Most claims for workers’ compensation benefits are accepted and benefits initially paid by the claimant’s employer or its insurance carrier without any dispute, and without the need for a decision by the Workers’ Compensation Board (Board). However, issues do sometimes arise with respect to claims for workers’ compensation benefits. For example, there may be a dispute concerning whether an injury is work-related, claimant’s degree of disability, the monetary awards payable to the claimant, or what medical treatment is appropriate. The Board is responsible for resolving those questions. It is also sometimes necessary for the Board to a issue a decision formally finding that a claim is established for a particular injury or injuries, or that the claimant was paid benefits for a period of time, even though those findings are not in dispute.
Some simple issues can be addressed by the Board informally, without a hearing, while more complex disputes require a formal hearing before a Workers’ Compensation Law Judge. Depending upon the issue, the following methods may be used by the Board to resolve issues arising in a claim.
Administrative decisions can be issued by the Board in any claim to commemorate findings and awards which are not in dispute, with respect to any issue in an uncontroverted claim involving minor injuries, and to assess certain penalties against employers and insurance carriers. All administrative decisions are reviewed and approved by a Workers’ Compensation Law Judge.
An administrative decision will indicate the date the decision was “filed” and sent to the parties, as well as the date on which the decision will become “final,” which will be at least 30 days later. The parties may file a written objection to an administrative decision at any time before the decision becomes final. When it receives a timely objection to an administrative decision, the Board will notify the parties that the decision will not be made final and, as may be appropriate, refer the matter to the conciliation process, refer the matter for a hearing before a Workers' Compensation Law Judge, or issue a modified administrative decision.
Once an administrative decision becomes final, the parties have 30 days to file a request for administrative review of the decision with the Board.
Whenever an issue arises which cannot be resolved by an administrative decision, but does not warrant a formal hearing before a Workers’ Compensation Law Judge (WCLJ), the claim is referred to the conciliation process. The matter will be reviewed by a “conciliator,” who is an attorney employed by the Workers’ Compensation Board (Board), who will issue a proposed conciliation decision which attempts to reconcile and resolve the issue in dispute. If the claimant is not represented by an attorney or licensed representative, the proposed conciliation decision will be reviewed and approved by a Workers’ Compensation Law Judge.
A proposed conciliation decision will indicate the date the decision was “filed” and sent to the parties, as well as the date on which the decision will become “final,” which will be at least 30 days later. The parties may file a written objection to a proposed conciliation decision at any time before the decision becomes final. When it receives a timely objection to a proposed conciliation decision, the Board will notify the parties that the decision will not be made final and the claim will be referred for a hearing before a Workers’ Compensation Law Judge.
Once final, a proposed conciliation decision is binding on the parties and cannot be appealed.
When an employer or its insurance carrier fails to timely approve or object to a request submitted by a claimant’s treating health care provider for authorization for special medical services (including certain surgeries), or for treatment which varies from the Board’s Medical Treatment Guidelines, the Board may issue an Order of the Chair approving the special services or variance. An Order of the Chair may not be appealed.
Formal hearings before a Workers’ Compensation Law Judge (WCLJ) are held when complicated issues arise. Often it is necessary to take the testimony of the claimant and other witnesses in the presence of the WCLJ. In years past, all hearing were conducted in-person at a Workers’ Compensation Board hearing location. Today, however, advances in technology allow parties, legal representatives and witnesses to attend Virtual Hearings online.
When a hearing is held, a written “notice of decision” reflecting the findings and awards made by the Workers’ Compensation (WCLJ) at the hearing is typically issued within a few days of the hearing. However, when a WCLJ must decide an especially complex issue, or needs time to review the testimony taken at a prior hearing, or the deposition testimony of the health care provider, the WCLJ may not render findings and awards at the time of the hearing, and instead will delay or “reserve” decision until after they have thoroughly reviewed evidence in the record. When this occurs, a “reserved decision” will be issued, usually a week or more after the last hearing, setting forth in writing the WCLJ’s findings and awards.
All findings and awards made by a WCLJ, whether reflected in a “notice of decision” or a “reserved” decision, are subject to administrative appeal.
The parties have 30 days from the date an administrative decision, or a decision of a Workers’ Compensation Law Judge (WCLJ) is filed, to file a request for administrative review of the decision. The opposing parties then have 30 days to file a rebuttal. Upon the filing of a complete and timely request for administrative review, a three-member panel of the Workers’ Compensation Board will issue a written “memorandum of decision” of its findings and conclusions on the issues in dispute.
The parties have 30 days from the date a “memorandum of decision” is filed to request that the decision be reviewed by the full Board. The Board may either grant review by the full Board and issue a new decision, or may advise the parties that full Board review has been denied.
The parties may also appeal a “memorandum of decision” of a three-member Board panel, a decision denying a request for review by the full Board, or a decision of the full Board, to the Appellate Division, Third Department .
The parties may resolve outstanding issues by entering into a written stipulation which will become binding on the parties upon approval by Board. Parties to a claim for workers’ compensation benefits may also enter into a written agreement permanently settling all or part of claim. An agreement waiving a claimant’s right to further lost wage or medical benefits will not be enforceable until it is approved by the Board and after the parties are given time to withdraw from the agreement, if they so choose.