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Workers Compensation Terms and Definitions

It is important for you to understand some of the legal terms and their definitions that you may come across during your workers compensation claim.  To get more information on any of these legal terms, contact our Workers' Compensation department for legal help.

Accident (Work-Related):

An event, arising out of and in the course of employment, that results in personal injury to a worker. (WCB)

Accident Date:

Refers to either (a) the date the accident is deemed to have occurred or (b) the date of onset assigned to an occupational disease. The accident date is officially established by a Law Judge. (WCB)

Accident, Notice and Causal Relationship (ANCR):

Minimal conditions that must be met before financial responsibility can be assigned to a claim for workers' compensation:

·      Specifically, it must be established that a work-connected accident covered by the Workers' Compensation Law occurred.

·      Following the accident, the claimant notified his/her employer within the time limit required by the Workers' Compensation Law.

·      A causal relationship exists between the accident and a resulting injury or disability. (WCB)

Adjourn (a Hearing):

To put off or suspend until a future time, without making any findings. (WCB)

Appeal:

A legal action taken by one of the parties to the Appellate Division, Third Department, to reverse or amend a decision or direction made by a Board Panel or the Chair of the Workers' Compensation Board. (WCB)

Apportionment:

A proportionate division of all or part of the liability in a case between two or more sources of disability for the same claimant, based on an evaluation of the relative contribution that the sources of disability have made to the claimant's permanent disability. (WCB)

Arising Out of and in the Course of Employment:

Two necessary conditions that must be met to establish a work-connected accidental injury; an injury that "arises out of" is one that results from a hazard of the employment, while an injury "in the course of employment" is one that occurred at a time, place and under circumstances related to the employment. (WCB)

Attorney Fees:

Fees approved by the Board for claimant attorneys in workers' compensation cases. Under WCL .24, no claims for services or supplies are enforceable unless approved by the Board and, if approved, such claims become a lien upon the compensation awarded. (WCB)

Average Weekly Wage (AWW) for Workers' Compensation Claims:

Wage used to calculate total disability benefit rates for most claimants. Defined at 1/52nd of the injured worker's average annual earnings (200-300 times average daily wage, depending on work schedule), based on the prior year's payroll data. If an injured worker has not worked a substantial portion of the immediately preceding year, the average wage of a comparably employed worker is used in the Board's calculations. (WCB)

Average Weekly Wage (AWW) for Disability Benefits Claims:

Wage used to calculate disability benefit rates. AWW for disability benefits is based on the disabled employee's earnings during the eight weeks prior to the start of disability. (WCB)

Board Panel:

A panel, usually comprised of three Workers' Compensation Board members (at least one of whom must be a lawyer), that reviews requests to amend decisions made by Workers' Compensation Law Judges, reopens closed cases and considers applications for lump sum non-schedule adjustment awards. (WCB)

Case:

A reported work injury or illness which has been assembled and assigned a case number (indexed) by an indexing unit of the Workers' Compensation Board. (WCB)

Case Number:

A unique identifier assigned by the Workers' Compensation Board at the time a case is assembled. The case number consists of 8 characters and begins with an alpha character, followed by seven numeric characters. For example, G1234567.

Volunteer ambulance workers' cases will begin AA, followed by six numbers (e.g. AA123456).

Volunteer firefighters' cases will begin with FA, followed by six numbers (e.g. FA123456).  (WCB)

Cause of Accident:

Object, substance or condition that directly contributed to the occurrence of an accident. (WCB)

Claim:

A request, on a prescribed Form C-3, for workers' compensation for work-connected injury, occupational disease, disablement, or death (Form C-62). A claimant must file a claim within a two-year period from the occurrence of the accidental injury, knowledge of occupational disablement, or death. Failure to file a claim may bar an award for compensation unless the employer has made advance benefit payment or fails to raise the issue, in which event the claim filing requirement is deemed waived. (WCB)

Continue (a Case):

To complete a hearing on a case without closing the case, leaving additional matters to be resolved at a future hearing. (WCB)

Controverted Claim:

A claim challenged by the insurer on stated grounds. The Board sets a pre-hearing for the determination of the grounds and directs the parties to appear and present their case. (WCB)

C-2:

A Board form titled "Employer's Report of Work-Related Accident or Occupational Disease" filed by employers within ten days after an accident occurs, as required by WCL .110. The form includes a section identifying the case and principal parties and additional sections labeled "Accident," "Injured Person," "Nature of Injury," "Cause of Accident," and "Fatal Cases." Failure to make timely C-2 filings subjects employers to potential administrative and criminal penalties.

C-3:

A Board form titled "Employee's Claim for Compensation," that should be completed by the injured worker and submitted to the Board within two years of the accident or onset date. The C-3 form contains much of the same information as the C-3 (sections describing the Injured Person, Employer, Place and Time of accident, Injury, Nature and Extent of Injury, Medical Benefits received, Compensation Benefits received/claimed, etc.).

C-4:

A Board form titled "Attending Doctor's Report," that requests information about claimant/claim identification, claim parties of interest, injury history, diagnosis, treatment, disability, causal relation of accident to disability, and degree of impairment. The form is to be filed by the doctor within two days of initial treatment, with additional reports during continued treatment, including a final report.

C-7:

A Board form titled "Notice that Right to Compensation is Controverted," that a carrier (as appropriate) must file within (1) 18 days of the date disability begins or (2) ten days of the date the employer first had knowledge of the alleged injury, whichever is later. Within 25 days from the Board's mailing of a notice of indexing in volunteer firefighter or volunteer ambulance worker cases.) The form contains

information identifying the claim, person (allegedly) injured, employer and carrier,

a description of the alleged injury and town/county/state where alleged injury occurred, reasons why right to compensation is controverted, dates for start of alleged disability, employer/carrier first knowledge of injury, receipt of a C-2 from the employer and statement concerning whether notification has been given to the disability benefits insurance carrier, and date of notification.

Decision:

A determination arrived at after consideration. A report of a conclusion. (WCB)

Dependent:

A person eligible to receive death benefits in a fatal injury case; the regular receipt of contributions by the alleged dependent upon which he/she relies and needs to sustain his/her customary mode of living constitutes dependency. Surviving widows and children under age 18 years are eligible for benefits without proving dependency, and other eligible recipients (if dependency is established) may include dependent handicapped children over age 18 years of age, grandchildren, brothers and sisters under age 18, dependent parents and grandparents. (WCB)

Examiner:

Incumbent in the Workers' Compensation Examiner job title series who performs examining work, applying knowledge of law and of Board rules, regulations, policies and procedures to compensation and disability benefit case information.  Among the actions regarding workers' compensation cases that Examiners may perform:

·      Determining whether a case should be indexed

·      Evaluating claim forms and developing information required by judges for case decisions

·      Requesting information (by phone, letter, etc.) needed for case development

·      Evaluating whether a compensation case may be processed on an informal calendar

·      Referring appropriate cases to the conciliation process; and

            preparing formal notices of decision based on judge's directions.

Hearing:

The WCL provides that no case may be closed without notice to all interested parties, with all such parties having an opportunity to be heard. Board hearings are held before Workers' Compensation Law Judges who hear and determine claims for compensation, for the purpose of ascertaining the rights of the parties. The Board, upon receipt of an application for review of a judge's decision, may also hold hearings. (WCB)

Indemnity Benefits:

Compensation paid to the workers' compensation claimants for non-medical loss resulting from an injury or illness. Six types of award are permitted by the WCL:

·      Temporary total disability benefits (for periods of total wage loss)

·      Temporary partial disability benefits (for periods of partial wage loss)

·      Facial disfigurement awards (at judge's discretion but subject to a maximum, for cosmetic facial disfigurement resulting from the accident or exposure)

·      Permanent partial disability benefits (for loss if physical function or for periods of partial wage loss after a claimant has been classified as having a permanent partial disability)

·      Permanent total disability benefits (for loss of wage earning capacity after a claimant has been classified as having a permanent total disability)

·       Death benefits (compensation benefits awarded to spouse, children or under certain circumstances, other family members following a work-related death)

Indexed Claim:

A claim case folder which has been assembled and assigned a case number by the Board's Claims Unit. (WCB)

Lost Time:

A period of total wage loss and loss of earning capacity, beyond the statutory waiting period, caused by the claimant's work-connected disability. In workers' compensation cases only, if the disability period exceeds 14 days, compensation will be paid from the first day of disability. There is no waiting period for volunteer ambulance worker or volunteer firefighter cases. (WCB)

Lump Sum Settlement:

A negotiated and Board-approved agreement, termed a "non-schedule adjustment," between a claimant with a non-schedule permanent partial disability and the insurer(s). As a result of the agreement the claimant receives a sum of money representing all future compensation for his/her disability, and the case is considered closed. Under WCL .15(5-b), granting of a settlement by the Board requires that (a) the right to compensation has been established and compensation has been paid for at least three months, (b) the continuance of disability and of future earning capacity cannot be ascertained with reasonable certainty, (c) there has been a physical examination of the claimant prior to approval, and (d) the Board considers the settlement "fair and in the best interest of the claimant." In practice, lump sum settlements are usually final, but the law provides for reopening's if the Board finds that there has been a change in condition or degree of disability not contemplated at the time of the settlement. (WCB)

Manual Rates:

The listed premium, stated as dollars per $100 of weekly earnings for each employee, in a state's current schedule; in New York the manual rates are linked to the Classification Code system (i.e., rates are stated for each work classification code used in the state).

Maximum Medical Improvement (MMI):

An assessed condition of a claimant based on medical judgment that (a) the claimant has recovered from the work injury to the greatest extent that is expected and (b) no further change in his/her condition is expected. A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant. (WCB)

Medical Benefits:

Medical treatment provided, under the Workers' Compensation Law, to injured workers as a result of injuries arising out of and in the course of employment.

Medical Fee Schedule:

A schedule, established by the Chair of the Workers' Compensation Board, of charges and fees for medical treatment and care furnished to workers' compensation claimants.

Medical Treatment:

Care (other than first aid) administered by a physician, chiropractor or podiatrist or on a physician's referral, by a psychologist, or physical or occupational therapist. (WCL)

Misclassification:

(An action by an employer to intentionally attempt to reduce required workers' compensation insurance premiums by misclassifying employees as "independent contractors", and/or misclassifying the work that of a business to a classification that is less hazardous. An employer must keep accurate records of the number of employees, classification, wages and accidents for their business for four years. Failure to keep adequate and/or accurate records may result in a fine of $1,000 per every 10-day period of noncompliance or two times the cost of compensation. Additionally, the fine for criminal conviction is from $1,000 to $50,000.

Misrepresentation:

An action by an employer to intentionally attempt to reduce required workers' compensation insurance premiums by not keeping accurate/adequate payroll records, paying workers "off the books", misclassifying employees as "independent contractors" and/or misclassifying the work that of a business to a classification that is less hazardous. An employer must keep accurate records of the number of employees, classification, wages and accidents for their business for four years. Failure to keep adequate and/or accurate records may result in a fine of $1,000 per every 10-day period of noncompliance or two times the cost of compensation. Additionally, the fine for criminal conviction is from $1,000 to $50,000.

Modify a Decision:

A decision that partially changes a previous decision -- e.g., a Board Panel memorandum of decision which amends a Workers' Compensation Law Judge decision.

Motion Calendar Hearing:

In a case in which no controversy or outstanding issue exists, a proposed decision is prepared and the parties are notified. A hearing is held only if one of the parties objects to the proposed decision. (WCB)

New York Compensation Insurance Rating Board:

A private, non-profit association of licensed insurance companies that provide workers' compensation insurance in New York; the organization is responsible (among other things) for collecting and reviewing compensation loss experience from carriers, developing policy forms and rating plans, conducting actuarial analyses and preparing rate filings with the New York State Insurance Department.

Non-Compensated Case:

A closed case which has never awarded indemnity benefits.

Non-schedule Permanent Partial Disability:

Non-fatal injuries that do not involve schedule permanent partial disabilities or cosmetic facial disfigurement and in which the claimant retains some earning capacity are assigned permanent disability benefits based on the claimant's actual or presumed wage loss, with benefits to continue for the duration of the wage loss disability.

Notice:

Written notification from an employee to his/her employer, indicating that a work-connected injury or injury has occurred. For accidental injuries, notice must be given no later than 30 days after the accident; the Board must excuse a failure to give notice on the grounds that a) for some reason, notice could not have been given; b) the employer had knowledge of the accident; or c) the employer's case has not been prejudiced. In cases involving occupational diseases, the time period for notice is 2 years from the date of disablement or from the date when the employee knew, or should have known, that the disease was due to the nature of employment.

Occupation:

A numeric coding structure widely adopted by federal, state and private occupation analysts, for identifying the occupation of an injured worker.

Occupational Disease (OD):

A disease arising from employment conditions for a class of workers, with the disease occurring as a natural incident for particular occupations, distinct from and exceeding the ordinary hazards and risks of employment. To be considered an occupational disease, there must be some recognizable link between the disease and some distinctive feature of the workers' job.

Occupational Disease, Notice and Causal Relationship (ODNCR):

Minimal conditions that must be met before financial responsibility can be assigned to a claim for workers' compensation based on occupational disease. Specifically, it must be established that (a) the claimant has an occupational disease recognized by the WCL, (b) the claimant has, after the onset of the disease, notified his/her employer within the statutory time limit (two years from date of disablement or from date when claimant knew or should have known that the disease was due to the nature of the employment, whichever is greater), and (c) a causal relationship exists between work-related activities and exposure, the development of the occupational disease, and a subsequent disability. (WCB)

Occupational Illness:

Any abnormal condition or disorder, other than one resulting from an occupational injury, caused by exposure to environmental factors associated with employment; it includes acute and chronic illnesses or diseases which may be caused by inhalation, absorption, ingestion or direct contact.

Occupational Injury:

Any injury, such as a fracture, sprain, amputation, etc. - which results from a work accident or other exposure involving a single accident in the work environment.

Party of Interest:

The claimant, employer, carrier and any statutory fund that may be liable in the particular case.

Planned Coverage:

An employer may provide benefits under a Board approved Plan for Disability Benefits (or one negotiated by agreement and accepted by the Chair of the Board as meeting the requirements of the NYS Disability Benefits Law (DBL)) ONLY when such a Plan is insured through one of the carriers licensed by New York State to write statutory disability benefits insurance policies or by an employer who has been authorized by the NYS Workers' Compensation Board to self-insure for disability benefits. All Plans accepted by the NYS Workers' Compensation Board shall cover only those employees that are eligible for benefits under the NYS DBL. Such accepted Plans must meet ALL statutory requirements as set forth by the NYS DBL.

Reduced Earnings:

A compensation rate based on the claimant's partial wage loss or partial loss of earning capacity due to a condition related to a compensable work-connected injury. (WCB)

Reimbursement, Request for:

A request by an employer for reimbursement for wages paid to an employee for a period during which the employee was eligible to receive workers' compensation or disability benefits. A request by a compensation carrier for reimbursement out of the Special Disability Fund. A request by a disability benefits carrier for reimbursement of benefits paid to a claimant while the workers' compensation case was being litigated.

Reopened Case:

A workers' compensation case which has been closed by a Workers' Compensation Law Judge or a Board Panel that is subsequently made active again to determine the claimant's eligibility for benefits.

Reopened Cases Fund:

A fund established to assume liability for additional awards in cases in which the application to reopen the case occurs more than seven years from the date of injury and more than three years from the payment of the last payment of compensation. The Fund is financed through payments in non-dependency death cases and through assessments made periodically against all carriers. (WCB)

Request for Further Action:

When a Party-of-Interest in a case requests Board intervention.

Rescind (a Decision):

A Board Panel memorandum of decision which voids or annuls a Workers' Compensation Law Judge decision. Decisions to rescind are usually issued without prejudice in order to allow the parties to present evidence or testimony not previously presented to a Workers' Compensation Law Judge. (WCB)

Rescind (a Penalty):

In certain instances the NYS Workers' Compensation Board issues a penalty for noncompliance with the mandatory coverage provisions of the NYS Workers' Compensation Law for workers' compensation and/or disability benefits to a legal entity that is not required to carry such insurance policy(ies). The Workers' Compensation Board will review documentation submitted by the legal entity that shows that such coverage is not required and the Workers' Compensation Board will "rescind" (withdraw or cancel) the penalty action. The legal entity is not required to pay the penalty amount related to the rescinded penalty. (WCB)

Review Bureau:

A department of the Workers' Compensation Board which processes requests for reopening's of closed cases and objections to Workers' Compensation Law Judge decisions. In addition, the unit previously processed requests to close compensation cases with lump sum non-schedule adjustments, but since 1995 such requests have been handled by the district offices. (WCB)

Review, Request for:

A written request for a Board Panel review of a Workers' Compensation Law Judge decision. (WCB)

Schedule Permanent Partial Disability:

Maximum benefit week schedules in the WCL are generally used in determining lifetime benefits for injuries to major body parts. Injuries amounting to less than a 100 percent functional loss are awarded a percentage of the scheduled weeks, and there are also provisions for additional weeks required for a protracted healing period. (WCB)

Symptomatic Treatment:

Medical treatments aimed at providing relief from the symptoms of a disease or injury, rather than providing a permanent remedy to the underlying condition.

Tentative Rate:

A weekly rate assigned by the Workers' Compensation Board for carrier indemnity payments, pending final adjudication of outstanding issues relating to benefit rates.

Third Party Action:

This term refers to lawsuits against equipment manufacturers, facility owners and other non-employer parties whose products or services contributed to the occurrence of an accident. Under WCL, a compensation claim is a workers' sole remedy against the employer, but lawsuits may be initiated against third parties for contributory negligence, product defects, etc. (WCB)

Total Disability:

With meaning of workers' compensation acts, means lack of ability to follow continuously some substantially gainful occupation without serious discomfort or pain and without material injury to health or danger to life.

Trial Calendar Hearing:

A regularly scheduled hearing on a case conducted by a WCLJ that is designed to permit the introduction of evidence and/or witnesses and the presentation of arguments by the parties. (WCB)

Wage Expectancy:

A decision element assigning an artificial wage rate to a young claimant, based on the authority of WCL .14(5). (WCB)

Wage Replacement:

The proportion of pre-injury wages replaced by workers' compensation benefits. (WCB)

Waiting Period:

Period covering the first seven days of disability resulting from a work-connected injury or illness. Workers' compensation indemnity benefits are not allowable for the first seven days of disability, except that (a) in cases where the disability period exceeds 14 days, indemnity awards are allowed from the date of disability, and (b) there is no waiting period for VAWBL/VFBL cases. (WCB)

Workers' Compensation Board, New York State (WCB):

(a) The agency charged with administering the Workers' Compensation Law, the Volunteer Ambulance Workers' Benefit Law and the Volunteer Firefighters' Benefit Law and the Disability Benefits Law. (b) The thirteen member Board responsible (directly or through review of delegated authority) for determining all issues involving claims under the WCL. Members are appointed to seven-year terms by the Governor, by and with the advice and consent of the Senate. The Governor designates the Chair and Vice-Chair.

(b) Workers' Compensation Law (WCL):

Chapter 67 of the Consolidated Laws, governing the workers' compensation system; separate laws cover compensation benefits for volunteer firefighters and volunteer ambulance workers.

Workers' Compensation Law Judge (WCLJ; Compensation Claims Referee):

An officer appointed by the Chair of the Workers' Compensation Board from a Civil Service competitive process to hear and determine claims and to conduct such hearings and investigations and make such orders, decisions and determinations as may be required in the adjudication of the claims. A Judge's decision is deemed the decision of the Board unless the Board modifies or rescinds such decision. (WCB)