Claims Resolution

Workers’ compensation differs from other types of insurance in that claims take a longer period of time to develop and are often said to have a long tail. For this reason, proactively managing lost time claims is very important. During the life of a claim the injured worker receives monetary relief and medical benefits. But how is a claim finally resolved?

Scheduled v. Non-Scheduled Awards

The WCB places a certain value on the loss of use of certain parts of the body resulting from work related injury or illness. These are known as scheduled injuries. All other claims are known as non-scheduled injuries.

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Closing on a Schedule Loss of Use Award

If there is a loss of use of an eye, arm, hand, finger, leg, foot, toe, or a combination thereof, NYSIF attempts to close the case on a scheduled award. A claimant may receive a schedule loss of use award after returning to gainful employment.

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What is classification?

Classification is the disposition of cases with a continuing or progressive impairment resulting in a disability.

There are four types of classification:

  1. Permanent Total Disability - Claimant cannot return to gainful employment due to disability caused by the work-related injury.
  2. Permanent Partial Disability - Claimant has a permanent reduction in earning capacity due to the accident.
  3. Statutory Permanent Total - Section 15 subdivision 1 of the WCL states that loss of both hands, both arms, both feet, both legs, or any two thereof constitutes a permanent total disability.
  4. Industrial Total Disability - Claimant is unable to return to the type of work in the industry in which the claimant was engaged at the time of the accident, and is incapable of being retrained for any other type of employment due to poor educational skills.

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How does NYSIF limit liability for classified claims?

NYSIF uses a proactive team approach to claims case management that includes

  • working with the employer to alter job duties to meet a claimant’s limitations;
  • using vocational rehabilitation to retrain the injured worker for another type of employment;
  • obtaining relief under the state-administered Second Injury Fund (often referred to as Section 15-8 of the WCL) to limit liability for both compensation and medical payments;
  • attempting to structure a settlement under Workers’ Compensation Law Section 32.

Limiting liability in a permanent total case is difficult. Many of the above options are not viable in every case. Where appropriate, NYSIF makes every effort to control claim costs in all cases.

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Section 32 Settlements

Section 32 settlements allow for complete and final resolution of a workers’ compensation claim. Claims settled by Section 32 are not subject to reopening, appeals, modification or review unless by mutual consent of all parties, with WCB approval.

Section 32 win-win settlements offer claimants the opportunity to control their financial destiny, while providing employers effective cost containment through case closure.

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