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Top Questions Doctors Should Ask Regarding Workers’ Compensation Claims In NY

What is Workers’ Compensation?

Simply put – workers’ compensation is an insurance policy that every employer (some exceptions) must have that will pay for lost wages and medical care if a worker is injured during the course of work. There are lots of rules and limits, but the basics are designed to get medical care to injured workers quickly and some pay while out of work. If all works out the employee will be able to return to work in a reasonable amount of time.

Why do I have to fill out special forms, why can’t I just send in my normal report?

If you treat injured workers as part of the NY Workers’ Compensation System you must be ‘coded’ (pre-approved) to do so. Part of obtaining your code letters is an agreement that you will follow the medical treatment rules and guidelines that include filing medical reports that are prescribed by the workers’ compensation board (such as the C4 form). The idea behind the forms is to make sure that all doctors are providing the information needed so that the Workers’ Compensation Board and Law Judges can make legal decisions in a consistent way.

What if I don’t fill out the proper form?

Failing to fill out the proper from, or do so in the right way, has two major immediate effects: 1) it could cause your patient to lose his or her benefits or not get treatment they need, and 2) the insurance company may not have to pay you for the services you provided. Bottom line – it is a bureaucratic system and you have to follow the rules, dot the i’s and cross the t’s.

Do I have to state what a person’s DISABILITY is?

No. You read that right. Under New York law your obligation as a medical provider is to examine an injured worker, provide treatment and file a report that indicates what that worker’s “IMPAIRMENT” is, not whether they have a “DISABILITY”. What I mean can best be understood by the statement that “DISABILITY” is a legal determination that a Law Judge makes based on a person’s physical and mental impairment (the medical impairment!), functional capacities and vocational capacities. So if someone insists you make statement about DISABILITY that is really not correct under the law!

I don’t want to treat a work injury case since the injured worker has to stay out of work even if I believe they can return!

This is a myth! While some attorneys and patients will tell you they need to stay out of work, the reality is that when a person is able to return to work they should. Under New York law a person could actually still receive benefits and treatment after they return to work. And it serves the purpose of rehabilitating people and getting them back to gainful employment. However, if you medically believe a person should NOT be working then say so and say why!

But won’t a Jury think it odd if I send someone back to work?

No! First, there are no juries in a workers’ compensation case – it is an administrative hearing before a Law Judge. Second, workers’ compensation is NOT a lawsuit. As noted, workers’ compensation is a no-fault insurance benefit that every employer purchases to protect workers. A lawsuit is an actual civil legal claim against a wrongdoer. In New York you cannot sue your employer if hurt on the job.

What is the real reason for the Permanency Report – C4.3?

In 2007 the New York Workers Compensation Law changed. Part of that change was to try to find a way to limit or cap awards to injured workers when they were found to be permanently disabled. As a result, the Workers’ Compensation Board created the C4.3 form that combines the notion of maximum medical improvement (nothing more you can do to improve the condition) and permanent impairment (residual function limitations – what can the person do). When asked to fill out this form it is a two-step process. Step 1 is answering whether the person has reached Maximum Medical Improvement. If no, then put in information about the condition and what is needed. If yes, then proceed to figuring out the residual function and severity of the injury.