May 28, 2019
The New York State Workers' Compensation Board (WCB) has made updates to forms that are used for disability benefits claims. Two disability benefits claim forms have been updated to streamline the process of reviewing a total or partial payer rejection of a disability benefits claim, while two other disability benefits forms have been made obsolete. In addition, the mailing address of the Board’s Disability Benefits Bureau has changed.
Notice and Proof of Claim for Disability Benefits (Form DB-450)
The Notice and Proof of Claim for Disability Benefits (Form DB-450) has been updated to collect additional clarifying information regarding eligibility and collection of other benefits (e.g., workers’ compensation, unemployment insurance, etc.) that impact eligibility for disability benefits.
Part A must be completed by the claimant, and Part B must be completed by the claimant’s health care provider prior to submission. The form may be submitted to either the claimant’s employer or payer but must be submitted within 30 days of the first day of work missed due to disability.
Payers may delay payment and/or request additional information to support the disability benefits claim, but may not modify Form DB-450 to include additional questions or reject a claim as untimely if the additional information is not provided within a payer-defined deadline.
Claimants may visit Forms or contact their employer or payer to obtain this form. Use of version 5/19 of the form will be effective June 1, 2019. Version 9/17 of the form will continue to be accepted through September 30, 2019.
Notice of Total or Partial Rejection of Claim for Disability Benefits (Form DB-451)
The Notice of Total or Partial Rejection of Claim for Disability Benefits (Form DB-451) has been updated to provide a more comprehensive list of rejection reasons and provide clearer instructions on how the form and different rejection reasons should be used.
Payers may contact the WCB Forms Department at firstname.lastname@example.org to obtain this form. Use of version 5/19 of the form will be effective June 1, 2019. Older versions will continue to be accepted if mailed to the claimant on or before September 30, 2019; requests for review of Form DB-451s sent to the claimant on or after October 1, 2019, using older versions will be found in favor of the claimant.
Notice of Disability Benefits Payment (Form DB-455) and Tables of Permanent Contributions (Form DB-791) are obsolete and no longer in use. These forms have been removed from the Board’s website.
Effective April 1, 2019, all correspondence to the Disability Benefits Bureau should be mailed to the below address:
Workers' Compensation Board
Disability Benefits Bureau
PO Box 9029
Endicott, NY 13761-9029
Correspondence that should be mailed to the Disability Benefits Bureau is limited to:
- Form DB-450 when the claimant is claiming/receiving Unemployment Benefits and has a disability that started more than four weeks from the last day worked;
- Form DB-451 when the claimant is requesting a Board review of a total or partial payer rejection of a claim for disability benefits;
- Application for Board Review (Form RB-89);
- Rebuttal of Application for Board Review (Form RB-89.1);
- Application for Reconsideration/Full Board Review (Form RB-89.2);
- Rebuttal of Application for Reconsideration/Full Board Review (Form RB-89.3); and
- Any additional forms or correspondence requested by the Disability Benefits Bureau as necessary to process a Form DB-450 or Form DB-451 as described above.
Clarissa M. Rodriguez