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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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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 LLC Partner Tackles Fraud Case

Congratulations to Jones Jones LLC Partner Katherine Caracappa and her all-female construction defense team for securing a disallowance on a recent fraud case before the New York State Workers’ Compensation Board. Fraud and construction are being scrutinized by both the Board, as well as other state and federal entities due to the recent Racketeer Influenced and Corrupt Organizations Act (RICO) cases making headlines throughout New York.

 

In the case at hand, the plaintiff originally reported slipping on debris causing injury while working at a construction site. A similar case was also filed by another plaintiff with very similar fact patterns and medical details.   Both plaintiffs claimed to be injured on the same day, at the same jobsite and appeared to be injured in the same manner. The two individuals initially went to the same hospital, were treated by the same physicians, were represented by the same law firm and switched to another law firm together. In addition to the questionable coincidences, the original claimant reported contradictory medical histories regarding the nature of their injuries and failed to mention the supposed witness (the other plaintiff) on his employee claim (C-3) form.

 

During cross-examination, Caracappa and her team pushed the claimant on conflicting testimonies including differing mechanisms of injuries that was recounted in a variety of documents- both legal in nature and medical.  Additionally, Caracappa was able to bring to the Law Judge’s attention the plaintiff’s failure to mention any witnesses -including the other alleged plaintiff- and the interesting question as to how both plaintiffs come to have the same legal representation.

 

The undertones of the recent RICO cases impacting the New York construction industry prompted the law judge’s decision to find fraud on this case. The law judge noted similar fact patterns in both cases, with neither acknowledging each other in their own cases. Based on the RICO concerns throughout the case, the law judge also noted it would be referred for criminal prosecution.

 

“Katie and her team exemplified an aggressive and thorough strategy that resulted in this outcome,” said Jones Jones Managing Partner Sarah Thomas. “Construction fraud in New York is a reality, as can be seen with the recent RICO cases. Law judges are taking notice and one key to success with these types of cases is looking for inconsistencies as Katie and her team did in this situation. We are proud the contributions these talented attorneys made in addressing a statewide problem that impacts real-world inflationary items like rising real estate costs, insurance premiums and more.”

 

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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New Jersey Workers’ Compensation Fact Sheet 2024

Jones Jones LLC knows that workers’ compensation claims can be complex. In an industry bogged down by forms, statutes, and filings, we aim for efficiency in all we do.  To that end, we wanted to make sure that you, our clients, had access to the most up-to-date pertinent information regarding New Jersey workers’ compensation.

Are you an examiner that is looking for a quick reference? Are you a risk manager overseeing New Jersey claims? Are you an employer addressing your first workers’ compensation case? Please look no further than the Jones Jones LLC New Jersey Workers’ Compensation Fact Sheet.

New Jersey Workers Compensation Fact Sheet 2024

New York Workers’ Compensation Fact Sheet 2024

Jones Jones LLC knows that workers’ compensation claims can be complex. In an industry bogged down by forms, statutes, and filings, we aim for efficiency in all we do.  To that end, we wanted to make sure that you, our clients, had access to the most up-to-date pertinent information regarding New York workers’ compensation.

Are you an examiner that is looking for a quick reference? Are you a risk manager overseeing New York claims? Are you an employer addressing your first workers’ compensation case? Please look no further than the Jones Jones LLC New York Workers’ Compensation Fact Sheet.

New York Workers Compensation Fact Sheet v2