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New York State Workers’ Compensation Board Announces New Claim Conciliation Procedure for Additional Sites of Injury and Consequential Injuries

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.  

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Jones Jones LLC Educates on Continued RICO Fraud Cases with All-Staff Webinar

In October 2024, the New Jersey and Manhattan offices of Jones Jones LLC came together virtually for an informative webinar on the recent rise in cases being investigated by the Racketeer Influenced and Corrupt Organizations Act (RICO) throughout New York. This webinar is one of many educational sessions and trainings Jones Jones offers staff and clients alike to remain at the forefront of litigation trends and changes.

In these cases, an insurer is claiming construction workers, local lawyers, doctors and other vendors have collaborated to stage accidents in an alleged scheme to commit insurance fraud. These instances of fraud are on the rise and have caused costly claims for insurers as well as increased insurance premiums for insureds.

Jones Jones has recently handled a number of workers’ compensation cases tied to the RICO cases, including a case that Partner Katherine Caracappa outlines in a recent Major Win Alert blog. Jones Jones remains at the forefront of litigation claims related to RICO cases and continues to win these cases as we use in-depth knowledge of workers’ compensation law and thorough research tactics to address these cases. Meetings and trainings such as the RICO webinar help Jones Jones staff stay aware of the cases, as well as informing all attorneys on tactics to continue to secure positive outcomes.

The construction team, made up of Supervising Partner Rosanna Shamash, Partner Dana Sabghir and Partner Katherine Caracappa, presented to the entire Jones Jones staff during this lunchtime webinar.

Jones Jones LLC offers educational meetings and informational trainings, such as the RICO webinar to clients to help them remain at the forefront of trending industry issues and mitigate risk to their business. If you are interested in hosting Jones Jones for a training session, please contact our appellate team at clientservices@jonesjonesllc.com.

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Major Win Alert: Jones Jones LLC Partner Breaks Claimant’s Credibility, Secures Disallowance

Congratulations to Jones Jones LLC Partner Katherine Caracappa for securing a disallowance before the New York State Workers’ Compensation Board. Caracappa and her team found the claimant lacked credibility due to a number of inconsistencies between their testimony and C-3 form, or employee claim form.

In this case the claimant stated they were conducting work to build a deck for their employer when a heavy object fell and injured them. On their C-3 the claimant stated they gave notice to an alleged witness on the date of the incident and noted they were not sure if anyone witnessed the accident. During testimony, the claimant stated they had not spoken to the alleged witness, and thought the witness would have heard about the incident through word of mouth or by reviewing camera footage. The claimant also stated in their testimony that the accident happened in front of a lot of people, but no one helped them up. The witness testified they had not spoken to the claimant about the incident and heard about it from another worker a month after the claimant stopped working.

During cross-examination, Caracappa and her team pushed the claimant on their inconsistencies between the C-3 and their testimony. The claimant could not explain these inconsistencies and their testimony fell apart. Additionally, the claimant failed to list any witnesses to the accident on their C-3 but named multiple people during their testimony, creating more inconsistencies. Caracappa and her team made Summations on behalf of the client due to the number of inconsistencies and inappropriate nature of the claimant naming witnesses in their testimony that were not listed in their C-3. The Law Judge agreed to the Summations and based on the claimant’s ultimate statement that they did not report the incident to their superior, the Law Judge found the claimant was not credible and disallowed the claim.

Caracappa and her team showcased exhaustive research skills in finding the many inconsistencies between testimonies and C-3. The team also exemplified strong cross-examination skills. Congratulations to Caracappa and her team on this positive outcome. If you are in need of assistance with a workers’ compensation case, please contact our team at clientservices@jonesjonesllc.com.

Major Win Alert: Jones Jones Secures Dismissal for International Airline

Jones Jones LLC congratulates Associate Erica Francisco-Lau and her team on securing an out-of-state dismissal on behalf of an international airline in New Jersey. This dismissal comes amid a rise in filings of similar Pennsylvania workers’ compensation cases in the state of New Jersey.

In this case, the medical provider of a Pennsylvania worker for a major airline filed a claim to recover bills for surgery and appointments totaling over $61,000. The worker was injured in Pennsylvania while working as a baggage handler since 2012. As a New Jersey resident, the petitioner received some medical treatment in New Jersey where the claim was filed. In a trend we have seen applied in similar out-of-state cases, the claim was filed in New Jersey because the reasonable and customary standard is considerably higher than the Pennsylvania fee schedule prescribes.

After working closely with the airline, Erica and her team confirmed that the petitioner was hired in Pennsylvania and never worked for the airline in New Jersey. The team filed a motion to dismiss the claim in court on the basis that the medical provider’s counsel could not prove that New Jersey had any jurisdiction over this Pennsylvania worker’s compensation claim. The judge granted the motion and dismissed the case with prejudice, forcing the medical provider to consult the Pennsylvania’s Workers’ Compensation Board to dispute the bill amount paid.

Erica and her team produced an incredible outcome for our client, securing this dismissal thanks to her team’s keen understanding of workers’ compensation law, particularly across state lines. Please join us in congratulating Erica and her team. If you are in need of assistance with a workers’ compensation case, please contact our appellate team at clientservices@jonesjonesllc.com .

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Major Win Alert: Jones Jones Associate Wins Order of Dismissal

Congratulations to Jones Jones LLC Associate Erica Francisco-Lau and her team for leading a successful Order of Dismissal in front of the Jersey City Workers’ Compensation Court.

 

In this case, the medical provider claim in question originated in New York, with the claim stating the petitioner was injured in New York and works for a New York employer. The petitioner is a New Jersey resident and received medical treatment associated with her claim in New Jersey. As the usual, reasonable, and customary standard is higher in New Jersey than the New York fee schedule, the applicant filed their claim in New Jersey.

 

Francisco-Lau filed a response to the New Jersey medical provider claim denying jurisdiction as the petitioner works in New York, her accident occurred in New York, and she had a New York claim. The team further argued jurisdiction could not be established on the sole basis of residency. The motion to dismiss was opposed by the petitioner’s representation because the petitioner claimed she was hired remotely while in New Jersey.

 

The petitioner was unable to present a copy of her hiring documents to confirm where she was hired, and the petitioner stated she could not recall where she was hired and only worked in New York. Opposing counsel confirmed the petitioner would consent to the Order for Dismissal with prejudice to be entered by the Court. The Court filed the executed Order of Dismissal with prejudice signed by the judge earlier this year.

 

Please join us in congratulating Francisco-Lau and the entire Jones Jones LLC team. If you are in need of assistance with a workers’ compensation case, please contact our team at clientservices@jonesjonesllc.com.