Major Win Alert: Jones Jones Secures Reversal

Jones Jones LLC congratulates Associate Diane Mandleur on successfully reversing a decision regarding restarting and continuing awards in front of the New York State Workers’ Compensation Board.

In this case, the claim previously established injuries to the claimant’s left ankle and foot with a temporary moderate degree of disability. The claimant’s podiatrist later stated the claimant had 100% degree of disability. In a later hearing, the workers’ compensation law judge (WCLJ) directed the claimant to submit proof of labor market attachment, such as job applications, due to concern from the self-insured employer (SIE) . The WCLJ determined the claimant had provided sufficient proof of labor market attachment and awarded benefits for the corresponding period of time.

 

When appealing the decision, Mandleur researched each individual job posting submitted by the claimant and calculated the distance and time it would theoretically take them to get to work. Of the 96 job applications filed, 71 of the locations were at least 45 minutes from their home with numerous employers an hour and a half away. This distance would make it difficult for the claimant to work these jobs as they do not have a car or drive.

 

Additionally, the claimant did not participate in reemployment services or vocational programs that qualify as displaying labor market reattachment under American Axle. As a result, the WCLJ found that the record did not support a finding of a good-faith job search in support of continuing awards.

 

Mandleur’s diligent research and close attention to detail secured a reversal of the decision. If you are in need of assistance with a worker’s compensation case, please contact our appellate team at clientservices@jonesjonesllc.com.

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NY Governor Announces Legislative Updates Expanding Workers’ Access to Medical Treatment

New York Governor Kathy Hochul recently announced four legislative proposals aimed at improving access to timely, high-quality medical treatments for injured workers. The proposals would provide workers with the ability to choose their own medical provider when seeking treatment for a work-related injury.

 

The first two proposals would universally authorize all eligible health care providers, including resident and fellow physicians under supervision, to treat patients seeking treatment related to workers’ compensation claims. The third proposal would focus on making increased access to providers more enticing for all parties with additional language aimed at reducing delays in treatment for workers.

 

Details on these proposed changes can be found on the New York State website.

 

What this Means for Employers and Insurers

 

With these new proposals, there will be more treatment options available to injured workers. In expanding provider access, claimants can find nearby treatment and avoid a delay that could worsen the initial injury. Injured workers will likely receive more timely treatment, leading to a faster return to work.

 

Finally, this expansion of access to medical treatment may make it more difficult for individuals who misuse the system. Under a proposed amendment insurers will have up to a year to admit liability while covering the cost for medical treatments.

 

Steps Jones Jones is Taking

As these changes take place, Jones Jones will closely monitor the cost of medical treatment related to workers’ compensation claims to determine the impact of Governor Hochul’s proposal. Jones Jones remains committed to achieving excellence on behalf of our clients, including monitoring for legislative changes that could impact the state of the workers’ compensation industry, such as those proposed by Governor Hochul.

 

If you have questions about how this new proposal may impact you, please contact us at clientservices@jonesjones.com.

CMS Updates Pertaining to WCMSAs and Section 111 Reporting

FROM THE DESK OF MANAGING PARTNER SARAH THOMAS 

 

Dear Valued Clients, 

 

Jones Jones is aware the Centers for Medicare & Medicaid Services (CMS) will be implementing changes to impacting Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) in the first half of 2025. These changes are based on a review of the current WCMSA guidance and feedback from the WCMSA community.  

 

The changes being implemented in 2025 are as follows: 

 

  • Expanded Section 111 Reporting Requirements: Effective April 4, 2025, CMS has begun requiring Section 111 reporting for WCMSAs involving Medicare beneficiaries. If a claimant is a Medicare beneficiary, details of the settlement must be reported to CMS, including on claims involving a $0 WCMSA, and settlements below $25k.  

 

  • Amended Reviews: Effective April 7, 2025, amended review requests will be allowed at any time after a WCMSA case is approved. This is a change from the prior amended review request process which requires a one-year waiting period after a WCMSA case has been approved. 

 

  • Zero-Dollar Set-Asides: Effective July 17, 2025, CMS will no longer accept or review WCMSA proposals with a zero-dollar allocation. Entities should still consider the parameters available in the WCMSA Reference Guide to determine whether a zero-dollar WCMSA allocation is appropriate and should maintain documentation to support that allocation.  

 

 

What This Means for our Clients 

 

The upcoming changes will have an impact for insurance carriers and their insureds. The changes outlined above will have the following effect:  

 

  • CMS will have unprecedented visibility into the facts of a full and final settlement involving a Medicare beneficiary, including on claims that do not meet the $25k threshold for CMS approval.  
  • If an individual’s medical situation has changed, or if they have had a significant surgical procedure that was originally included by the CMS, parties can now apply for amended review as soon as the case is approved.  

 

  • If CMS approved a medical set aside that was otherwise untenable, an insurance carrier can now submit for amended review to get the set aside reduced more quickly.  

 

 

The changes outlined above will reduce delays in securing final settlements and will facilitate more settlements in general, increasing the potential for cost savings and positive outcomes.  

 

Steps Jones Jones is Taking 

 

At Jones Jones, we work to communicate all changes from legislative and government administration bodies that may impact our clients. We are prepared to take action in response to ensure compliance and cost-savings to our clients. 

 

As a result of the upcoming WCMSA changes, a team of Jones Jones’ attorneys is prepared to: 

 

  • Work with clients to update their settlement protocols to reflect the new Section 111 Reporting Requirements. 

 

  • Assist clients who would like to consider amended review of a medical set aside that previously obtained CMS approval.  

 

  • Review any medical set asides for potential opportunities for cost savings.  

 

We can confer and provide recommendations regarding the new reporting requirements, or the possibility of a WCMSA amended review request, and take appropriate measures. Our goal at Jones Jones is to strive toward excellence each day with you, our clients. Any client who would like to confer regarding the above-mentioned updates should contact clientservices@jonesjonesllc.com. 

 

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NY Governor Signs Amendment with Guidance on Interpreting Work-Related Stress in New Mental Injury Legislation Allowing New Yorkers to Apply for Workers’ Compensation

The New York State Workers’ Compensation Board has provided an update on the December 2024 Mental injury legislation, providing clarity for employers, insurers, and legal counsel alike on the interpretation of extraordinary work-related stress. For context, on December 6, 2024, Governor Hochul signed legislation amending Section 10 of the Workers’ Compensation Law (WCL) with respect to claims for mental injuries resulting from work-related stress, subject to a chapter amendment agreed to by the Legislature and the Governor (Laws of New York, 2024, Chapter 546, Approval Memorandum 21 [enacting S6635/A5745]).

On February 14, 2025, the Governor signed a chapter amendment (Laws of New York, 2025, Chapter 79 [enacting S755/L1677]). The amendment says that covered employees must demonstrate that the mental disorder arose out of extraordinary work-related stress attributable to a distinct work-related event or events directly related to the employment and occurring during the performance of the employee’s job duties.

The new amendment will take effect June 4, 2025.

What this Means for Employers and Insurers

The key in this new amendment is the word extraordinary. Defining what constitutes extraordinary will come down to each case or judge and cannot be definitively determined until litigation begins in June. The same can be said for the word distinct when referring to distinct work-related events or an event. While the definition and impact of these terms won’t be clarified until June, there are other impacts that these amendments bring, including:

  • The amendments to WCL § 10 in S6635/A5745 were superseded by the chapter amendment signed on February 14, 2025 (S755/L1677) and are no longer in effect.
  • The amendments to WCL § 10 in S755/L1677 that go into effect on June 4, 2025, will apply to all pending claims, regardless of the date of accident.
  • Prior to June 4, 2025, pending claims will be decided based on existing law.

Of note, a new paragraph (c) will be added to subdivision (3) of WCL § 10, providing:

(c) The board may not disallow a claim by a covered employee upon a factual finding that the stress was not greater than that which usually occurs in the normal work environment where a claim for post-traumatic stress disorder (PTSD), acute stress disorder or major depressive disorder resulting from work-related stress is filed upon submission of medical evidence based on the criteria contained in the version of the Diagnostic and Statistical Manual of Mental Disorders in effect on the date of accident, or as otherwise adopted by the board, provided that such adoption shall be no more stringent than the current or immediately preceding version of the Diagnostic and Statistical Manual of Mental Disorders. Such covered employee must demonstrate that such disorder arose out of extraordinary work-related stress attributable to a distinct work-related event or events directly related to the employment and occurring during the performance of the employee’s job duties.

What Jones Jones is Doing

Jones Jones will continue to monitor New York State Workers’ Compensation Law for additional updates, as well as work closely with legislators, judges, clients and others to clarify how the term work-related stress is now interpreted. We will also continue to closely watch any upcoming mental injury workers’ compensation cases or decisions made on mental health injuries to prepare for the potential influx of newly filed claims.

For more information on this new legislation, please visit the New York State website. If you have questions about how this new legislation may impact you, or if you have a mental injury connected to extraordinary work-related stress claim, please contact us at clientservices@jonesjonesllc.com

The legislation signed by New York Governor @Kathy Hochul on Dec. 6 and a February 14 amendment are set to take effect June 4, 2025, amending Section 10 of the Workers’ Compensation Law (WCL) with respect to claims for mental injuries resulting from work-related stress. Jones Jones will continue to monitor the NYSWCB for additional updates and prepare to take necessary action for the potential influx of newly filed claims.

 

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Major Win Alert: Jones Jones Secures Disallowance Ruling

Jones Jones extends a well-deserved congratulations to Jones Jones LLC Associate Michelle Nagesar and her team on succeeding in disallowing a recent case before the New York State Workers’ Compensation Board.

 

In this case, a paramedic transporter alleged an injury to their knee after their ambulance was involved in a traffic accident. While the claimant had a history of knee pain, internal footage showed the claimant did not appear to be injured in this incident. In the internal video footage, the claimant’s knee did not come into contact with any surface during the accident, and they did not appear to be in any kind of immediate pain.

 

Previously, prima facie medical evidence, or first impression medical evidence, was introduced supporting the claim. However, Nagesar and her team produced an additional independent medical examination (IME) which found the claimant’s knee to be casually related, but merely an aggravation from the prior injury. Nagesar and her team argued that this claim should be disallowed in its entirety as the record contained conflicting histories regarding the mechanism of injury. The claimant’s treating physician testified that the claimant’s injuries upon examination were similar to the claimant’s injuries prior to the date of accident, and that the claimant’s testimony was not credible.

 

Due to these arguments, the IMA and claimant waiving their right to depose the IMA, the law judge agreed with Nagesar’s team and disallowed the case.

 

Nagesar and her team closely examined and deftly rebutted the prima facie evidence in this case and secured a disallowance due to their attention to detail. 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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