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    • NEW YORK WORKERS' COMPENSATION STATISTICAL - PART IV -
      1. REPORTING OF LOSSES
      1. Losses must be reported with the classification code corresponding to the classification to which the employee’s payroll was assigned for premium determination purposes.

      2. All claims must be reported to the Rating Board when, as of the valuation date, there are loss values in paid losses, incurred losses and/or ALAE, including those with only paid allocated loss adjustment expense amounts. Refer to Item Item (5)(b) of this Part for specific medical loss exception. The medical portion of losses on policies providing Excluding Medical coverage in accordance with Rule VIII (E) of the New York Workers’ Compensation and Employers’ Liability Manual should not be reported. All claims must be reported to the Rating Board when, as of the valuation date, there are loss values in paid losses, incurred losses and/or ALAE, including those with only paid allocated loss adjustment expense amounts. Refer to of this Part for specific medical loss exception.

      3. A claim, initially reported, but subsequently closed without payment at a later valuation must be reported as a closed claim with $0 indemnity and $0 medical loss amounts at that later valuation.

      4. An accident resulting in an injury to one worker, but on which losses are incurred under different coverages of the policy (e.g., workers’ compensation; employers’ liability) must be reported as one claim and be identified with the appropriate Type of Claim Code. Refer to Item (17)(d) of this Part for Type of Claim codes.

      5. When an accident results in two or more reported claims, each claim must be reported separately, and an appropriate Catastrophe Number must be assigned. Refer to Item (19) of this Part for instructions on the use of Catastrophe Number.

      6. Recoveries from subrogation and fraud determination, but not from reinsurance or deductible reimbursement, must net down the claim amounts.  Refer to Item (8) of this Part for instructions regarding Fraudulent Claims, and to Item (10) of this Part for instructions regarding Recoveries.

      7. Claim Grouping Option: The grouping of claims for statistical reporting purposes is not permitted in New York for losses that occur on policies effective January 1, 2011 and subsequent.

    • NEW YORK WORKERS' COMPENSATION STATISTICAL - PART IV -
      5. INCURRED LOSSES

      Report all loss amounts on a gross basis prior to any reimbursement of indemnity and/or medical payments by the employer if a deductible applies.

      1. Incurred Indemnity Amount

        Report the total amount of incurred indemnity costs for each claim as of the valuation date. Incurred indemnity loss amounts consist of all paid and outstanding benefits, including compensation paid to the deceased prior to death, burial expenses, payments to the state and employers’ liability losses, including related expenses as described in Item (7) of this Part. Allocated loss adjustment expenses for other than employers’ liability coverage must be excluded from reported incurred indemnity amounts and must be reported separately as allocated loss adjustment expense.

        1. Outstanding Benefits

          The outstanding indemnity costs are the carrier's individual case estimates of future indemnity payments, except in the case of pension claims where any outstanding loss valuation, as set forth in Article 3, Section 27 of the New York State Workers’ Compensation Law, must be determined by use of the appropriate tables published by the New York State Workers’ Compensation Board.

        2. Reporting Special Payments:

          Where the New York State Workers’ Compensation Law specifies that, in conjunction with certain types of injury, a specified amount shall be paid into a special fund, and that such amounts are in addition to the compensation payable to the injured worker or the dependents, then the combined total amount must be reported as the incurred indemnity amount on the unit statistical report.

          Examples of Special Payments:

          1. Payments in no-dependent death cases
          2. Specified percentage of permanent partial awards designated for assignment for the Aggregate Trust Fund

          Note: Assessments on the basis of total premium or total incurred or paid losses, instead of on a per claim basis, must not be included on unit statistical reports.

        3. Reporting Recoveries

          Incurred indemnity amounts must be reported net of recoveries from subrogation, special funds, fraudulent activities and findings of non-compensability. Refer to Item (8) of this Part for instructions regarding Fraudulent Claims, and to Item (10) in this Part for instructions regarding Recoveries.

        4. Final Awards

          Where a final award has been made by the New York State Workers’ Compensation Board, the total incurred compensation must be in agreement with such award, except under the following circumstances:

          1. Where a claimant has appealed for a higher award for a compensable claim, the carrier must report at least the amount of the award, but may report a higher amount if, in its judgment, the facts in the case indicate an additional reserve is advisable.

          2. In cases where a claim has been officially declared non-compensable, but an appeal has been filed and is pending as of the valuation date, the carrier must report the incurred cost that would have been reported had there been no declaration of non-compensability.

          3. In cases where a claim has been officially declared non-compensable, but the period during which an appeal may be filed has not expired by the valuation date, the carrier may report the incurred cost that would have been reported had there been no declaration of non-compensability.  In any case where the period for filing an appeal has expired subsequent to the valuation date, but prior to the submission date of the next statistical report, without an appeal having been filed, the carrier may eliminate from the report the reserve for the non-compensable claim.

            Note: The term "declared non-compensable", as used in this Rule, means either:

            1. An official ruling by the New York State Workers’ Compensation Board, specifically holding that a claimant is not entitled to benefits under the provisions of the New York State Workers’ Compensation Law;

            2. A claim was not filed during the two-year period provided by Law for the filing of a claim, and the carrier closes the case without medical or indemnity loss; or

            3. The carrier has raised the issues of accident, notice or causal relation prior to the valuation date and continues to contest the claim, and the claim is officially closed because of the claimant's non-appearance or failure to prosecute his/her claim without an official ruling on the questions raised, such closing is regarded for the purpose of this Rule as the equivalent of a specific official declaration of non-compensability.

              Note: Where the carrier has appealed an award, it must report the full amount of such award until the appeal is decided.

          4. If a final award has not been made, but compensation for the injury is subject to a definite schedule of benefits, the provisions of the New York State Workers’ Compensation Law must be reflected in the amount of compensation reported.  In all other cases, the amount reported must reflect the carrier's estimate of incurred cost in the light of all information available on the date of valuation.

        5. Other Amounts

          Expenses, any general allowances for contingencies and any supplemental non-statutory benefits not otherwise provided for in this Plan must be excluded from the amount of losses.  Reserves in excess of the amount shown on the final settlement receipt must not be included in the loss amounts reported under this Plan.  At the completion of all payments, losses must only include settlement amounts filed with the New York State Workers’ Compensation Board or other body having jurisdiction over workers’ compensation claims.

      2. Incurred Medical Amount

        Report the total incurred medical loss amount associated with each claim as of the valuation date. Incurred medical loss amounts consist of all paid and outstanding benefits.

        Incurred medical amounts must include all payments to doctors and hospitals, as well as physical rehabilitation costs and prescription drug costs, and reserves for future payments, but must not include any claim expense.

        Incurred medical amounts must include surcharges on hospital and related medical services imposed pursuant to the New York State Health Care Reform Act (“HCRA”).

        Incurred medical amounts from claims not required to be reported to the New York State Workers’ Compensation Board, as defined in Section 110 of the New York State Workers’ Compensation Law, provided that the employer pays the claim in the first instance or reimburses the carrier for the treatment rendered to the employee, must not be reported to the Rating Board.

        Note: An employer is not required to file a claim notice with the New York State Workers’ Compensation Board if the accident or illness requires ordinary first aid, or causes loss of time from work of only one day beyond the working day or shift on which the accident or illness occurred.

    • NEW YORK WORKERS' COMPENSATION STATISTICAL - PART IV -
      7. EXPENSES INCLUDED IN LOSSES
      1. Medical or Legal Expenses Incurred for the Benefit of the Claimant

        Medical or legal court expenses incurred for the benefit of the claimant, or that the carrier is required to produce for the benefit of the claimant, must be reported as either an indemnity or medical loss depending upon the nature of the expense.

      2. Employers’ Liability Loss Adjustment Expense (LAE)

        Employers’ liability losses must include allocated loss adjustment expenses, as defined in Item 13 of this Part. The entire amount of losses and allocated loss adjustment expenses for an employers’ liability claim must be reported as incurred indemnity losses on the unit statistical report.  If a deductible program applies, both losses and loss adjustment expense must be reported on a gross basis.

      3. Impartial Examinations Ordered by the New York State Workers’ Compensation Board

        Expenses for impartial examinations ordered by the New York State Workers’ Compensation Board are to be reported as incurred losses.

      4. Awards

        When an award to a claimant includes the cost of witness fees, attorney fees and other court costs or expert medical witness fees, the amount so awarded must be considered as part of the cost of benefits and must be included with the incurred indemnity amount reported.  With respect to claims brought by persons against whom an employee has brought a third-party common-law action, such costs must be reported as an incurred indemnity loss whether or not a recovery is made against the third-party by the employee.

      5. Penalties for Delays In Making Compensation Payments

        If the carrier is liable for penalties for reasons beyond its control that accrue as benefits to the injured worker or his or her dependents, the penalties must be reported as indemnity losses; e.g., interest on awards or for penalties imposed upon the employer for improper controversion of awards. If the carrier is liable for penalties for any reason within the carrier's control, the penalties must be considered as unallocated loss adjustment expense and not reported as loss.

      6. Physical Rehabilitation Expenses

        Physical rehabilitation costs incurred due to the purchase of physical rehabilitation services from outside vendors must be reported as part of incurred medical loss. For the purposes of this Rule, physical rehabilitation concerns all medical activities performed, and/or services rendered, in the treatment of an industrial injury or disease to achieve maximum recovery, relief and/or cure. The following physical rehabilitation activities by medically trained persons, including registered nurses, performed by outside vendors must be reported as incurred medical losses:

        1. Various necessary evaluations and therapies including physical, occupational, speech and hearing.

        2. Coordination of services such as necessary medical equipment or special nursing care in a facility or the home.

        3. Necessary consultation(s) with physician(s).

        4. Monitoring the treatment and progress of a claimant's medical condition.

        5. Coordination of family, agency, and community services to provide optimal recovery.

        In addition, expenses associated with the above activities performed by carrier personnel (other than claims supervisors’ or claims adjusters’ efforts to return an injured worker to gainful employment) must also be reported as part of medical losses if the carrier personnel are medically trained as one of the following:

        1. Physicians

        2. Licensed registered nurses

        3. Licensed speech therapists

        4. Registered physical therapists

        5. Dentists and dental technicians

        6. Occupational therapists

        7. Chiropractors

        8. Podiatrists

        9. Licensed physician assistants

        10. Licensed cardio-pulmonary technicians

    • NEW YORK WORKERS' COMPENSATION STATISTICAL - PART IV -
      9. NON-COMPENSABLE REPORTING
      1. Entire Claim Non-Compensable

        When the entire claim has been determined to be non-compensable, in accordance with Part IV – Section (17)(e) of this Plan:

        1. As of the 1st report valuation, and the claim does not include any paid losses, incurred losses, and/or ALAE, the claim must not be reported.
        2. As of the 1st report valuation, and the claims includes paid losses, incurred losses, and/or ALAE, the claim must be reported with these loss values. Report this claim with the Type of Settlement (Loss Condition) Code 05.

        3. After the 1st report valuation and prior to the 10th report valuation, correction report(s) are required for all previously submitted unit reports to report the Type of Settlement (Loss Condition) Code 05. The paid losses, incurred losses, and/or ALAE must continue to reflect the loss values as of each specific report level(s).

        Example #1

        At the 1st unit report level, the following claim was reported:

        1. Policy Number: W123456 (Exposure State New York)
        2. Claim Number: 12345 (Jurisdiction State New Jersey)
        3. Incurred Indemnity: $20,000; Incurred Medical: $20,000
        4. Paid Indemnity: $1,000; Paid Medical: $1,000
        5. Paid ALAE: $2,000
        6. Claim Status: 0 (Open)

        Between the 1st and 2nd unit reports, there was an official ruling that determined the claim was noncompensable.

        This claim requires a correction to be reported on a 1st unit report to update the Type of Settlement Code to 05 Dismissal or Take Nothing (Non-Compensable). The Claim Status remains 0 (Open) and the loss amounts remain unchanged as originally reported.

        Since this claim was open as of the 1st report, it will continue to be reported with Type of Settlement Code 05 until the claim is closed.

        Example #2

        At the 1st unit report level, the following claim was reported:

        1. Policy Number: W123456 (Exposure State New York)
        2. Claim Number: 23456 (Jurisdiction State New York)
        3. Incurred Indemnity: $20,000; Incurred Medical: $20,000
        4. Paid Indemnity: $1,000; Paid Medical: $1,000
        5. Paid ALAE: $2,000
        6. Claim Status: 0 (Open)
        1. At the 2nd unit report level, the following claim was reported:
        2. Policy Number: W123456 (Exposure State New York)
        3. Claim Number: 23456 (Jurisdiction State – New York)
        4. Incurred Indemnity: $45,000; Incurred Medial $55,000
        5. Paid Indemnity: $45,000; Paid Medical: $55,000
        6. Paid ALAE: $10,000
        7. Claim Status: 1 (Closed)

        Between the 2nd and 3rd unit reports, there was an official ruling that determined the claim was non-compensable.

        In response to this ruling, the carrier submitted a correction to the 1st and 2nd unit reports to code the claim as non-compensable with Loss Condition Code – Type of Settlement 05 Dismissal or Take Nothing (Non-compensable). All loss amounts and Claim Status remain unchanged on both the 1st and 2nd reports.

        This claim requires a correction to be reported to the 1st unit report, to include the Type of Settlement Code 05. The Claim Status remains 0 (Open) and the loss amounts remain unchanged as originally reported.

        This claim requires a correction to be reported to the 2nd unit report to include the Type of Settlement Code 05. The Claim Status remains 1 (Closed) and the loss amounts remain unchanged as originally reported.

      2. Portion of a Claim Non-Compensable

        When a portion of a claim has been determined to be non-compensable, the claim is not reported as a non-compensable claim. Only the compensable portion of the claim is reported as follows:

        1. As of the 1st report valuation, and the claim does not include any paid losses, incurred losses, and/or ALAE, the claim must not be reported.
        2. As of the 1st report valuation, claims that include paid losses, incurred losses, and/or ALAE, must be reported with these loss values. Report this claim with the Type of Settlement (Loss Condition) Code other than 05.

        3. After the 1st report valuation, correction report(s) are required for all previously submitted unit reports to report the Type of Settlement (Loss Condition) Code other than 05. The paid losses, incurred losses, and/or ALAE must be corrected to reflect
Current and Archived Manuals
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The Digital Library is a feature enhanced, database driven version of our Workers' Compensation Manuals, Plans and References. The conversion from text publications to database driven web applications is intended to benefit our Users, Members and Subscribers with faster, easier and more accurate information regarding the New York Workers Compensation rules, procedures and protocols. All of the information in prior PDF publications has been captured and retained; and in most cases this information has been enhanced either aesthetically and/or functionally.

What's New?
Noted changes to past procedures would include changing the page reference identification system from "page based" (e.g., R-1, R-50, R-70) to "paragraph based" (e.g., Rule 3 - Paragraph D). A new Revision History feature has been adapted in support of this new reference system. For instance, each Paragraph of each Rule now contains a complete history of revisions for that specific Paragraph while also retaining an archived history of prior versions of that Paragraph dating back to the Original Printing of the Manual. A listing of the latest revisions are available for the entire Manual by selecting the History icon at the top of the users screen.