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Insurance carriers contest claims for a variety of reasons, including that the injury was not related to work, or the employee is not injured to the extent claimed. An employer can request that the insurance carrier contest the claim. However, if the insurance carrier has assumed the liability for the claim, it is not required to comply with the employer's request.
NYSIF has found the best way to collect proper premium and pay workers’ compensation claims on behalf of our policyholders is with an actual audit. In addition, NYCIRB requires an annual audit of any policyholder with an annual premium of $5,000 or more.
NYSIF follows an underwriting process and premium audit verification, as directed by NYCIRB. NYSIF's classification procedure is to assign one, basic classification that best describes the business of the employer within the state. Subject to certain exceptions, each classification includes all types of labor found in a business. It is the business which is classified, not the individual employments, occupations or operations within a business.
Write to the New York Compensation Insurance Rating Board (NYCIRB) Underwriting Department with a detailed description of your operation(s). NYCIRB will determine if it authorized a classification. If NYCIRB does not have an inspection on file, it will schedule an inspection of your business or request additional information to determine the correct classification(s). If NYCIRB disagrees with the classification assigned to your business it will instruct the insurance carrier to use the correct classification code.
If a policyholder hires or utilizes individuals who have been deemed as compensable employees by a Workers’ Compensation Board (WCB) Law Judge in the past, we are obligated to include them.
NYSIF auditors follow standard guidelines when estimating payrolls. Rates and percentages vary depending on the premium size, longevity of the policyholder, and specific facts related to the risk. The goal of the estimate is to generate enough premium to cover the potential exposure to NYSIF and, secondly, to provide the impetus for the policyholder to provide a full set of records to our auditors.
Many times relatives are not paid or are paid less than a non-relative doing the same work. However, if relatives are injured the judge sets their wage replacement benefits based on that of a comparable worker.
Hiring a lawyer is the claimant's decision. Attorney fees are deducted from a claimant's award, as determined by the Workers' Compensation Law Judge. A claimant must not pay an attorney directly. A WC Law Judge may assist a claimant not represented by an attorney.
You may file an application for review with the WCB within 30 days of the filing of the judge's decision, specifying why you disagree with the decision.
By law, insurers may designate the pharmacy, pharmacy network or mail-order pharmacy you use to get your medications. The network we have chosen must include pharmacies that are either within a reasonable distance from you or that offer mail order service. If there is a medical emergency, when it is not reasonably possible to obtain the medicine you need immediately from the pharmacies in the chosen network, you can purchase the drugs from any pharmacy.
Section 32 Waiver Agreements are a negotiated between the injured worker and the insurance carrier to settle indemnity and/or medical benefits on a claim. A waiver agreement ends the right of an injured worker to future benefits in exchange for a lump sum payment or an annuity. Talk to your attorney about your eligibility for a Section 32 settlement.
