Workers' Compensation Coverage
What To Do When An Accident Happens
Controverting a Claim
The insurance carrier can contest the claim for a variety of reasons, including that the injury was not related to work, or the employee is not injured to the extent that he or she is claiming. An employer can also request that the insurance carrier contest the claim. However, since the insurance carrier has assumed the liability for the claim, it is not required to comply with the employer's request.
Once a claim is controverted, a hearing will be scheduled to give a Judge the opportunity to hear both sides of a disputed issue. The Board may hold a hearing or hearings before a WCL Judge. The Judge may take testimony, order depositions, review medical and other evidence and will decide whether the claimant is entitled to benefits. If the claim is determined to be compensable, the Judge determines the amount and duration of the compensation award.
Special Note: The Reform Legislation of 2007, and a special report by the New York State Insurance Department Reform Task Force, have given the WCB some new mandates and "guideposts" to follow in the handling of controverted claims, with an eye toward the fastest and most thorough resolution of issues possible. New forms, requiring more complete information from all parties, special Controverted cases time frames for processing and resolution, and many other internal changes to procedures at the Board will be forthcoming in the fall of 2008, when new rules and regulations are expected to be formally adopted by the Board, and implemented. This area of the employee handbook will be updated with the new procedures at that time.