Workers compensation laws differ widely from state to state. Although almost every state requires that employers carry workers compensation insurance, the benefits provided to injured workers vary quite a bit. For example, some states allow the injured employee to choose a treating physician, while others require that the worker see a physician chosen by the employer or its insurer. Additionally, some states, such as Washington, allow the worker to be treated by an M.D., a D.O. (osteopathic physician), a nurse practitioner or a physician assistant. Others require the treating provider to be either an M.D. or a D.O.
In New York State, an injured worker can choose any health care provider who is authorized by the state’s Workers Compensation Board. That said, if the worker has an employer-sponsored HMO or PPO, they may be limited to choosing a provider who participates in the insurance network for the first 30 days after the injury occurred.
Here’s a summary of some of the other stipulations of N.Y. Workers Compensation Laws.
Workers Compensation insurance pays for all medical care for an injured worker as long as it is “reasonable and necessary.” Emergency care is, as a rule, always covered as long as the worker seeks treatment as soon as possible after the injury occurs. After that, the patient’s primary treating physician will determine what treatment the injured person needs. However, if the primary physician requests a specialist consultation, diagnostic procedure, surgery or therapy that costs more that $1,000 it must — except in an emergency — be approved by the insurer or the Workers Compensation Board. The insurer or WCB has 30 days to deny the request. If they don’t do so within 30 days, it is automatically approved.
Additionally, New York State is in the process of adding a Workers Compensation formulary to its Workers Compensation Laws. This formulary will determine what drugs physicians may prescribe for injured workers without prior authorization and for how long. The proposed formulary rules have been the subject of much debate, and have not yet been solidified. A new draft of the rules was proposed by the WCB on Oct. 17, 2018.
Injured workers in New York are eligible to receive partial wage replacement based on the degree and duration of their disability. The degree of disability is determined by the injured person’s treating physician and can range from zero to 100 percent. Additionally, the disability may be temporary or permanent.
Total Temporary Disability
If the injured worker’s treating physician determines that they are 100 percent disabled for a limited period of time, the person is eligible to receive two-thirds of their average weekly pay for the previous 12 months up to a set maximum weekly amount for as long as they are disabled. Beginning July 1, 2018, through June 30, 2019, the maximum benefit is $904.74 per week.
Partial Temporary Disability
There are two circumstances under which a worker in New York state who is partially, temporarily disabled due to a workplace injury can receive wage replacement under N.Y. Workers Compensation laws.
- If the person is unable to return to work in any capacity, they can receive two-thirds of their average weekly pay multiplied by the percentage of their disability. So, if an injured worker averaged $1,000 per week during the previous year, and they are 50 percent disabled, their total weekly benefit would be $330. (One half of two-thirds of $1,000, or $660.)This amount is also capped at $904.74 per week.
- If the person is able to return to work, but has been forced to take a cut in pay due to their injury, they may receive two-thirds of the difference between their former and current weekly pay. For example, a worker who made an average of $1,000 per week prior to their injury and returns to a job that pays $600 per week may be eligible for wage replacement in the amount of $264 per week (two-thirds of $400).
If, after a period of medical treatment, an injured worker is still unable to return to work, and their treating physician determines that their condition is unlikely to improve, the doctor can declare the worker permanently disabled. If the person is 100 percent disabled (that is, unable to work at all) they will receive two-thirds of their average weekly pay for the duration of the disability.
If, however, the injured worker is only partially disabled, New York State determines how long it will pay disability benefits based on the body part involved and the degree to which that body part is impaired by the injury. For example, let’s say a person loses 50 percent use of their right leg in a workplace accident. The state will replace two-thirds of the person’s lost wages for a set number of weeks based on that loss of use. However, it decreases the duration of benefits based on the percentage of use lost. So, if the Schedule of Loss says the aforementioned person would receive benefits for 500 weeks if he lost all use of his leg, he will get benefits for 250 weeks based on his 50 percent loss of use.
Complicating matters further, there are many injuries that do not fall under the loss of use schedule. For these injuries, workers can receive time-limited benefits equal to two-thirds of the difference between their former average weekly pay and their current “earning capacity” (as determined by the state). State law also determines the duration of benefits according to a fixed schedule based on the percentage of earning capacity lost. For example, a person who has lost 91 percent of their earning capacity can receive 500 weeks of benefits, whereas a person who has lost 15 percent can receive benefits for 225 weeks.
Additionally, workers who sustain disfiguring injuries to the face, head or neck may be eligible for an additional award of up to $20,000.
In addition to medical care and wage replacement, N.Y. Workers Compensation Laws provide vocational rehabilitation services to workers who can’t return to their former job due to a workplace injury. Further, Workers Comp will pay funeral expenses up to a predetermined maximum amount and a death benefit to the surviving spouse and family of a worker who is killed on the job.
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