The Hearings Process & Disputed Claims

New York Workers’ Compensation – Hearing Process & Disputed Claims

Once a claim has been filed, the employer and its insurance company can immediately begin payment of cash benefits and provide coverage for medical care and services. They can also deny coverage altogether. If payments begin immediately, the insurance company can agree to the validity of the claim for the stated injury or illness or reserve its right to contest such issue a future date.

Either way, in most cases, the claim will not be officially established or contested until the first hearing is held by the workers’ compensation board. At the hearing the employer will state whether they are accepting the case pursuant to the claims set forth in the workers C3 claim form or contesting some or all of the issues. If the case is entirely accepted, the board will issue a decision with a finding that the worker has a compensable injury and/or illness, state the worker’s average weekly wage and make the appropriate cash awards based upon the percentage of disability and duration of the injury or illness. In such a case, medical care and services will also be granted and continuing weekly monetary awards will be made if the disability continues.

If the employer contests the case, each issue in controversy will be stated for the record. It the court determines that the employer has stated a valid objection to the claim, such objection will decided by a judicial determination by trial at a later date. If the court finds that the employer has not raised a valid objection, a decision will be made in favor of the claimant with the employer reserving its right to appeal such determination.

Here are some of the issues commonly in dispute in a new claim:

• Employer Employee Relationship – The employer alleges that the claimant is not an employee within the meaning of the law. The employer will allege that the claimant is an independent contractor, or that they have no knowledge of or relationship with the claimant.
• Accident or Illness – The employer alleges that either no accident occurred or that no illness exists, or that the injury/illness was a result of some non work-related activity.
• Average Weekly Wage – The employer alleges that the claimant earned less than what he or she claimed. This typically arises when wages are made in cash as compared to a check.
• Notice – The employer alleges that the claimant did not timely file the claim or notify the employer of the workplace accident or injury.

Other than the average weekly wage issue, if the employer is successful with any of the other objections, the claim will be denied. This however, is not to say that employers are routinely successful. They must overcome a favorable presumption that an accident that occurred while the claimant was performing his or her work duties is presumed to arisen out of and in the course of employment. A similar presumption exists for a claim involving an occupational disease or illness.

An experienced New York workers’ compensation attorney will be able to bolster the presumptions in favor of the claimant and provide the best possible evidence to establish the claim for compensation. Every issue is extremely important to the claimant and must be accurately established. For instance, even a $10.00 per week difference in the establishment of a claimant’s average weekly wage can mean a loss of thousands of dollars over the life of the claim.

What happens if a claimant neglects to include a smaller injury because the major injury is much more serious? This could have dire consequences. Even though such injury may seem small, it must be raised and established as an additional injured site or else medical care and treatment and future wage loss as a result of this injury will be denied. It is not uncommon for an injury to lay dormant only to flare up with debilitating consequences later. Medical treatment remains available for the lifetime of the claimant, but only if the injured site is established. As such, the failure to establish the additional site could result in enormous medical bills in the future. An experienced attorney will make sure that all compensable claims are established and preserved for the lifetime of the claimant.

Issues involving lack of notice and employer/employee relationship involve a fact-driven determination that is based largely on the credibility of the witnesses. An experienced attorney will be able to prepare a claimant to testify and articulate the facts in a convincing manner as well as gathering and presenting documentary evidence to support the claimant’s position and present it in the most favorable light.

If you have suffered an unfortunate accident at work, or have been the victim of a medical condition caused from the nature of your job, you may be entitled to significant compensation from your employer or other responsible party. Don’t go it alone, The Law Offices of David Smoren, PLLC has the expertise and resources to file and prosecute a successful workers’ compensation claim on your behalf. Employers have attorneys protecting their rights and so should you.

The Law Offices of David Smoren, PLLC has successfully handled hundreds of workers’ compensation claims resulting in millions of dollars in compensation and medical benefits for our clients. There is never a fee unless we are successful in recovering benefits for you. Call 718 225-6700 today for a free phone consultation or to arrange for an office or in home consultation or simply post a comment or question on the contact form.