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Answers to the Quiz

by | Aug 10, 2015 | MAD News |

Test Your NY Workers’ Compensation Chops

As promised, here are the answers to the quiz posted last week.  How did you do?  Do you have M.A.D. skills?

1.  What is the Special Funds WCL § 15(8)(d) reimbursement form and what are the time frames for seeking reimbursement once WCL § 15(8)(d) is established?

  • C-251 is the request for reimbursement
  • When § 15(8) is established the carrier has one year from the date of establishment to submit a claim for all post 260 week benefit
  • Thereafter, Carrier pays and then submits reimbursement every six months if requesting reimbursement
  • Claims are not allowed if it is for an illegally employed minor.

2.  What is the percentage of medical impairment for a claimant whose provider has opined a class II severity E impairment?

  • 33% medical impairment. See, Nastasi & Associates Inc., 2014 NY Wrk. Comp. 0005952, 2014 NY Wrk. Comp. LEXIS 5088 (NY Wrk. Comp. 2014) the Board specifically noted thatan E lumbar spine permanent impairment severity ranking . . . equates to a 33.33% medical impairment . . .pursuant to theMedical Impairment Severity Crosswalk.”)

3.  What are the three exceptions to written notice under WCL § 18?

  • There was no reason for failing to provide timely notice;
  • The employer had actual knowledge of the event; and
  • There was no prejudice to the employer due to the lack of notice.

4.  When do the medical treatment guidelines apply?

  1. When claimant lives in state and the doctor treats in state?
  2. When claimant lives out of state and the doctor treats in state?
  3. When claimant lives in state and the doctor treats out of state?
  4. When claimant lives out of state and the doctor treats out of state?
  • a, b, and c.

5.  What is needed in a Chiropractor’s report for there to be a well-documented exacerbation to allow for treatment in the absence of a variance?

  • When and how the exacerbation occurred;
  • Objective changes from the baseline function;
  • Expected type and frequency of treatment believed necessary to return the patient to baseline function; and
  • The response to treatment through measures of objective functional improvement.

6.  Under what circumstances can a carrier deny a variance without contrary medical evidence?

  • Not an established injury site;
  • Burden of proof not met
  • Substantially similar request

7.  If the carrier commences payment of temporary compensation, how much time do they have to electronically file a notice of controversy before they would be deemed to have admitted liability for the claim and a decision would be issued establishing the claim?

  • Within one year from the commencement of payment.

8.  An IME report must be filed within 10 business days after the examination with the Board. Does a holiday within the period count as a business day and does only a holiday that falls on the 10th day count as a holiday that requires that the IME report be submitted on the next business day?

  • A holiday is not a business day.

9.  If the claim is not controverted, when is a SROI late and what is the penalty?

  • The 18/10/ day rule: Pay and report to chair within 18 days of disability or 10 days after employer first has knowledge of the alleged accident, which ever period is greater. Failure to comply will result in a penalty of $50 pursuant to §25(3)(e).

10.  What is the significance of the filing of notice of indexing?

  • If the claim is going to be controverted, it must be controverted no later than within 25 days of the filing of the notice of indexing.

11.  When the employer or carrier is under a direction to continue payments to the claimant following a hearing or issuance of a decision pursuant to rule 300.23, it is permissible to suspend benefits without a hearing under certain circumstances. True or false?

  • Normally the carrier has to file an RFA-2 notice to suspend/reduce accompanied by supporting evidence.  Copy to claimant/his/her attorney/licensed representative within 1 day if submitted electronically to Board.
  • The Rule provides 4 exceptions when payments can be suspended without a hearing.

Notwithstanding any provision to the contrary in this subdivision, the employer or carrier upon the filing of an electronic notice as prescribed in section 300.22(f) of this Part may suspend or reduce such payments:
Where a notice of return to work, or other written substantial legal evidence of claimant’s return to work, has been submitted to the board in the format prescribed by the chair together with or on the same day that the notice to suspend or reduce is electronically filed; or
Where the supporting evidence submitted to the board in the format prescribed by the chair together with or on the same day that the notice to suspend or reduce is electronically filed includes payroll records for at least two calendar weeks which warrant such suspension or reduction; or
Where the claimant’s medical evidence indicates that the claimant has no disability. When such medical evidence is not part of the official board file, it shall be submitted to the board in the format prescribed by the chair together with or on the same day that the notice to suspend or reduce is electronically filed; or
Where supporting evidence submitted to the board in the format prescribed by the chair together with or on the same day that the notice to suspend or reduce is electronically filed includes proof of incarceration upon conviction of a felony.
12.  How are actual reduced earnings calculated?

  • (AWW – RTW wages) * 2/3 not subject to the minimum.

13.  When can MMI be determined?

  • In cases that do not involve surgery or fractures, MMI cannot be determined prior to 6 months from the date of injury or disablement, unless otherwise agreed to by the parties.

14.  How long does a self-insured employer have to make the mandatory deposit into the ATF following classification with a PPD for a claim with a date of accident after 7/1/07?

  • None because self-insureds do not have to make payment into the ATF.

Oh ho!  A trick question at the end!  Hope you enjoyed brushing up on/confirming your comp chops.