Understanding the New York workers' compensation claims process

The claims process for workers' compensation in the state of New York can be quite complex, and individuals need to know what to do in order to protect their claims.

Sustaining a workplace injury can be a challenging experience. The physical recovery process itself is often difficult enough. Stress from mounting medical bills and lost wages only makes things worse.

On top of all this, navigating the workers' compensation process can be overwhelming and confusing. Knowledge of the workers' compensation process can provide you with some basic ideas about what happens at each step and can ensure that you are prepared for what can be a very difficult and time-consuming process.

In this article, we provide you with some general information about how workers' compensation cases are handled in New York. We also discuss what happens when your injuries may require additional treatment due to conditions that linger after your case has been closed.

You may have questions about your case, and we welcome the opportunity to talk with you in detail about your specific situation. This article is not legal advice, but rather an opportunity for you to become familiar with the process, which can alleviate some of the stress you may be feeling at this time.

Filing your claim for benefits

The first step after suffering a workplace injury is to obtain whatever medical care is necessary to treat your illness or injury. Your supervisor should also be notified of the injury at this time. However, even after notifying the supervisor, the employer must be notified, in writing, regarding the specifics of the injury. This must be done within 30 days of the injury.

The next immediate step for you is to complete what is called the Employee Claim (C-3) as soon as possible. This form comes from the New York State Workers' Compensation Board. Completing the C-3 form is required within two years of the accident that produced the injury.

Doctor and employer responsibilities

Within 48 hours of the accident, the doctor from whom medical care was sought must complete a preliminary medical report, which discusses your injuries or illnesses and potential care that may be needed.

This specific form is called the Form Doctor's Initial Report (C-4). The C-4 must be distributed to the Board, as well as the employer or its insurer. Within 10 days of receiving notification of the accident, the employer must also report the workplace injury to the Board and its insurer.

Insurer responsibilities

The next step is for the employer's insurer to communicate with you about your claim. Specifically, the insurer is required to provide you with a written statement of your rights under New York state law. The deadline for this requirement is 14 days after receiving the employer's report or with the first payment check, whichever occurs earlier.

Soon afterwards (18 days after receiving the employer's report), the insurer is to begin payments of benefits. Along with this step, the insurer must notify the Board that payments have commenced or, if not, what the reasons are for delay or denial.

Determination on the status of your case

If your claim has been approved, you will begin to receive the compensation allotted to you under New York state law. If the claim is denied, you will need to determine the appropriate next step to take, which could include appealing the decision reached in your case, meaning the process could take longer before you start to receive compensation.

The amount and duration of benefits will depend on several different factors, which must be analyzed to determine exactly what you are entitled to under the law. In the event that your condition does not improve and your benefits end, you will have to determine what to do in order to get the benefits you need to deal with the additional treatment costs.

Reopening a workers' comp claim

Some on-the-job injuries are straightforward and easily corrected. A simple broken ankle, for example, will usually heal in a relatively short time with no long-term effects. A repetitive motion-induced condition like carpal tunnel syndrome can often be addressed with activity modifications, a course of physical therapy or a relatively basic surgery.

Other injuries, however, aren't necessarily so simple. A complex fracture or soft tissue injury can have lasting impact well beyond required surgeries and rehabilitation. There may be nerve damage, weakness or chronic pain that can flare up years afterward. In those instances, you shouldn't have to foot the bill for new medical treatment, so it may make sense to either reopen the initial workers' compensation claim or file a new one in order to have those expenses covered. Claims could also be reopened to seek additional benefits or compensation if a disability worsens or results in new medical conditions. Conversely, a disability insurer could reopen a claim if they feel that too much compensation has been paid.

Revisit your old claim – or file a new one?

You may wonder how to best move forward with your request to seek additional compensation for your injury. There are specific things that you need to keep in mind about past claims, and your ability to go back and recover the benefits you need to pay for these treatments. Generally, a workers' compensation claim could be reopened if:

  • There has been a change in the claimant's condition
  • Some fraud comes to light (on the part of the claimant, the employer or the insurer that paid the benefits claim)
  • There was an overpayment of benefits
  • A clerical error was made that impacted the claim
  • There was a mistake/misinterpretation of a material fact in the case

It is important to note that if a claim was resolved via a "full and final settlement" or a "compromise and release," it usually cannot be reopened absent compelling evidence of some fraud on the part of one party to the agreement.

With the recent closure of the New York Fund for Reopened Cases (sometimes referred to as the "25A fund,"), reopened claims are now paid directly by work comp insurers, and the process for reopening a claim has changed slightly. However, an application still needs to be made to the state's Workers' Compensation Board.

In circumstances when it isn't possible to reopen an existing claim, it may behoove a claimant to simply open a new one to seek compensation. There may be procedural or strategic differences in a new claim based upon an old injury, though, so you need to be careful about what you do at this time. Of course, legal representation is always a good idea, but it may be particularly helpful in this instance. For help determining if you should reopen a New York work comp claim, or help with any other matter connected to your case, contact the Staten Island law firm of Angiuli & Gentile.