Common Questions About the Law

What is covered under Workers’ Compensation Law?
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Injuries on the job and work-related illnesses, as well as occupational diseases.

What if I don’t file a claim for workers’ compensation?
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You may lose the right to benefits for lost wages and medical care. You should file a C-3 reporting your own injury or illness, even though your employer’s insurer must notify this Board when it accepts or disputes your case.

How is the cash benefit for temporary total disability determined?
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The temporary total disability benefit is two-thirds of the average weekly wage you earned in the year before the accident. There is a maximum amount you can receive per week (see page 6). Your maximum benefit is set by what is in effect on the date of the injury.

Is medical care provided even if no time is lost from work?
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Yes. Medical care is provided for your condition even if no time is lost from work.

Must I wait for medical care?
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No, but physicians must request authorization to perform procedures that cost more than $1,000 each. This $1,000 threshold pertains to each procedure, not the total cost of care. Insurers must respond to the request within 30 days. Authorization is not necessary in case of an emergency.

May a doctor treat me if the insurer does not answer a request for approval?
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Yes. Insurers have 30 days to reply to an authorization request. If the insurer does not reply in 30 days, the provider may perform the services. If the service is a diagnostic test and the carrier requires claimants to use its network, the test must still be obtained from a network provider.

Are prescription medications covered under the law?
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Yes. Once your claim is established, pharmacies may bill the insurer directly. You may receive a card or document you can show a pharmacy stating you have coverage. If the carrier has a pharmacy network, it will tell you, and you must use those pharmacies. The only exceptions are in a medical emergency, or if the pharmacies don’t offer mail order and there isn’t a location reasonably close to you. You may have to pay the pharmacy for service before your claim is established. The carrier must then pay you when the case is established. There is no copayment.

What happens when an insurance carrier contests a claim?
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To contest a claim, a carrier must notify the Board within 18 days of the disability, or within 10 days of learning of the accident, whichever is later. The carrier must explain why it disputes the claim. You are then entitled to present your case to the Board. You will be notified of a pre-hearing conference. The Board seeks to resolve most cases within 90 days.

Must I have a medical examination when the employer or insurer requests it?
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Yes. The insurer may have you examined by a qualified provider who is authorized by this Board, within a reasonable distance for you to travel. Refusing this exam may affect your claim.

May an insurer suspend or change the cash benefits?
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Yes, but you are then entitled to a hearing. A carrier must submit evidence for the change to the Board, and the Board decides. A carrier may not change your benefitt after the Board decides it without the Board’s approval.

Do I have to use an attorney?
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No, but an attorney can be helpful in disputed and complex cases. You may represent yourself, or use an attorney or a licensed representative (see www.wcb.ny.gov for a list of licensed representatives). Fees are approved by the Board and deducted from your award. Do not pay your counsel directly.

What can I do if I disagree with the Board’s decision?
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You may appeal in writing within 30 days of the ling date of the decision. You must explain why you disagree with the decision. Three Board commissioners will review your case. If you disagree with that review, you can appeal to the full Workers’ Compensation Board of Commissioners. They may or may not consider it.

What can I do if I’m not satisfied with the outcome of the appeal?
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You may appeal to the Appellate Division, Third Department, within 30 days after a decision is served.

Are there penalties for falsehoods in claims?
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It’s a felony to willfully misrepresent a case to obtain benefits. Penalties include up to seven years imprisonment and fines. You may also lose the right to benefits. It’s also a felony for an insurer to raise a false issue in an attempt to deny a worker benefits it knows the worker is entitled to receive.

How do I know whether I am covered by workers' compensation?
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Determining whether or not you are covered by workers' compensation can sometimes be complicated. Generally, there are two main factors that determine your status: first, whether you are an employee, and second, whether your injury occurred as a result of your employment. It should be noted that neither of these factors is an absolute guarantee that you will be covered by workers' compensation. For example, depending on the rules in place in your state, some employees (such as agricultural workers) are not covered by workers' compensation.