1
- 15-8 Cases
- §15-8 is a section of the NYS WC law relating to disability following previous permanent physical impairment. §15-8 no longer applies for loss dates after June 30, 2007. See Second Injury Fund definition.
2
- 25-A Cases
- §25-A is a section of the NYS WC law that applies to cases closed (NFA), in which the date of accident is more than seven (7) years ago, and in which the date of the last indemnity payment is more than three (3) years ago. If the WCB establishes 25-A, then medical and indemnity payments will be made by Special Funds Conservation Committee, and not the employer or insurance carrier.
A
- A-Rate
- An “A-Rated Classification” is a classification with no predefined manual rate shown in the rate pages of the NYCIRB Manual.
- Accident Date
- Refers to either (a) the date the accident is deemed to have occurred or (b) the date of onset assigned to an occupational disease. The accident date is officially established by a WCLJ.
- Accident Notice and Causal Relationship (ANCR)
- The finding made by a WCLJ that certain conditions have been met to assign financial responsibility for a claim. Specifically, it must be established that (a) a work-related accident covered by the Workers' Compensation Law has occurred; (b) following the accident, the claimant notified her/his employer within the time limit required by the Workers' Compensation Law; and (c) a causal relationship exists between the accident and the resulting injury or disability.
- Accident (Work Related)
- An event, arising out of and in the course of employment, which results in personal injury to a worker.
- Actuary
- A person who calculates insurance and annuity premiums, reserves and dividends.
- Adjourn (a hearing)
- The Workers' Compensation Board WCLJ can put off or suspend until a future time, without making any findings.
- Adjusted manual rate premium
- A premium level charged a risk under a NYSIF workers' compensation policy, produced by applying an experience modification to the manual rate premium on either a deposit premium bill or an audit bill.
- ADL
- Activities of Daily Living.
- Administrative Decision (AD)
- In an effort to reserve the hearing calendar process for more complex cases, the WCB can make determinations on cases outside of the regular hearing process by administrative decisions.
- Advocate for Business
- The New York State Workers' Compensation Board Advocate for Business assists employers by resolving problems and answering questions about the New York State workers' compensation system.
- Advocate for Injured Workers
- The New York State Workers' Compensation Board Advocate for Injured Workers accepts complaints related to workers' compensation, and investigates and attempts to resolve them. In addition, the Advocate provides information to injured workers to enable them to protect their rights in the workers' compensation system.
- Affidavit
- A written statement under oath or affirmation made or taken before an officer having authority to administer such oath.
- Agent
- See: Insurance Agent
- Aggregate Trust Fund (ATF)
- A trust fund established via NYS WC law § 27, entrusting NYSIF as the administrator for the Trust to assure payment of workers’ compensation in claims involving permanent partial disability, permanent total disability, the loss of major members (limbs or eyes) and fatal injuries.
- Anniversary Date
- The date each year upon which a policy is renewed; usually based on the original inception date.
- Appeal (Workers' Compensation)
- A legal action taken by one of the parties to reverse or amend a decision or direction made by a WCLJ, WCB board panel or the WCB Chair.
- Application Tracking Number (ATN)
- Application Tracking Number is the 10-digit number generated when a new business application is entered in the system. If approved, the ATN (with the last two digits removed) becomes the 8-digit policy number.
- Apportionment
- A proportionate division of all or part of the benefit costs in a case between two or more injury claims for the same claimant, based on an evaluation of the relative contribution that the injuries have made to the claimant's permanent disability.Apportionment can involve another NYSIF case, another carrier’s case, or a prior existing medical condition of the claimant.
- Arbitration
- The adjudication process that determines the fair value of a disputed medical bill rendered by a physician, chiropractor, physical therapist, occupational therapist, podiatrist, or psychologist authorized to render treatment under the WC law.
- Arising Out of and in the Course of Employment (ACOE)
- Two necessary conditions that must be met to establish a work-connected accidental injury. An injury that "arises out of" is one that results from a hazard of the employment, while an injury "in the course of employment" is one that occurred at a time, place, and under circumstances related to the employment.
- Assignment of Interest
- The transfer of an insurance policy from one person or entity to another.
- Assured
- See insured
- ATF (Aggregate Trust Fund)
- See Aggregate Trust Fund
- ATN (Application Tracking Number)
- See Application Tracking Number
- Attorney Fees
- Fees approved by the WCB for claimant attorneys in workers' compensation cases, which will be a lien on the award. (WC law §24)
- Audit (NYSIF Premium)
- The act of inspecting the accounting books, electronic accounts and tax records of a policyholder to determine the actual exposures, which existed during a specified period of time, in order to develop the proper premium.
- Authorized Chiropractor
- New York State licensed chiropractor authorized by the WCB Chair to render chiropractic care under the WC law within the limits prescribed by the Education Law.
- Authorized Podiatrist
- New York State licensed podiatrist authorized by the WCB Chair to render podiatry care or treatment under the WC law. (WC law § 13-k)
- Authorized Provider
- New York State licensed physician authorized by the WCB Chair to render medical care or treatment under the WC law. (WC law § 13-b, Subd. 2)
- Authorized Psychologist
- New York State licensed psychologist authorized by the WCB Chair to render psychological care under the WC law within the limits prescribed by the Education Law.
- Authorized Representative
- An individual or company whom the assured or applicant selects (in writing) to act as that assured's agent. Some common examples of an authorized representative are an insurance broker, an insurance agent, an attorney and an accountant. When the assured is in a Safety Group, the Group Manager automatically becomes the assured's representative.
- Average Weekly Wage (AWW)
- A calculation that reflects the employees' average pay rate used as a basis for determining benefits in workers' compensation insurance. (WC law § 14)
- Award
- Decision given by a WCLJ at a hearing to pay or not pay compensation and/or medical expenses to a claimant.
B
- Binder
- An agreement to furnish protection until an insurance policy can be issued. NYSIF does not use binders for workers' compensation coverage.
- Board Panel Review
- Where a Workers' Compensation Law Judge’s decision is disputed, the aggrieved party may file an application for a review. A panel, usually comprised of three Workers' Compensation Board members (at least one of whom must be a lawyer), reviews these requests to amend decisions made by Workers' Compensation Law Judges.
C
- Cancellation
- The act of terminating an insurance policy before its expiration date, either by the policyholder or by the company.
- Carrier
- An insurance company.
- Carrier Case Number (CC#)
- A unique identifier assigned by the insurance company at the time a workers' compensation case is created for a work-related injury or illness. On correspondence from NYSIF, this number will be identified as the NYSIF Claim Number. This number is different than the WCB case number.
- Causal Relationship
- The connection between the claimant’s injury or illness and the work-related accident or disease. (WC law § 2, Subd. 7)
- Cause of Accident
- Workers' Compensation Board definition: Object, substance or condition that directly contributed to the occurrence of an accident.
- Certificate of Insurance
- A document that provides evidence of the existence and terms of a particular policy.
- Certified Safety Consultant
- Safety and health staff designated as New York State Certified Safety Consultants (CSC) by the New York State Department of Labor. This credential can be used only by those persons who have qualified for and been issued a verification under the Workplace Safety and Loss Prevention Program (Industrial Code Rule 59, NYS Workers’ Compensation Law).
- Chiropractic Fee Schedule
- The schedule established by the WCB with charges and fees for chiropractic treatment and care furnished to workers’ compensation claimants. (WC law § 13-1)
- Claim
- A demand for an amount alleged to be due under an insurance policy following the occurrence or event against which the coverage protects.
- Classification Code
- A system of insurance risk classification based on industrial or occupational categories.
- Classification Rate
- See Rate
- CMS-1500
- A uniform claim form created by the Centers for Medicare & Medicaid Services (CMS) used to bill for medical service rendered. (Formerly known as form HCFA-1500)
- Compulsory
- Required
- Conciliation
- A WCB process established to resolve, in an expeditious and informal manner (e.g. through meeting or telephone conferences), issues involving non-contested claims in which the expected duration of benefits is 52 weeks or less. Each claim that is filed shall be reviewed for possible transfer for conciliation. Failure to reach an agreement through the conciliation process results in the case being scheduled for a hearing.
- Concurrent Employment
- If a claimant has more than one job, the compensation rate is calculated by adding the wages from all of the claimant’s jobs.
- Consequential Accident
- A second accident resulting from a prior accidental injury which arose out of and in the course of employment,e.g., a claimant who falls down a flight of stairs at home while using crutches because of a leg injury incurred at work.
- Continue (a Case)
- Completion of a hearing on a case without closing the case, leaving additional matters to be resolved at a future hearing.
- Controverted Claim
- A claim challenged by the insurer on stated grounds. The WCB sets a pre-hearing for the determination of the grounds and directs the parties to appear and present their case. (WC law § 25)
- Coverage
- Protection afforded by an insurance policy.
- CPT (Current Procedural Terminology)
- The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.
D
- Death Benefit Award
- Awarded by the WCB when the death of a claimant is causally related to the accident that initiated the claim. Benefits are payable in order of priority to: surviving spouse, then children, then all others with equal priority such as dependent parents, grandparents, grandchildren, brothers and sisters. Dependency is determined as of the date of the accident.
- Death Claim
- Claimant died as a result of a work-related injury.
- Debtor in Possession
- This term refers to a debtor that keeps possession and control of its assets while undergoing a reorganization under chapter 11 of U. S. Bankruptcy Code, without the appointment of a case trustee.
- Decision
- Determination arrived at after consideration by the WCB.
- Declaration
- A document issued by an insurance company on a new policy which contains specific information identifying the insured and the coverage afforded. Also known as a New Information Page.
- Deductible
- A policy provision that requires an insurer to only pay that amount of any loss which is in excess of a specified amount.
- Deficiency Compensation
- The compensation and medical benefits payable after the carrier has exhausted its credit against the claimant's net third party recovery.
- Department of Financial Services (NYS)
- The New York State Department of Financial Services is responsible for supervising and regulating all insurance business in New York State.
- Dependent
- A person eligible to receive death benefits in a work related fatal injury case. (WC law § 15)
- Deposition
- Witness testimony ascertaining the facts. Depositions are taken where witnesses cannot appear at a hearing before the WCB. The questions and answers are part of a proceeding before an official person. (WC law § 121; Board Rule 19)
- Diagnostic Testing Network
- A legally and properly organized network of providers or facilities that perform diagnostic tests, x-ray examinations, magnetic resonance imaging (MRI), or other radiological tests for claimants.
- Differential
- A premium rate charged by NYSIF that is greater than the sum of the loss cost in effect for the classification of employees and the applicable expense factor used by NYSIF.
- Disability Benefits Insurance
- New York State disability benefits insurance provides temporary cash benefits paid to an eligible wage earner when he/she is disabled by an off the job illness or injury, and for disabilities arising from pregnancies. Employers with one or more employees are subject to the provisions of the New York State Disability Benefits Law. The Disability Benefits Law provides weekly cash benefits to replace, in part, wages lost due to illness or injury that do not arise out of or in the course of employment. Disability benefits include cash payments only. Medical care is the responsibility of the claimant. Medical care is not paid for by the employer or insurance carrier.
- Disability Benefits Insurance Claim Benefits - Statutory
- NYSIF statutory disability insurance claim benefits equal ½ the average weekly wage of the employee, up to a maximum weekly claim benefit of $170, for 26 weeks (if required) within a 52-week period.
- Disability Benefits Insurance Claim Benefits - Enriched
- NYSIF enriched disability benefits insurance claim benefits equal ½ the average weekly wage of the employee at the maximum weekly claim benefit determined by the policyholders annual selection of coverage, for 26 weeks (if required) within a 52-week period.
- Disability Benefits Statutory Insurance Rates
- Disability benefits insurance rates are determined by each insurer. These rates must be filed and approved by the New York State Insurance Department. The NYSIF statutory disability benefits premium rate for a standard risk policyholder is calculated at $.14 per person, applicable to each $100 of covered payroll limited to a maximum payroll of $340 per person, per week. NYSIF Standard Rates may be increased by a premium modification based upon the annual cost of claims.
- Disfigurement
- Serious and permanent disfigurement to the face, head or neck may entitle the injured worker to compensation up to a maximum of $20,000, depending upon the date of the accident.
- Dividend
- A portion of the premium which may be distributed to a Disability Policyholder or Safety Group policyholder.
E
- Earning Capacity
- The ability of a claimant, who has suffered a work-related disabling injury, to earn wages in the labor market. (WC Law § 15, Sub. 5-a)
- Effective Date
- The date coverage begins on a policy.
- eFROI
- Employer’s First Report of Injury.
- Employee
- One who, for a wage or salary, or as a volunteer, performs services for another under a contract of hire, acting under the direction and control of the person by whom she/he is hired. (WC Law § 2, WC Law § 201)
- Employer's Liability
- The responsibility of an employer to reimburse an injured employee for accidents occurring in the course of employment. Such liability is separate from and is in addition to any statutory liability created under Workers' Compensation Law. Employer's liability is usually insured by a separate section (1B) under a workers' compensation policy.
- Endorsement
- A form attached to a policy in order to modify its terms.
- Enriched Disability Benefits Insurance
- Enriched disability benefits insurance offers policyholders claim benefits that exceed the New York Statutory Disability Benefits claim rate of $170 per week in partial wage replacement for off-the-job injury or illness. NYSIF enriched disability benefits insurance is offered to policyholders who request in writing to increase the level of claim benefits annually, upon renewal, or at the time of application for a new policy. Policyholders may annually choose a greater maximum weekly claim benefit for their employees at incremental levels that exceed the statutory claim benefit.
- Enriched Disability Benefits Insurance Rates
- Enriched disability benefits insurance rates must be filed and approved by the New York State Insurance Department. NYSIF enriched disability benefits premium for a standard risk policyholder is calculated at $.14 per person, applicable to each $100 of covered payroll limited to a maximum payroll of $340 per person, per week, times the selection of coverage chosen by the policyholder. NYSIF standard rates may be increased by a premium modification based upon the cost of claims.
- Entity
- A person, partnership, corporation or political subdivision that can be shown as a named insured in a policy. A legal entity can be served with legal notice and sued in a court of law.
- EOB
- See Explanation of Benefits
- Excess Loss Limit
- Within the context of a NYSIF safety group, it is a monetary amount above which the remaining cost of a claim is paid by reinsurance or the NYSIF and is not deducted as a loss against a safety group’s contingent balance or surplus.
- Exclusion
- A provision in an insurance policy that indicates what is denied coverage under that policy.
- Exclusive Remedy
- The legislature has established the Workers’ Compensation Law as the exclusive remedy of an employee and his /her dependents in a death case, against the employer who has secured workers’ compensation. It is the sole recourse that the injured employee, dependents or representatives have against the employer for injuries or death resulting from a work-connected accident or occupational disease. If an employer who is required to secure workers’ compensation insurance fails to do so, the employee, if disabled due to a work-connected injury, has the right to elect to either claim workers’ compensation or to maintain an action against the uninsured employer for damages. (WC Law § 11)
- Executive Officer
- A corporate president, vice-president, secretary or treasurer appointed in accordance with the charter or by-laws of such corporation.
- Expense Constant
- A policy fee charged on every WC policy, regardless of premium size, to compensate for the basic costs of administering the policy.
- Experience
- The record of losses that is used in predicting future losses and in developing premium rates.
- Experience Modification
- A percentage higher than or less than 100% by which the Manual Rate Premium is increased (experience rate charge) or decreased (experience rate credit) when a risk is eligible for the Experience Rating Plan.
- Experience Rating
- A form of individual risk rating which takes into consideration the loss experience of the particular risk as a credit or a debit to the manual rate for the employer’s classification.
- Explanation of Benefits (EOB)
- An itemization of services provided, amount billed, and amount paid for each claimant represented in a payment to a medical provider.
F
- Facial Disfigurement Award
- An award of compensation for serious permanent facial or head disfigurement. (WC Law § 15, Sub. 3)
- Final Adjustment (FA) Hearing
- WCB hearing held in cases involving the loss or scheduled loss of extremities, sight, hearing, or facial disfigurement in which the principal issue is the extent of loss or loss-of-use. (WC Law § 15, Sub. 3)
- Fraud
- Any person who, knowingly and with intent to defraud, presents causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer or purported insurer, or any agent thereof, any written statement as part of or in support of, an application for the issuance of or the rating of an insurance policy for compensation insurance or a claim for payment or other benefit pursuant to a compensation policy which he or she knows to (i) contain a materially false statement or representation concerning any fact material thereto, or (ii) omits any fact material thereto, shall be guilty of a class E felony.
- FROI
- An acronym used in the insurance industry for First Report of Injury. See NYSIF eFROI.
- Functional Capacity Evaluation (FCE)
- Type of medical exam which helps to verify and determine a claimant's physical capacity.
- Fund for Reopened Cases
- A fund created under the WC law to assume liability for claims of compensation in certain “stale” cases where specified time limits have elapsed.
G
- General Contractor
- An individual or business firm who contracted to perform all or part of a specified job.
- General Employer
- The general employer is the regular or parent employer who makes the employee available to a special employer. The general employer usually exercises indirect control. Either may be liable for the compensation due to the injured employee. (WC law § 2, Sub.3,4)
- General Liability Insurance
- Coverage for an insured when negligent acts and/or omissions result in bodily injury and/or property damage to a third party.
- Governing classification
- The classification which describes the operations of the employer and produces the greatest amount of payroll.
- Guaranteed Cost
- A premium charged on a prospective basis, fixed or adjustable, or on a specified rating basis, but never on the basis of loss experience. In other words, the cost is guaranteed to the extent that it will not be adjusted based on the loss experience of the insured during the period of coverage. Contrast with Retrospective Rating.
H
- Hazard
- Situation or condition which either causes or increases chances of a peril taking place.
- HCPCS (Healthcare Common Procedural Coding System)
- HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies.
- Hearing
- The WC law provides that “no case shall be closed without notice to all interested parties and without giving to all such parties an opportunity to be heard.” These “hearings” are held before a WCLJ who hears and determines claims for compensation for the purpose of ascertaining the substantial rights of the parties. (WC law § 20, 150)
- Hearing Point Locations where the WCB holds hearings.
- HIPAA
- The Health Insurance Portability and Accountability Act of 1996. A law enacted by Congress requiring the U.S. Health and Human Services Department to adopt standards for transmission of information between parties while carrying out financial or administrative activities related to health care. These standards also must address security of protected health information.
I
- Independent Medical Exam (IME)
- Independent medical examination means an examination performed by an authorized or qualified independent medical examiner for purposes of evaluating or providing an opinion with respect to schedule loss, degree of disability, validation of treatment plan or diagnosis, causal relationship, diagnosis or treatment of disability, maximum medical improvement, ability to return to work, permanency, appropriateness of treatment, necessity of treatment, proper treatment, extent of disability, second opinion or any other purpose recognized or requested by the Board.
- Inception Date
- The date on which coverage takes effect.
- Incurred Cost
- The total anticipated ultimate cost of a claim. The incurred cost is the sum of all past payments and a reserve for all future payments.
- Indemnity
- The act of providing restitution for a loss or claim that has been discharged or paid by another liable party.
- Indemnity Benefits
- Compensation paid to the Workers' Compensation claimants for lost time resulting from an injury or illness.
- Independent Contractor
- One who undertakes to do a specific job and retains control of the means, method and manner of performance.
- Indexed Claim
- A claim case folder that has been assembled and assigned a case number by the WCB Claims Unit. (WC law § 141)
- Information Page
- A document issued by an insurance company on a new policy which contains specific information identifying the insured and the coverage afforded. Also known as the Declaration page.
- Insurance
- A contractual arrangement under which one party agrees to indemnify another against loss or damage from an unknown event for a certain sum called a premium.
- Insurance Agent
- An insurance agent represents the insurance company and can enter into contractual obligations on the insurance company's behalf. NYSIF does not have insurance agents.
- Insurance Broker
- An insurance broker is someone licensed to represent an insurance applicant in the negotiating for insurance. Also see Authorized Representative.
- Insured
- The person or entity to be indemnified by the insurer in the event of a covered loss or damage. Also "policyholder."
J
- Joint and Several Liability
- A condition where two or more persons or legal entities are jointly and severally responsible for an obligation.
- Joint Venture
- Two or more employers (usually contractors) who associate and collaborate for the purpose of undertaking one or more projects. The projects under taken by a Joint Venture are usually of a limited duration with specified objective(s).
- Judgment
- The final order or decision by a court or referee on a legal action.
- Jurisdiction
- The WCB has jurisdiction over cases with employment in New York State. Notable exclusions from WCB jurisdiction in NYS include: federal government workers and certain employees of local government. Workers covered by separate compensation systems under federal laws (maritime employment, merchant seafarers, interstate railroad employees, etc.) may elect to submit to NYS jurisdiction by waiving their federal rights and remedies.
L
- Liability
- An obligation imposed by law or equity.
- Licensed Representative
- A person other than an attorney who is authorized by the WCB to represent claimants, or carriers before the WCB. (WC law § 24a, 50-3b, 225, Board Rule Licenses)
- Limit of Liability
- The maximum monetary sum payable under an insurance policy.
- Loss Cost
- The portion of a premium rate that represents the anticipated costs of claims and associated loss adjustment expenses, including one or more trend factors, but which does not include provisions for insurer-specific expenses such as acquisition costs, overhead and taxes, or profit. Loss costs are based on loss data provided by all workers’ compensation insurers and are filed by the rate service organization for workers’ compensation (the New York Compensation Insurance Rating Board) with the New York State Department of Financial Services.
- Loss Cost Multiplier
- The portion of the premium rate not included in the loss costs filed by the rate service organization for workers’ compensation (the New York Compensation Insurance Rating Board), which includes insurer-specific expenses such as acquisition costs, overhead, taxes and profit.
- Loss Ratio
- The losses incurred expressed as a percentage of earned premium.
- Loss Reserves
- Funds set aside for the payment of losses which have been incurred, but are not yet due.
- Lost Time
- This is the time lost from work directly related to a workers’ compensation claim. A claimant is not entitled to lost time wages (Indemnity Benefits) until after the statutory waiting period of seven (7) days.
- Lump Sum Settlement
- A negotiated and WCB-approved agreement, termed a "non-schedule adjustment," between a claimant with a non-schedule permanent partial disability and the claim defendant(s). As a result of the agreement the claimant receives a sum of money representing all future compensation for her/his disability, and the case is considered closed. Under WCL§15(5-b), granting of a settlement by the Board requires that (a) the right to compensation has been established and compensation has been paid for at least three months; (b) the continuance of disability and of future earning capacity cannot be ascertained with reasonable certainty; (c) there has been a physical examination of the claimant prior to approval; and (d) the Board considers the settlement "fair and in the best interest of the claimant."
M
- Maximum Medical Improvement (MMI)
- An assessed condition of a claimant based on medical judgment that (a) the claimant has recovered from the work-related injury to the greatest extent that is expected, and (b) no further change in her/his condition is expected. A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant.
- Medical Benefits
- Medical treatment provided, under the WC law, to injured workers as a result of injuries arising out of and in the course of employment.
- Medical Fee Schedule
- The schedule established by the WCB Chair of charges and fees for medical treatment and care furnished to workers’ compensation claimants. (WC law § 13, Sub. A)
- Medical Treatment
- Care (other than first aid) administered by a physician, chiropractor or podiatrist or on a physician's referral, by a psychologist, or physical or occupational therapist.
- Minimum Premium Deposit
- The least amount required in order for a policy to be issued.
- Motion Calendar Hearing
- The Motion Calendar has been replaced by the Administrative Decision process. A Motion Calendar case was previously a case with no controversy or outstanding issue.
- Multi-factor authentication
- Multi-factor authentication adds a layer of protection against unauthorized access to your account by asking for information only you know or possess in addition to your username and password.
N
- Named Insured
- The person or entity named in a policy as being protected by such policy.
- National Council on Compensation Insurance (NCCI)
- The National Council on Compensation Insurance, Inc., manages the nation’s largest database of workers' compensation insurance information. NCCI analyzes industry trends, prepares workers' compensation insurance rate recommendations, determines the cost of proposed legislation, and provides a variety of services and tools to maintain a healthy workers' compensation system.
- National Drug Code
- The National Drug Code (NDC) is a unique code that identifies the vendor (manufacturer), product and package size of a drug recognized by the Food and Drug Administration.
- National Institute for Occupational Safety and Health (NIOSH)
- An agency within the U.S. Department of Health and Human Services and part of the Center for Disease Control and Prevention. NIOSH is generally responsible for conducting research and making recommendations for the prevention of work-related illnesses and injuries.
- National Provider Identifier (NPI)
- Standard unique identifier that must be used by health care providers for electronic health care transactions covered under HIPAA.
- Negligence
- An act or omission in which there is a failure to use the ordinary care that a prudent person ought to use under the circumstances. Negligence can cause or create a legal liability.
- New York Compensation Insurance Rating Board (NYCIRB)
- An association of workers’ compensation insurers licensed by the Superintendent of the Department of Financial Services as the rate service organization (RSO) for workers’ compensation in New York. It collects and analyzes loss data and, as the designated RSO, files loss costs with the Insurance Department for rate making purposes. It also administers experience rating and classifications of employers for determining premium.
- New York Construction Classification Premium Adjustment Program (NYCCPAP)
- The NYCCPAP was adopted on April 1, 1993 to address premium differences between high wage and low wage paying employers having similar construction operations. Premium credits based upon the hourly wage rate paid by the employer and the distribution of classifications shown on the employer’s policy are developed by the Rating Board and applied to the insured's premium.
- No Compensable Lost Time (NCLT)
- Claimant has not lost time from employment beyond the statutory waiting period (the first seven days of disability) as a result of work related injuries. (WC Law § 12)
- No Further Action (NFA)
- A decision of no further action (NFA) is based on a WCLJ determination that no issues need to be adjudicated by the WCB at the time of the finding. If or when further WCB action is required, a hearing must be requested by one of the parties to the claim.
- No Lost Time (NLT)
- Claimant has not lost time from employment beyond the date of the accident as a result of a work-related injury. (WC Law § 12)
- Non-Insurer
- An employer who has failed to provide for the payment of benefits to employees under the WC law or under the Disability Benefits law. (WC law § 50, 220)
- Notice (VFBL & VAWBL)
- Under the Volunteer Firefighters' Benefit Law and the Volunteer Ambulance Workers' Benefit Law, notice of injury or death must be given by the injured volunteer firefighter or ambulance worker or dependents within 90 days after the injury or death.
- Notice (WC Law)
- Employees who are injured on the job must give their employers notice in writing of the occurrence as soon as possible but not later than 30 days thereafter. The WCB may excuse the failure to give notice on the ground that notice for some sufficient reason could not have been given, on the ground that the employer had knowledge of the accident, or on the ground that the employer had not been prejudiced thereby. In addition, a report of injury or illness must be filed with the WCB within two years. Failure to file a report of injury or illness may bar an award of compensation unless the employer has made advance payments to the injured worker, or has failed to raise the issue at the first hearing at which all parties were present. (WC law § 18, 28, 40, and 45)
- NYCIRB
- See New York Compensation Insurance Rating Board
- NYSIF Claim Number
- NYSIF's carrier case number also known as a workers' compensation claim number or loss id (e.g. 12345678 - 123). The last three numbers typically identify the NYSIF claim unit handling this claim.
O
- Occupational Disease (OD)
- A disease arising from employment conditions for a class of worker, with the disease occurring as a natural incident for particular occupations, distinct from and exceeding the ordinary hazards and risks of employment. To be considered an occupational disease, there must be some recognizable link between the disease and some distinctive features of the worker's job. (WC law § 2 (15), 3(2), 37)
- OSHA
- The Occupational Safety and Health Administration was established by the OSH Act of 1970. Under this federal law, the US Department of Labor has responsibility of formulating safety and health standards for all businesses engaged in interstate commerce.
P
- Paid Family Leave (PFL)
- Effective January 1, 2018, the New York State Paid Family Leave Program provides New Yorkers job-protected, paid leave to bond with a new child, care for a loved one with a serious health condition or to help relieve family pressures when someone is called to active military service. NYSIF offers PFL coverage as part of NYSIF disability benefits (DB) policies.
- Partial Disability
- Disability which allows a claimant to engage in some kind of gainful employment. The difference between the claimant’s pre-accident earnings and post-accident earnings is determinative of the reduced earnings rate. (WC law § 15, Sub.5, 5-a)
- Party of Interest (POI)
- Any person or organization (ex: the carrier, claimant, representative, employer, hospital, etc.) that is placed on notice for hearings and/or decisions.
- PASS (Premium Audit Scheduling System)
- NYSIF's online Premium Audit Scheduling System (PASS) allows NYSIF policyholders scheduled for a premium audit to choose a more convenient date and time, or to change the audit location. Policyholders can also schedule a virtual audit using this system.
- Permanent Partial Disability (PPD)
- Part of the employee's wage-earning capacity has been permanently lost. There are two types of permanent partial disability benefits, depending on the body part affected and the nature of the permanent disability: schedule loss of use (SLU) and non-schedule. The severity of the disability is measured when the employee has reached maximum medical improvement (MMI). MMI is presumed to occur no more than two years after the date of injury.
- PPD Cap
- The maximum number of weeks of compensation, from 225 to 525, that a claimant classified as PPD may receive, based on percentage finding of lost earning capacity. The cap applies only to non-scheduled PPD cases with a date of accident on or after March 13, 2007.
- PPD Extreme Hardship
- An Extreme Hardship redetermination may be made in a capped PPD case where the claimant was classified with a finding of lost earning capacity which exceeds 80%. The claimant may request a reclassification at the WCB for a Permanent Total Disability (PTD) or Total Industrial Disability (TID). (WC Law § 35)
- Permanent Total Disability (PTD)
- The employee's wage-earning capacity is permanently and totally lost. There is no limit on the number of weeks payable. In certain instances, an employee may continue to engage in business or employment, if his/her wages, combined with the weekly benefit, do not exceed the maximums set by law.
- Pharmacy Benefits Manager (PBM)
- A network of pharmacies and mail order services under the direction of an organization, which provide prescription benefits under contract or agreement with a carrier or employer.
- Physical Hazard
- A physical hazard is a feature in the construction, maintenance, use or condition of a work location that creates the possibility of an accident.
- Policyholder
- A party to whom a policy is issued, and who pays a premium to an insurer in consideration of the latter's promise to provide insurance protection.
- Policy Number
- The number that is assigned to your insurance policy.
- Policy Year
- The year commencing with the effective date of a policy or with the renewal date of that policy, to be distinguished from calendar year, which always starts January 1.
- PPD
- See Permanent Partial Disability.
- Pre-Existing Condition
- Injuries, sickness or medical conditions existing prior to the injury or onset of the occupational disease.
- Preferred Provider Organization (PPO)
- Network of medical providers that renders services (at contracted rates) for the treatment of workers' compensation injuries and illnesses to employees of participating policyholders.
- Pre-Hearing Conference
- If a case is controverted, the WCB must schedule a pre-hearing conference before a WCLJ within 60 days of the receipt of notice of controversy from carrier or employer. This hearing is for the purpose of identifying witnesses, limiting issues and, if possible, to establish the case upon the agreement of the parties
- Premium
- The rate that an insured is charged reflecting their expectation of loss or risk.
- Primary Insurance
- Insurance that responds first to a claim (i.e., it provides coverage on a first-dollar basis), sometimes subject to a deductible.
- Protracted Healing Period
- In the case of temporary total disability and permanent partial disability both resulting from the same schedule injury, if the period of temporary total disability continues for a longer period than the normal healing period as set forth in WC law §15, Sub. 4-a, the period of temporary total disability in excess of such normal healing period is added to the schedule award. (WC law §15, Sub. 4-a, WC law and § 9)
R
- Rate
- Cost of insurance per unit used as a means or base for the determination of premium.
- Ratemaking
- Ratemaking is a process by which historical insurance statistics are compiled, analyzed and projected into the future by trained actuarial professionals in order to produce adequate and equitable manual rates or loss costs. The Actuarial Department of the New York Compensation Rating Board is responsible for calculating the appropriate loss cost for each of approximately 600 classifications of businesses throughout the state.
- Rate Service Organization (RSO)
- A Rate Service Organization (RSO) is an entity designated by the Superintendent of the New York State Department of Financial Services for the collection and analysis of workers' compensation data.
- Rating Date
- The anniversary rating date is the effective month and day of the policy in effect and each annual anniversary thereafter unless a different date has been established by the Rating Board. Normally the anniversary rating date is the same as the policy effective date. However, the rating date can be different from the policy effective date, e.g., if a policy has been short termed on an experience rated policy for which the rating date remains the same. The rating date determines which rates are to be applied for a given period regardless of the policy anniversary date.
- Reduced Earnings
- A compensation rate based on the claimant’s reduced earning or reduced earning capacity due to a condition related to a compensable injury (WC law § 15).
- Rehabilitation
- The process of restoring injured workers to productive employment through physical means, medical procedures, vocational retraining, selective placement, and social readjustment. Rehabilitation is an integral part of the medical care and other services furnished a claimant under the law. (WC law §13, Sub. a)
- Remarriage Award
- An award of two years’ compensation paid in a lump sum, to the surviving widow or surviving widower of a fatally injured worker upon his or her remarriage. (WC law § 16, Sub. 2)
- Renewal
- A document issued by an insurance company extending the terms of a policy for a subsequent period of time. It reestablishes the in-force status of a policy. All NYSIF policies with in-force status are automatically renewed unless instructed otherwise by the policyholder or their representative.
- Reopened Case
- A case that has been closed by a WCLJ or the WCB, and is subsequently made active again to determine the claimant’s eligibility for benefits. (WC law § 22, 23, and 224)
- Rescind (a Decision)
- A WCB Panel memorandum of decision which voids or annuls a WCLJ decision. Decisions to rescind are usually issued without prejudice in order to allow the parties to present evidence or testimony not previously presented to a WCLJ.
- Reserve
- The amount of money set aside to pay the potential future cost of a claim.
- Retrospective Rating
- An insurance plan for which the final premium is not determined until the end of the coverage period and is based on the insured's own loss experience for that same period.
- Risk
- The entity, property or other exposure to be insured. Also used to signify uncertainty about financial loss.
- Return to Work (RTW)
- A Return to Work program is a written plan designed to get employees back to work as soon as medically possible following an on-the-job injury or illness, and can be initiated by either the employer or the carrier. It is mutually beneficial to both employees and employers.
S
- Safety Group
- Safety Group is a loss sensitive insurance program that enables employers in the same industry to pool their insurance premiums with the goal of reducing the cost of workers' compensation insurance.
- Scheduled Loss of Use (SLU)
- An SLU occurs when an employee has permanently lost use of an upper extremity (shoulder, arm, hand, wrist, finger), lower extremity (hip, leg, knee, ankle, foot, toe), or eyesight or hearing. Compensation is limited to a certain number of weeks based on the body part and severity of the disability, according to a schedule set by law. Temporary benefits that have been paid are deducted from the total SLU award.
- Second Injury Fund
- Unofficial name for the Special Disability Fund established to encourage employers to hire workers with physical handicaps. When workers with pre-existing conditions suffer further work-related injuries, or disease, that results in a greater disability, the employer, through the insurer, is responsible for only part of the benefits. The Second Injury Fund is responsible for the rest (WC law § 15, Sub. 8). This provision no longer applies for loss dates after June 30, 2007.
- Section 32 Settlement
- WC Law § 32 Waiver Agreements allow for complete, full and final resolution of a WC claim.
- Self-Insurance
- A method by which an employer or group of employers may secure the payment of workers’ compensation or disability benefits for its employees by depositing securities, cash, letters of credit or a surety bond in an amount required by the WCB Chair. (WC law § 50, § 211)
- Short Rate Cancellation
- Termination of a NYSIF WC policy before its normal expiration date which in turn causes a refund of premium which is less than that which would ordinarily be due to the insured for the proportion of time that coverage was in force.
- SIF Manual Rate Premium
- Where the loss cost for a given classification is based on payroll exposure, the SIF manual rate premium is computed by multiplying the estimated annual payroll by the rate (expressed in dollars and cents per $100 per payroll), which is arrived at by multiplying the approved loss cost by the SIF loss cost multiplier and dividing the result by 100.
- Sole Proprietorship
- Individual ownership of a business or other institution.
- Special Funds
- Funds established under the WC law to assure payments of benefits associated with claims, usually by transferring all or part of the liability to Special Funds.
- Special Funds Conservation Committee (SFCC)
- The Special Funds Conservation Committee was established in 1938 for the purpose of maintaining and defending the Special Disability Fund and the Fund for Reopened Cases under § 15-8 and § 25-a of the Workers’ Compensation Law.
- Subcontractor
- An individual or business firm contracting to perform part of or all of another's contract. More about Subcontractors.
- Subpoena
- A legal writ commanding a designated person to appear and give testimony at a compensation hearing under penalty for failure to do so. The Chair, Board Members, Judges, officers of the WCB designated by the Chair and any attorney may sign and issue a subpoena, or a subpoena duces tecum, the latter requiring the production of records. (WC law § 119, 142 -3, 231)
- Subrogation
- The right of a secondary party (e.g., insurance company) to stand in the place of another (e.g., a policyholder or claimant) after making payment to a creditor (e.g., claimant) to enforce the creditor's right against the party primarily liable for such payment in order to obtain indemnity from such primary party.
- Subsequent Report of Injury (SROI)
- A record of an event sent to the WCB that completes a subsequent report of injury requirement.
- Symptomatic Treatment
- Medical treatments aimed at providing relief from the symptoms of a disease or injury, rather than providing a permanent remedy to the underlying condition.
T
- Temporary Partial Disability (TPD)
- The wage earning capacity is lost only partially, and on a temporary basis.
- Temporary Reduced Earnings (TRE)
- A temporary reduced earnings rate of compensation pending adjudication of the actual amount of reduced earnings or the determination of the claimant’s reduced wage earning capacity.
- Temporary Total Disability (TTD)
- The injured worker's wage-earning capacity is lost totally, but only on a temporary basis.
- Third Party Action
- In workers' compensation cases, the term often refers to lawsuits against parties such as equipment manufacturers, facility owners and other non-employer entities whose products or services contributed to the occurrence of an accident.
- Third Party Administrator (TPA)
- An independent organization that has been contracted to administer identified services. These services may include claims administration, premium collection, enrollment and other administrative functions.
- Third Party Settlement
- When a claimant’s work related injury is the result of negligence or wrongdoing of a party other than the employer or a fellow employee, the claimant may sue. A carrier that has paid compensation or disability benefits has a lien on any sums recovered in a third party action. (WC law § 20, 29, 227 and VFBL and VAWBL)
- Total Disability
- No wage earning capacity. (WC Law § 15, Sub. 1,2)
- Total Industrial Disability (TID)
- Complete loss of earning capacity due to claimant’s permanent partial disability. This is based on medical factors, combined with other vocational factors (such as limited education), which render the claimant incapable of any gainful employment.
- Trial Calendar Hearing
- A regularly scheduled hearing on a case conducted by a WCLJ that is designed to permit the introduction of evidence and/or witnesses and the presentation of arguments by the parties.
U
- Underwriter
- The person authorized by an insurance company to bind coverage and make changes to policy terms.
- Uninsured Employers' Fund (UEF)
- A special fund that provides for the payment of workers’ compensation in cases where the employer was not insured or self insured. (WC law § 26-a)
V
- Voluntary Compensation
- An addition to a workers' compensation policy that covers benefits to employees who are not required to be covered by a state's WC law.
- Volunteer Ambulance Workers’ Benefit Law (VAWBL)
- Chapter 64-B of the Consolidated Laws provides medical and compensation benefits or, in the case of death, death and survivor benefits to their dependents for volunteer ambulance workers.
- Volunteer Firefighters’ Benefit Law (VFBL)
- Chapter 64-A of the Consolidated Laws provides medical and compensation benefits or, in the case of death, death and survivor benefits to their dependents for volunteer firefighters.
W
- WA-1 (Work Activity Form)
- A NYSIF form periodically sent to claimants requesting certification of current employment status and continued entitlement to worker's compensation benefits.
- Wage Expectancy
- The wages of a claimant who is under the age of 25 when the accident occurs are presumed to increase under normal conditions. The WCB may consider this fact in establishing the claimant’s compensation rate if the injuries are permanent. (WC law § 14, Sub. 5)
- Wage Replacement
- The proportion of pre-injury wages replaced by workers' compensation benefits.
- Wages
- The money rate at which employment with an employer is recompensed under the contract of hiring with the employer and shall include the reasonable value of board, rent, housing, lodging or similar advantage received under the contract of hiring. (WC law § 2, Sub. 9, § 201, Sub. 12)
- Waiting Period
- Period covering the first seven days of disability resulting from a work-connected injury or illness. Workers' compensation indemnity benefits are not allowable for the first seven days of disability, except in cases where the disability period exceeds 14 days, indemnity awards are allowed from the date of disability (WC law § 12, § 204 and § 211). There is no waiting period for VAWBL and VFBL cases (WC law § 43).
- Waiver Agreement Management Office
- Waiver Agreement Management Office (WAMO) under the supervision of the chair of the Workers' Compensation Board. WAMO will be dedicated to expediting Section 32 Settlements on §15-8 (Second Injury) established cases, pursuant to WC Law.
- Waiver of Subrogation
- A voluntary release or relinquishment of a right of action (e.g., right to sue) on behalf of another.
- WCB Case Number
- A reported work injury or illness, which has been assembled and assigned a case number (indexed) by an indexing unit of the WCB. The WCB Case Number (workers' compensation) is eight characters beginning with an alpha character, followed by seven numeric characters. For example, G1234567. Volunteer ambulance workers’ cases begin with AA, followed by six numbers (e.g. AA123456). Volunteer firefighters’ cases begin with FA, followed by six numbers (e.g. FA123456).
- WCB Examiner
- A Workers' Compensation Board Examiner performs examining work, applying knowledge of WC law and of WCB rules, regulations, policies and procedures to compensation and disability benefit case information. Among the actions regarding workers' compensation cases that examiners may perform are:
- determining whether a case should be indexed;
- evaluating claim forms and developing information required by judges for case decisions;
- requesting information (by phone, letter, etc.) needed for case development;
- evaluating whether a compensation case may be processed on an informal calendar;
- referring appropriate cases to the conciliation process; and
- preparing formal notices of decision based on judge's directions.
- Without Prejudice
- The term implying employers or their insurance carriers may provide non-binding compensation or medical payments, including payments for medication, for up to one year without admitting liability or giving up specific legal rights.
- Workers' Compensation Board (WCB)
- A New York State agency, the Workers' Compensation Board is:
- (a) The agency charged with administering the provisions of the NYS WC law, including: Workers' Compensation Law, the Volunteer Ambulance Workers Benefit Law, the Volunteer Firefighters Benefit Law, and the Disability Benefits Law.
- (b) The 13-member board responsible, either directly or via review by delegated authority, for determining all issues involving claims under the Workers' Compensation Law.
- Workers' Compensation Insurance
- New York State Workers' Compensation insurance provides injured workers with medical and compensation benefits or, in the case of death, death and survivor benefits to their dependents for on-the-job injuries.
- Workers' Compensation Insurance Rates
- Rates are determined by the New York Compensation Insurance Rating Board (NYCIRB) and published in the Rating Board Manual. These rates are usually per $100 of payroll, with the rate being determined by job classification. There are several classifications, however, where the rate is not on a payroll basis, but rather on a per capita, per location, population or per policy.
- Workers' Compensation Law
- Chapter 67 of the Consolidated Laws, governing the workers' compensation system; separate laws cover compensation benefits for volunteer firefighters and volunteer ambulance workers.
- Workers' Compensation Law Judge (WCLJ)
- An officer appointed by the WCB Chair to hear and determine claims and to conduct hearings and investigations and make such orders, decisions and determinations as may be required in the adjudication of the claim. A Judge's decision is deemed the decision of the WCB unless the WCB modifies or rescinds such decision.
- Wrap-up Insurance
- A policy that covers all exposures for a large group that has something in common. For example, wrap-up insurance is written for all the various businesses working together on a particular project, to provide coverage for losses arising out of that work only.