Claims Guide for Small Businesses

This Quick Claims Guide describes the responsibilities of the employee, the employer and the doctor when a workers’ compensation claim needs to be filed. 

When to file a claim

You must have a policy with The New York State Insurance Fund (NYSIF) to file a claim with NYSIF for your employee. All on-the-job injuries are “reportable” if they result in:  (a) lost time of one day from regular duties beyond the work shift in which the accident occurred, (b) more than ordinary first aid, or (c) more than two first aid treatments.

A “reportable” injury requires the filing of Form C-2 "Employer’s Report of Work-Related Accident/Occupational Disease" with the Insurance Carrier and the Workers' Compensation Board.

First-aid option for non-reportable injuries

Employers can pay for medical treatment for injuries which are not “reportable,” or NYSIF will pay at the employer’s request, subject to reimbursement, without affecting the employer’s claims history.  In such cases, the employer does not need to file Form C2.

An employer who chooses this option must pay medical bills promptly to avoid Workers’ Compensation Board indexing, and keep an accident report on file for at least 18 years.  The employer must promptly supply accident details to NYSIF if it wants NYSIF to pay for medical bills.

When there is a claim

Everyone involved in a claim for a work-related accident or occupational disease shares responsibility for prompt and complete claims service.

What the employee should do:

• Tell the employer or supervisor about the injury as soon as possible.  Failure to notify the employer, in writing, within 30 days after the accident date can result in denial of benefits.  In case of occupational disease, the disabled person must give notice to the employer within two years of the disablement or within two years after the claimant knew or should have known that the disease was work-related.
• Obtain necessary medical treatment as soon as possible.  An injured employee can choose any physician or health organization authorized by the Workers’ Compensation Board (WCB) to give medical care.  The employee should not pay a fee directly to the doctor.  If the claim is disputed by NYSIF or the employer, the doctor may require the employee to sign a form guaranteeing payment for a disallowed claim or one discontinued by the employee.
• Follow doctor’s instructions to speed recovery.
• Attend hearings when notified to appear.

What the employer should do:

• Record all injuries or occupational illnesses incurred by employees in the course of employment.  Maintain these records for at least 18 years.
• Provide for immediate and necessary medical treatment if the employee is unable or does not desire to select a doctor.
• Provide written notice of “reportable” claims by filing a Form C-2 injury report with both NYSIF and the WCB as soon as possible, but not later than 10 days after the injury date.  Failure to maintain records and report accidents as above is a misdemeanor punishable by a fine of up to $1,000 and a WCB penalty of up to $2,500.*
• Comply with all requests for information about the injured worker from NYSIF or the WCB.  It is in the employer’s best interest to cooperate fully in providing all reports that may be required in establishing an employee’s earnings and work status before and after the injury.
• File Form C2 immediately if an accident that was not initially reportable subsequently meets any of the criteria for when to file a claim.

*Note to Employers:  In filing a C2 for a questionable claim, the employer should write:  “It is alleged that…” or “The employee claims that...;” Inform NYSIF about suspicious claims immediately by telephone, then in writing; and immediately with any new information in questionable cases.

What the doctor should do:

• Complete and file a preliminary medical report Form C4 with NYSIF and the WCB within 48 hours of first treatment.
• Complete and file a 15-day report of injury and treatment on Form C4 with NYSIF and the WCB within 17 days after first treatment.  Eye specialists file Form C5.
• Use the same forms to file Progress Reports with NYSIF and the WCB at intervals of 45 days or less while treatment continues.
• Use the same forms to file a Final Report immediately when treatment ends.

Important—All medical reports must be completed fully, accurately and filed on time for prompt payment of benefits.  Employers should transmit immediately to NYSIF any medical reports received directly from all doctors.  Employers and injured employees can ensure benefits continue uninterrupted by insisting on prompt reports from all doctors.

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