Author: Jones Jones

Jones Jones LLC is excited to announce a major win secured by Partner Dana Sabghir and Associate Katherine Caracappa.

This win highlights:

• The necessity to thoroughly review medical records submitted by treating doctors. Oftentimes, these records have a detailed history of the claimant’s prior medical history and treatment. This review, coupled with the history as given by a claimant in initial claim documents (C-3) and history as given by claimant to IME doctors could vary greatly, and very well may be the basis of a fraud finding by the Workers’ Compensation Board;
• The importance of seeking full medical records by way of subpoena in order to obtain the full picture of the claimant’s health prior to the workers’ compensation accident date; and
• How detailed fraud litigation can have an impact on the workers’ compensation case as well as a corresponding costly general liability claim.
  Jones Jones LLC attorneys Dana Sabghir and Katherine Caracappa secured a major win for a construction company that resulted in the claimant paying a significant amount of money back to the carrier.

The claim involved a claimant construction laborer, who upon initial filings (C-3), denied any prior conditions or prior accidents. The claim was established for bilateral knees, elbow, and the back. Soon after this establishment of injury, the claimant’s attorney filed for a hearing with the intent of expanding the case to numerous body parts and conditions. Our Jones Jones LLC attorneys subpoenaed records from the doctors who had submitted medical evidence in support of expanding the case to numerous other body parts. Upon a thorough review of these records, it became evident that the injured worker actually did indeed have extensive prior treatment to the bilateral knees, elbow, and back. Additionally, these prior records made reference to multiple prior accidents, prior surgeries, as well as significant results on diagnostic tests pre-dating our injury date in question. The claimant had also begun denying prior injuries to several of his own doctors as well as the independent medical consultants on the case. The misrepresentation of the prior physical condition of the claimant was spread not just to the documentation filed with the NY Workers’ Compensation Board; but also to the doctors tasked with treating the claimant’s injuries.

Jones Jones LLC raised fraud under WCL Section 114-A and requested that the Law Judge enter a formal finding that the claimant committed a material misrepresentation. The fact that prior injuries, surgeries, and conditions were denied on the initial claim filing documents as well as denied to a variety of doctors during treatment and evaluation was the basis for this request for a fraud finding.

Following litigation, the Law Judge did find that the claimant violated Section 114-A fraud as the claimant committed a material misrepresentation as it related to his prior physical condition. The New York State Workers’ Compensation Board held that the claimant was required to pay the insurance company approximately $40,000.00 back in workers’ compensation benefits as well as be permanently disqualified from receiving future indemnity benefits.

Additionally, as the accident in question involved a construction site accident, the claimant had a corresponding general liability claim. The fraud finding on this claimant’s workers’ compensation case had had significant impact on the future of the claimant’s general liability claim and his ability to close that case with a monetary gain.

Contact our attorneys today at clientservices@jonesjonesllc.com for any need you have regarding a fraud evaluation.

Welcome to Part Three of the Jones Jones LLC’s Loss Transfer Series! In this final installment of this series, you will learn how to successfully secure the actual loss transfer funds associated with your claim.  Previously, in Part One, you were given a primer on the basics of loss transfer; who can seek reimbursement and when does loss transfer apply. See: Loss Transfer Series: Part 1 – The Basics – Jones Jones LLC .   Part Two focused on what kind of benefits you may recover as a result of utilizing all that loss transfer has to offer. See: Loss Transfer Series: Part 2 – The Recovery.  Now, let’s focus on the details required in order for you to secure the loss transfer funds.

HOW DOES A CARRIER SEEK THE LOSS TRANSFER FUNDS?
The carrier or the self-insured employer must first serve the Respondent with an “Inter-Company Reimbursement Notification Form” as soon as reasonably practicable before filing for arbitration.  Note that the Respondent is the carrier or self-insured owner responsible for providing No-Fault benefits for the vehicle responsible for the underlying motor vehicle accident. The carrier or self-insured employer asserting the loss claim (often referred to as the “Applicant”) must file for arbitration with Arbitration Forums, Inc. The Applicant must also be aware of the timeline as the statute of limitations for filing for arbitration is three years from the date of each payment sought.

WHAT EVIDENCE IS NECESSARY TO PROVE CASE AT ARBITRATION?

• A copy of the timely served Inter-Company Reimbursement Notification Form.
• Proof of liability –Examples: Police report, internal accident documents, deposition transcripts, DMV expansions, etc.
• Proof of Damages- Minimum proof required is a printout or ledger of benefits paid with the following information for each payment:
  • Name of payee
  • Amount paid
  • Date of service
  • Date paid; and
  • Total amount paid.

Once the case is decided by an arbitrator, an arbitration award is usually published within one to three days. If the Respondent fails to issue payment of the arbitration award, the applicant has one year from the date of publication to file a petition to confirm the arbitration in court. If a party wishes to appeal an arbitration award, they must file a petition to vacate or modify the arbitration award within 90 days of publication.  Thank you for taking the time to read our educational series on Loss Transfer.  If you have any questions or would like to discuss further; please connect with us at clientservices@jonesjonesllc.com.

Have an idea for an education series? Would you like to learn more about a certain area of subrogation, New Jersey & New York Workers’ Compensation defense, or No-Fault? Contact us with what you want to hear more about today at clientservices@jonesjonesllc.com!

Welcome to Part Two of the Jones Jones LLC’s Loss Transfer Series! In Part One of this series, you were given a primer on the basics of loss transfer; who can seek reimbursement and when does loss transfer apply. See: Loss Transfer Series: Part 1 – The Basics – Jones Jones LLC .  Now we will review what kind of benefits you may recover as a result of utilizing all that loss transfer has to offer.

WHAT BENEFITS ARE RECOVERABLE VIA LOSS TRANSFER?
All No-Fault benefits are recoverable.   Additionally, Workers’ Compensation benefits are also recoverable, but only to the extent that that those Workers’ Compensation benefits are considered to be paid in lieu of No-Fault.  What does this mean?

Unlike No-Fault benefits, which are all recoverable, the benefits distributed under a Workers’ Compensation claim are only recoverable if No-Fault would have provided those same benefits.  This means that any indemnity, medical and death benefit that was paid as a Workers’ Compensation benefit in lieu of No-Fault benefits may be recovered via loss transfer. Also, please note that other benefits may be recovered (example: disability benefits) if those benefits were also paid in lieu of No-Fault benefits.

WHAT BENEFITS ARE PROVIDED UNDER NO-FAULT?
Any of the below benefits paid on a Workers’ Compensation claim are considered to be in lieu of No-Fault:

• Up to $2,000.00 in death benefits.
• Up to $50,000 of the following (combined, not separate):
  • Medical (as long as the medical benefit was paid in accordance with NYS Workers’ Compensation Fee Schedule); and/or
  • Lost Wages
    • Up to $2,000.00 per month
    • For 3 years following the date of accident

EXCEPTIONS: There is no benefit under the No-Fault law that is similar to the Schedule Loss of Use (“SLU”) award provided under NYS Workers’ Compensation Law. However, the Department of Financial Services (DFS) issued an opinion letter stating that a SLU award may be recovered via loss transfer even though there is no equivalent to a SLU under the No-Fault law.  Working alongside an attorney that is well versed in the benefits of a No-Fault claim, as well as any exception that may be present, is a key component to your loss transfer reimbursements being fully realized.

Stay tuned for Part Three of the Jones Jones LLC’s Loss Transfer Series to learn about the details of securing the actual loss transfer recovery funds. As always, the attorneys of Jones Jones LLC are beside you every step of the way and welcome any questions or thoughts you may have on this most important topic.  Contact our team today at clientservices@jonesjonesllc.com.

Have an idea for an education series? Would you like to learn more about a certain area of subrogation, New Jersey & New York Workers’ Compensation defense, or No-Fault? Contact us with what you want to hear more about today at clientservices@jonesjonesllc.com!

Welcome to Part One of the  Jones Jones LLC’s Loss Transfer Series! The purpose of this three part series is to educate and inform our readers on the importance of this application of the law.  Understanding and utilizing loss transfer will make a major impact on your mitigation recovery – which will equate to large savings to your clients.  You may have already read about Jones Jones LLC’s major success with our Loss Transfer Department—with over a 96% recovery rate on amounts sought via loss transfer.   Now, this three part series will take you through the basics of loss transfer under NY Insurance Law Section 5105(a) so that you can find opportunities in your own caseload to begin your journey towards loss transfer success.

WHAT IS LOSS TRANSFER?

Loss transfer is a carrier or self-insured’s right under NY Insurance Law Section 5105(a) to seek reimbursement  from another carrier or self-insured for benefits paid on certain claims arising from motor vehicle accidents.

WHO CAN SEEK REIMBURSEMENT VIA LOSS TRANSFER?

No-Fault carriers, as well as Workers’ Compensation carriers and any other carrier who provides benefits that could be considered to be “in lieu of No-Fault”.

WHO DO YOU SEEK LOSS TRANSFER REIMBURSEMENT FROM?

The carrier or self-insured owner responsible for providing No-Fault benefits for the vehicle responsible for the underlying motor vehicle accident.

WHEN DOES LOSS TRANSFER APPLY?

Loss transfer applies when ALL of the following criteria are met:

1. The underlying claim arose from a motor vehicle accident that was caused by a “covered person” as defined under NY Insurance Law Section 5104;
2. The motor vehicle accident occurred in New York State; and
3. At least one of the vehicles involved in the loss meets one of the following criteria:
   1. 1. 1. 1. Weighs 6,500 lbs unloaded; OR
            2. Is a Livery vehicle

WHO IS A COVERED PERSON?

A covered person is an operator of a motor vehicle that was either:

• An authorized self-insured company in New York;
• Insured by a companies authorized to issue No-Fault policies in New York (note: almost all major auto insurance companies fall under this category); OR
• Insured by an out-of-state company which has filed with the NY Commissioner of Motor Vehicles authorizing the commissioner to accept service of process on their behalf and stating that their policies will be varied to meet NY insurance requirements.

Stay tuned for Part Two of the Jones Jones LLC’s Loss Transfer Series to learn about what kind of benefits can be recovered under loss transfer! As always, the attorneys of Jones Jones LLC are beside you every step of the way and welcome any questions or thoughts you may have on this most important topic.  Contact our team today at clientservices@jonesjonesllc.com.

Have an idea for an education series? Would you like to learn more about a certain are of subrogation, New Jersey & New York Workers’ Compensation defense, or No-Fault? Contact us with what you want to hear more about today at clientservices@jonesjonesllc.com!