a medical visit with a doctor who prescribes medication that is related to the treatment of his injury. The prescribing of the medication or the continued use of the medication should be clearly spelled out by the treating physician in the medical narrative report. All medications should be written down at every medical visit. Do not hesitate to let your doctor know this.
  2. The prescription is not enough.
    Although your pharmacy will take your prescription and enter it into their system as a request, a prescription is not adequate documentation for the compensation insurance carrier to authorize the release of that medication to you. When you are first injured, you may get a one-time fill of medication which will be paid when the claim is accepted, or will be charged back to private insurance if the claim is not accepted. However, once past that first-time fill your prescriptions will go through the normal channels. From that point forward, the prescription will not be filled without clear medical evidence of the need for the medication. A prescription, therefore, is just a request without evidence or explanation.
  3. The Third Party
    There is a third party pharmacy administrator that stands between the pharmacy and the compensation insurance carrier. The third party administrator basically verifies all your prescription information and passes your prescription request on to the insurance carrier for authorization.
  4. The Insurance Adjuster/Case Manager.
    The insurance adjuster is the one who will receive the request from the third party administrator and authorize your prescription. Ongoing prescriptions that are clearly recommended by the guidelines will be the easiest to pass through the system. Prescriptions that fall outside the guidelines will require a secondary review, and will normally be rejected without a clear medical explanation of their necessity in the doctor’s medical reports. Often a separate Letter of Medical Necessity will be required.
  5. Adjusters take vacations.
    Compensation claimants need to be aware that insurance adjusters go on vacation, and “substitute” case managers are not always readily available, causing a delay in getting prescriptions. Contact your attorney with any issues.
  6. Nurse Case Manager, Utilization Review.
    Any prescription usage under New York Workers’ Compensation is subject to review by a medical professional, usually Nurse Case Managers. This is especially true with “chronic” users of medication who have been taking medications for extended periods (generally anything longer than 6 months). Any ongoing use of opiates and other narcotic medications is closely monitored. Requests falling outside the guidelines that are clearly indicated as necessary may be subject to Utilization Review.
  7. Durable medical equipment requests (braces, canes, wheelchairs).
    Durable medical equipment is treated as just another prescription, and is subject to the same processes and guidelines as any other medication.
  8. Contact your legal representative.
    If you are represented in your worker’s compensation claim, contact your attorney’s office with any prescription medication issues – Do not contact the insurance carrier directly.
  9. John M. Bellinger
    Paralegal

    Email: jbellinger@mcvlaw.com

    This entry was written by John Bellinger, who is part of the Worker’s Compensation team at MCV Law.

If you are receiving Worker’s Compensation benefits and file for Social Security disability benefits, you may not be able to collect the maximum amount of Social Security benefits based on your earnings record. Between Worker’s Compensation and Social Security Disability, you may only receive up to 80% of your average current earnings (ACE) in total. If the total of your Worker’s Compensation and Social Security Disability benefits exceed 80% of your average current earnings, your Social Security Disability benefit will be offset or reduced.
Take this example:

First figure out your average current earnings:
Your average current earnings is calculated either by averaging your highest consecutive 5 years of earnings or by taking the highest year of earnings in the last 5 years prior to your disability.
If your highest year of earnings in the five years before you became disabled was $40,000, then divide this number by 12 to get your monthly earnings of $3333.33.
Then multiply this number by 80 % (3333.33 X .80) to arrive at your average current earnings of $2666.66.

How much is your monthly Workers Compensation benefit?
Take the amount of your weekly Workers Compensation benefit and multiply by 52, then divide this number by 12, to get your monthly workers compensation benefit.
For example: Say you receive $400 per week in worker’s compensation.
Multiply this number by 52 ($400 X52) to get your yearly benefit of $20,800
Now divide this number by 12 to get your monthly Compensation benefit or $1733.33.
Now subtract your monthly compensation benefit from your ACE: $2666.66-$1733.33= $933.33. This number ($933.33) represents the highest amount of Social Security Disability benefits you could receive (using this example).
Remember that every case is different. It is very important to report all changes, in writing, in your Worker’s Compensation benefits to Social Security. It is also important to keep proof that you submitted the information to Social Security. You will also need to follow-up with Social Security to make sure they adjust your benefits as needed.
Kimberly Slimbaugh

Kimberly Slimbaugh
Partner

 

Email: kslimbaugh@mcvlaw.com

Phone: 315-471-1664

Kimberly Slimbaugh has been practicing law since 1992 and is a current partner at Meggesto, Crossett & Valerino, LLP.  In addition to the New York State Bar, she was admitted to the Massachusetts State Bar in 1992.  She is a member of the National Association of Social Security Representatives and regularly attends its national conferences.

 

 

 

 

 

 

 

 

Posted by: In: Workers Compensation 15 Sep 2015 Comments: 0

Give it a try!

During the course of a New York Workers’ Compensation claim, numerous issues arise that injured workers must be aware of as they can have a significant impact on entitlement to lost wage benefits. The New York Workers’ Compensation Board can place obligations on injured workers. Not fully understanding these obligations and not complying with them can have consequences. One example is the obligation for partially disabled workers to remain attached to the labor market.

The obligation for an injured worker to seek employment within his or her light duty capabilities arises when either the claimant’s treating physician or the insurance carrier’s consultant (IME) indicates that the person has some work ability to work.

While an injured worker’s partial disability may prevent him or her from returning to their prior work, it does not necessarily prevent the injured worker from returning to all types of work. Generally, the law imposes an obligation on the injured worker to seek work consistent with his or her abilities. If the injured worker fails to do so, the insurance carrier may assert that the injured worker has voluntarily removed his or her self from the workforce, thereby allowing them to stop ongoing weekly wage benefits.

Sometimes injured workers believe that they do not have to remain attached to the labor market because they are on Social Security Disability (SSDI), collect Unemployment Insurance, have been told by their previous employer that they cannot go back to work because of their disability, or they have been terminated because of their disability.

While there are few exceptions to this rule, the exceptions are very limited. To protect yourself, we recommend that all injured workers with a Temporary Partial Disability or a Permanent Partial Disability take appropriate steps to show that they are sufficiently Attached to the Labor Market so as to prevent the insurance carrier from suspending benefits.
Injured workers demonstrate attachment to the labor market in three main ways: by performing an independent job search, by working with programs such as ACCES-VR, and by working with one stop career centers. Injured workers must provide evidence of their work search efforts.

There is case law to support the proposition that, if you are attending school FULL-TIME for retraining purposes, you are attached to the labor market. It is important that you also document your participation in a full-time program.

We recognize that this obligation is often difficult for an injured worker, but the idea is to prove that you are actively looking for work. We recommend that you use the form C-258.

MCV Law is proud to announce the launch of its very own Job Search (C-258) Form Generator to help injured workers more easily keep track of their work search efforts to avoid a suspension of benefits. The new fillable/printable form can be found here.

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Christopher Stringham

 

Email: cstringham@mcvlaw.com

Phone: 315-471-1664

Christopher Stringham graduated from Western New England College School of Law in 2010 and was admitted to the New York State Bar as well as the United States District Court, Northern District of New York in 2011. He is a member of the New York State Bar Association, Onondaga County Bar Association, and the Injured Workers’ Bar Association of New York. He has been a member of Meggesto, Crossett & Valerino, LLP since October 2010.


Many times, the carrier will issue payments to you without prejudice. This means that the carrier is taking advantage of Section 21-a of the NYS Workers Compensation Law. Section 21-a allows the carrier to pay you without accepting your case. In other words, the carrier is asserting that the mere fact that they are issuing payments to you cannot be deemed an acceptance of liability for your claim. Rather, they are agreeing to issue payments to you while the record continues to develop or while they await further information.

This does not mean you will have to pay back the awards in the event that the carrier later asserts it is not liable. It simply means that the carrier is not accepting liability by making payments. The carrier may make payments without prejudice for up to one year. Unless the Carrier sends a notice of termination within the year, the payments are deemed an admission of liability.

Sometimes, the carrier may also grant certain treatment without prejudice. This usually pertains to treatment for body sites that are not presently established in your case. The insurance carrier is again saying that, while it is agreeing to pay for certain treatment, it is not accepting the liability for those body sites until the record is further developed. Again, you will not be responsible for the treatment in the event that the carrier later disputes liability for the body site.
Bethany Nicoletti

Email: barliss@mcvlaw.com

Phone: 315-471-1664

Bethany Nicoletti is a graduate of Ithaca College where she earned her B.A. in Communication Studies. She graduated cum laude from University at Buffalo Law School in 2013 and was admitted to the New York State Bar in the Fourth Judicial Department in 2014.

Yes, I said it – every injured worker needs a vacation; just like their coworkers, bosses, and friends.  Injured workers deserve a break from medical appointments, physical therapy, disputes over medication, and from the worry and stress that comes after an injury or illness.  Injured workers need time away from all of this stress to figure out exactly how they are going to move forward.

Every injured worker that Meggesto, Crossett & Valerino, LLP represents wonders “Will I get better? Will I be able to return to my old job? What happens if I can’t go back to the only work I know how to do?”

Injured workers also wonder “When will I be paid?  Will my check arrive regularly to I can pay my bills?  What happens if I do not receive my check?  Why is the amount of my check increasing or decreasing?”

These are all fair questions and concerns that we, as attorneys, strive to answer for our clients every day.  We often find that injured workers get caught up in the immediate, short-term battles, such as attending medical appointment and comprehending the amount of their benefits, and could really use a break from it all.

When the attorneys and staff at Meggesto, Crossett & Valerino, LLP talk to our clients and try to answer these questions, we stress the importance of being in control of their situation.  We consistently remind our clients that they are the “Masters of their Own Density.”  In doing this, we recommend courses of action and strategies that will maximize benefits in the short run, while keeping in mind that we must protect both injured workers and their families in the long run.

When you change your daily routine by waking up in a different place, and where the only decision you have to make is whether to go swimming or fishing, you give your mind a chance to clear itself.  Perhaps even day dreaming while enjoying the sun, or an afternoon spent outside, would held put your mind at ease.  You might find that, when you least expect it, a thought or answer might pop into to your head that you were too busy or anxious before to realize.

Now, I know it is not easy; you may not have the money to enjoy a vacation nor the freedom to delay medical procedures or treatments.  But, we strongly recommend clearing a week or two in your schedule to just get away, even if only to a public park, to clear your head and relieve the stress every injured worker experiences.

Before summer turns to fall, take my advice and find some time to get away.  Who knows – maybe you will have a flash of inspiration.  Even if you do not, simple acts such as shutting the television off, moving your medical appointments, or simply having a change of scenery, can be an easy but important step on the path to becoming the “Master of your Own Density.”

Bill_8861_270x163

William W. Crossett, IV
Partner

Email: crossett@mcvlaw.com

Phone: 315-471-1664

Mr. Crossett concentrates his practice in the representation of Injured Workers. Since 1982, he has regularly appeared before the Workers’ Compensation Board and the Courts of New York. As an advocate for the Injured Worker, he has testified before the New York State Senate and has presented many Continuing Legal Education programs. Presently, Mr. Crossett serves as President of the Injured Workers Bar Association of New York and is an active member of Workers Compensation Law Division of the New York State Bar Association. In 2012, he was inducted as a fellow in the College of Workers Compensation Lawyers. Mr. Crossett practices throughout Central New York with an office in Syracuse.


Filling out the C-257 mileage form used to be a long, tedious process. Luckily, MCV Law has made it easier with our new Mileage and Transportation Form Generator! With the ability to copy previous entries, filling out the C-257 is now a breeze. Simply click the link below and give it a shot.

Give a try!

MCV Law Attorneys

In order to settle the medical portion of a Workers’ Compensation claim, we are sometimes required to take into account Medicare’s interest. This requires us to obtain a Medicare Set-Aside. While this may seem confusing and unfamiliar, there are many advantages to settling your medical with a Medicare Set-Aside.

First, a Medicare Set-Aside is managed by you. This means that you no longer have to get pre-approval for your treatment and no longer have to wait for pre-approval from your adjuster at the pharmacy for your scripts. You can also treat at your leisure and are not required to follow the Medical Treatment Guidelines. Many of our clients find it easier to leave New York and get to warmer weather when they are in charge of their treatment. Often times, claimants find difficulty getting treatment out of New York State, and a Medicare Set-Aside fixes that problem. The money goes with you – and you use it as you see fit.

The second advantage to a Medicare Set-Aside arrangement assures that you have medical coverage for life. When the Centers for Medicare Services approves the amount of your Medicare Set-Aside, they are agreeing to pay your treatment, subject to their rules, once the monies in the set-aside are exhausted. This way, you have coverage for life, whether it comes from your Medicare Set-Aside monies or directly from Medicare.

During early settlement discussions with our clients, many are confused by the Medicare Set-Aside process, but quickly realize that it has many advantages and is actually quite simple. Given the advantages discussed above, many of our clients are happier using a Medicare Set-Aside than relying on the Carrier to manage their treatment.
Bethany Nicoletti

Email: barliss@mcvlaw.com

Phone: 315-471-1664

Bethany Nicoletti is a graduate of Ithaca College where she earned her B.A. in Communication Studies. She graduated cum laude from University at Buffalo Law School in 2013 and was admitted to the New York State Bar in the Fourth Judicial Department in 2014.

Calculating Weekly Benefits

How much will I get? This question is usually one of the first things a client asks us when discussing a Workers Compensation case. Previously, to answer this, we would have to get the necessary information from the client, then calculate the weekly benefits, and then finally contact them again so they could hear the result. Now, we have made it much easier! The only thing you have to do is follow the instructions on the calculator page and it will give you an estimate of the benefits you will receive!





The Average Weekly Wage (AWW) is one of the most important issues in your case. The AWW determines how much you will be paid in the event that you are out of work for a work-related injury. The higher the AWW, the higher your rate of pay. At MCV Law, one of the first things we look at is whether the AWW has been calculated correctly.

The Average Weekly Wage is just that – an average. It is calculated by taking your total earnings for the 52 weeks prior to your injury and dividing that by the number of days worked, giving you the average daily wage. The average daily wage is then subjected to a multiplier depending on the number of days worked, as provided for by Section 14 of the New York Workers’ Compensation Law. For example, Section 14 provides that a seasonal worker’s AWW should be calculated by multiplying the average daily wage by 200, whereas the AWW of an employee who works 6 days per week is calculated using a 300 multiple. However, the vast majority of employees work 5 days per week, and, thus a 260 multiple is generally used. There are various other arguments that can be made to increase an AWW. At Meggesto, Crossett & Valerino, LLP (MCV Law), we work to support the argument that is likely to produce the highest AWW.
The law also accommodates injured workers who had a second job at the time of their accident. This is referred to as “concurrent employment.” The assumption is that, if your injury prevents you from earning wages at another job, those wages should also be replaced. The concurrent employment must be “covered employment,” meaning that the concurrent employer must carry Workers’ Compensation insurance. Your total earnings from your concurrent job are added to your earnings at your primary employment. Just like the primary AWW, arguments can be made to maximize the concurrent AWW.

Section 14 of the law also accommodates minors. Under the Workers’ Compensation Law, the age of majority is 25. If you are injured at work before reaching the age of 25, a “Minor’s Wage Expectancy” calculation is assessed to determine what you would have been making at the age of 25. A Minor’s Wage Expectancy determination applies at the time of permanency. The determination is made by analyzing the injured worker’s performance reviews and potential for promotion, as well as looking at what other employees in the same field are earning. For many, this will substantially increase their AWW.

Lastly, the law sets forth maximum and minimum rates depending on the date of accident. Below is a chart demonstrating the maximum rates since 2009. The current minimum rate is $150.000.

Date of AccidentMaximum Rate
July 1, 2009 – June 30, 2010$600.00
July 1, 2010 – June 30, 2011$739.83
July 1, 2011 – June 30, 2012$772.96
July 1, 2012 – June 30, 2013$792.07
July 1, 2013 – June 30, 2014$803.21
July 1, 2014 – June 30, 2015$808.65
July 1, 2015 – June 30, 2016$844.29