From the Desk of Managing Partner Sarah Thomas
The New York State Workers’ Compensation Board (Board) has announced that starting in December 2024 they will begin using a new procedure to expedite claims for additional sites of injury and consequential injuries.
This means if the board receives a Request for Further Action by Legal Counsel (Form RFA-1LC) presenting prima facie medical evidence (PFME) for an unestablished injury or condition, they will expedite a determination by issuing a Proposed Decision finding PFME.
Next Steps for Insurers
Unless the insurer contends the finding of PFME was made in error, there should be no objection to the Proposed Decision.
Within 30 days of the Proposed Decision, the insurer should:
- If accepting the new body part or condition: Notify the Board by filing a FROI-02.
- If not accepting the new body part or condition: Proceed with development of the record by:
- Obtaining an independent medical examination (IME) within 60 days; or
- Waiving the IME and cross-examining the claimant’s health care provider within 60 days.
What this Means for Insurers
With this new procedure it will be more important than ever for carriers, third party administrators (TPAs) and self-insured employers to monitor their proposed decisions and respond in a timely manner. The turnaround period on these decisions is tight. Any delay could result in your acceptance or rejection of the decision not taking.
Similarly, a timely IME will be important. The turnaround period is just 60 days. With that in mind, work with your IME doctor to ensure they only comment on exactly what PFME you are agreeing to and nothing else.
Finally, before filing a Request for Further Action by Legal Counsel (Form RFA-1LC) with PFME, it will be important to review the PFME for any issues. Issues to look for include red flags such as undisclosed prior injuries. Such issues should be investigated by way of medical canvass and other investigative means and explained or resolved before filing Form RFA-1LC.
Next Steps for The Board
Once the Proposed Decision is finalized, the Board will determine next steps, which may include:
- A Proposed Decision establishing the injury/condition
- A Reserved Decision (if the record is complete)
- A Proposed Decision directing depositions (if there is a joined issue)
- A hearing for additional development of the record and a bench decision
Steps Jones Jones is Taking
In additional sites of injury and consequential injuries cases, testimony of a claimant is key. Each case is unique and not every issue is a straight medical issue. Jones Jones understands the complexity of such cases and will be working to ensure we have the space to address such issues before the board. In all cases we will work to question the claimant about the alleged consequential injuries. This includes situations where we move forward with producing an IME in response to a Proposed Decision.
For more information on this new claim conciliation procedure, please visit the Board’s Representatives webpage. If you have questions about how this new procedure may impact you, please contact us at clientservices@jonesjones.com.