Statistical Plan / PART IV

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.

Report the code that identifies the activity of the loss data on subsequent and correction reports.

For details regarding correction and subsequent reports, refer to Part V of this Plan.

Report the 12-position alphanumeric code that uniquely identifies the specific claim, excluding blanks, punctuation marks and special characters and which will make it possible to locate the claim records in the carrier files. The claim number must be reported consistently throughout the life of the claim.

1. To the extent possible, the claim number reported to the Rating Board on unit statistical reports should be the same claim number provided to the New York State Workers’ Compensation Board for the adjudication of the claim.

2. The claim number reported to the Rating Board on unit statistical reports must be the same claim number reported in the Rating Board annual individual claim data calls (e.g., NY 131-Large Loss and Catastrophe Claim Call; NY 132-Section 32 Claim Call; NY 141-Employers’ Liability Claim Call) as well as in the Medical Data Call and Indemnity Data Call.

Report, in the format (YYMMDD), the year, month and day on which the injury occurred. The accident date must be within the policy period. For a disease injury where the accident date is not specified, report the claimant’s last date of exposure to the conditions causing or aggravating the disease injury.

Note: The accident date cannot be the same as the expiration date of the policy.

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.

Expenses must be excluded from reported losses except as noted in Item (7) of this Part. Medical or legal expenses incurred for the benefit of the carrier are treated as loss adjustment expense. Refer to Item (7) of this Part for expenses developed for the benefit of the claimant.

Unallocated Loss Adjustment Expense (ULAE) is also excluded from losses. ULAE includes, but is not limited to:

1. Carrier employee salaries and traveling expenses that are considered loss adjustment expenses and are not incurred while doing activities listed as allocated expenses.

2. Fees paid to independent claims professionals or attorneys hired to perform the function of claim investigation normally performed by claim adjusters. Fees are paid for developing and investigating a claim so that a determination can be made of the cause or extent of responsibility for the injury or disease, including evaluation and settlement of covered claims.

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

A fraudulent claim is a claim that meets either of the following conditions:

1. The claim has been ruled (or officially declared) fully fraudulent by a court decision or a ruling of the New York State Workers’ Compensation Board.
2. The claim, or a portion of the claim, has been deemed to be partially fraudulent by a court decision or a ruling of the New York State Workers’ Compensation Board. 

1. Reporting Fully Fraudulent Claims

   When a claim has been ruled or declared to be fully fraudulent, the entire cost of the claim must be netted down to zero for unit statistical reporting.

   1. Ruling or declaration of fraud prior to 1^st Report: The claim is considered non-compensable and is not to be reported.

   2. Ruling or declaration of fraud subsequent to 1st Report: When a ruling or declaration of fraud is received by the carrier at any point subsequent to the 1^st unit report, but prior to the 10^th report valuation date a correction report (s) must be filed, reducing the incurred cost of the claim to zero.

2. Reporting Partially Fraudulent Claims

   When a portion of a claim has been ruled or declared to be partially fraudulent, the cost of the claim must be netted down to reduce the net incurred loss by the declared fraudulent amount.

   1. Ruling or declaration of fraud prior to 1^st Report: The net incurred cost of the claim on the 1^st report must reflect the reduction of the claim by the partially fraudulent amount.

   2. Ruling or declaration of fraud subsequent to 1^st Report: When a ruling or declaration of fraud is received by the carrier at any point subsequent to the 1^st unit report, but prior to the 10^th report valuation date a correction report(s) must be filed and the cost of the claim must be netted down to reduce the net incurred loss by the declared fraudulent amount. If the originally reported amount at a particular report level is lower than the net loss amount, no correction is required.

   The “net incurred cost” is defined as the gross incurred loss (i.e., the gross evaluation of the claim whether the claim is still open or not) minus the amount declared to be partially fraudulent.

   For example, consider a claim that has been reported as $10,000 (1^st report), $40,000 (2^nd report), and $60,000 (3^rd report). Subsequent to the 3^rd report, the claim was ruled partially fraudulent with the partially fraudulent amount set at $25,000.  The net incurred cost of the claim is the latest value minus the partially fraudulent amount: $60,000 - $25,000 = $35,000.  The net incurred cost ($35,000) is less than the claim value reported at the 2^nd and 3^rd reports. Correction reports must be submitted for the 2^nd and 3^rd reports in the amount of $35,000.  As the net incurred cost is higher than the $10,000 reported in the 1^st report, no correction report is needed for the 1^st report.

   When the partially fraudulent amount has not been allocated into indemnity and medical components by the adjudicator, the net incurred loss must be divided between indemnity and medical losses in the same proportion as the original gross incurred indemnity and medical amount.

Report the code that identifies the involvement of fraud in the claim.

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

1. Net Loss Reporting

   Except as noted below, when there has been recovery of loss due to subrogation, the amount of incurred loss reported must be the net incurred loss, and the amount of paid loss reported should be the net paid loss.

   The net incurred loss is the gross incurred loss (i.e., the gross evaluation of the claim prior to any actual or expected recovery on which the award was based, whether the claim is still open or not) minus the amount recovered less recovery expenses. The net paid loss is the gross paid loss minus the amount recovered less recovery expenses. When the allocation of recovery to indemnity and medical is unknown, the net incurred loss must be proportionally split between indemnity and medical losses in the same proportion as the original gross incurred indemnity and medical amounts, and the net paid loss must be proportionally split between indemnity and medical losses in the same proportion as the original gross paid indemnity and medical amounts.

   Exception: When the recovery expenses exceed the amount recovered, report the gross incurred loss instead of the net incurred loss and the gross paid loss instead of the net paid loss.

   A claim involving subrogation must be reported with Loss Condition Code — Type of Recovery Code 03 (Subrogation-Only).

2. Correction Reporting

   When a subrogation recovery is received by the carrier at any point subsequent to the 1st unit report, but prior to the 10th report valuation date, correction report(s) must be filed for prior reports that reflected a total incurred amount higher than the net incurred loss.

   If a correction is required:

   Report the net incurred indemnity loss amount if it is lower than the originally reported amount.
   Report the net incurred medical loss amount if it is lower than the originally reported amount.
   Report the net paid indemnity loss amount if it is lower than the originally reported amount.
   Report the net paid medical loss amount if it is lower than the originally reported amount.

3. Recovery by Employee or His/Her Dependents

   1. For cases involving recovery by the injured employee or his/her dependents, the net incurred loss must be:

      1. the deficiency, if any, between the outstanding compensation provided by the New York State Workers’ Compensation Law and the net amount of recovery actually collected by the claimant, and

      2. any other incurred indemnity and medical losses not recovered by the carrier’s lien on the proceeds of the claimant’s third-party recovery or by a third-party action pursued by the insurance carrier.

   2. When recovery by the injured worker or his/her dependents relieves the carrier of the liability for further compensation benefits as, for example, in the case involving recovery without the consent of the carrier, or where the recovery exceeds all future compensation benefits due, the net incurred loss must be the sum of all amounts paid and any amounts payable into any special fund, less the net reimbursements, if any, received from the claimant or third party. Where reimbursement is received by the carrier, and the allocation of the reimbursement to indemnity and medical is not known, the net liability incurred must be apportioned to indemnity and medical in the same proportion as existed in the amounts paid and/or payable by the carrier prior to the recovery.

      When the carrier is (1) relieved of liability for death benefits to dependents who have made a compromise settlement with a third party without the consent of the carrier, but (2) is liable for payments to the dependents not involved in such settlement, the sum of the net liabilities for dependency groups (1) and (2), each calculated separately in accordance with the forgoing rules, must be added to any other indemnity and medical incurred and paid loss amounts to determine the total net liability for the case.

4. Subrogation Reporting Additional Information and Examples

   Reporting Example #1

   The carrier submitted a claim on a 1st and 2nd unit statistical report, and a subrogation recovery was received between the 2nd and 3rd reports.

   A 1st unit report was submitted to include a claim with the following information:

   1. Claim Number: 12345
   2. Incurred Indemnity: $15,000; Incurred Medical: $15,000
   3. Paid Indemnity: $12,000; Paid Medical: $13,000

   As of the 2nd unit report, the claim remained open, and the updated loss information was as follows:

   1. Incurred Indemnity: $35,000; Incurred Medical: $25,000
   2. Paid Indemnity: $15,000; Paid Medical: $20,000

   Between the 2nd and 3rd unit reports, the carrier received a subrogation recovery of $25,000, and the carrier’s subrogation expenses were $3,000. The subrogation recovery and related expenses were allocated 60% for indemnity and 40% for medical.

   The carrier must first determine whether correction reports are required, and if so, which report levels need to be corrected, by calculating the net incurred loss.

   The net incurred loss represents the latest reported total incurred loss (Incurred Indemnity $35,000 + Incurred Medical $25,000 = ($60,000), less the subrogation recovery net of the subrogation expenses ($22,000 = $25,000 - $3,000):

   $60,000 – ($25,000 - $3,000) = $38,000 (net incurred loss).

   In this example, the determination whether correction reports are required for each report level is as follows:

   1. 2nd unit report – Correction required because the calculated $38,000 net incurred loss is less than the 2nd report total incurred loss of $60,000
      1st unit report – Correction not required because the calculated $38,000 net incurred loss is greater than the 1st report total incurred loss of $30,000

   The next step is to perform the loss allocation between indemnity and medical. Based on the 60% for indemnity and 40% for medical subrogation and expense allocation, calculations are performed as follows:

   1. Indemnity – 60% of the subrogation recovery (net of recovery expenses) is 60% x $22,000 = $13,200
   2. Medical – 40% of the subrogation recovery (net of recovery expenses) is 40% x $22,000 = $8,800

   The loss allocation of the net loss amounts at 2nd report is calculated as follows:

   1. Net Incurred Indemnity: $35,000 - $13,200 = $21,800
   2. Net Paid Indemnity: $15,000 – $13,200 = $1,800
   3. Net Incurred Medical: $25,000 – $8,800 = $16,200
   4. Net Paid Medical: $20,000 – $8,800 = $11,200

   In addition to reporting the revised loss amounts on the correction report, the appropriate Loss Condition Code — Type of Recovery Code must be reported as Code 03 (Subrogation-Only).

   Reporting Example #2

   The carrier submitted a claim on the 1st, 2nd, and 3rd unit statistical reports, and, as of the 3rd report, the claim was closed. Following the 3rd report, a subrogation recovery was received by the carrier.

   A 1st unit report was submitted to include the claim with the following information:

   1. Claim Number: 23456
   2. Incurred Indemnity: $20,000; Incurred Medical: $30,000
   3. Paid Indemnity: $18,000; Paid Medical: $20,000
   4. Claim Status Code 0 (Open)

   As of the 2nd unit report, the claim remained open, and the updated loss information was as follows:

   1. Incurred Indemnity: $35,000; Incurred Medical: $40,000
   2. Paid Indemnity: $22,000; Paid Medical: $28,000
   3. Claim Status Code: 0 (Open)

   As of the 3rd unit report, the claim was closed, and the updated loss information was as follows:

   1. Incurred Indemnity: $45,000; Incurred Medical: $55,000
   2. Paid Indemnity: $45,000; Paid Medical: $55,000
   3. Claim Status Code: 1 (Closed)

   Following the 3rd report, the carrier received a subrogation recovery of $45,000, and the carrier’s subrogation expenses were $3,000. The subrogation recovery and related expenses were allocated 30% for indemnity and 70% for medical.

   The carrier must first determine whether correction reports are required, and if so, for which report levels, by calculating the net incurred loss.

   The net incurred loss represents the latest reported total incurred loss (Incurred Indemnity $45,000 + Incurred Medical $55,000 = $100,000), less the subrogation recovery net of the recovery expense ($42,000 = $45,000 - $3,000):

   $100,000 – ($45,000 – $3,000) = $58,000 (net incurred loss)

   In this example, the determination of correction reports for each report level is as follows:

   1. 3rd unit report—Correction required because the calculated $58,000 net incurred loss is less than the 3rd report total incurred loss of $100,000
   2. 2nd unit report—Correction required because the calculated $58,000 net incurred loss is less than the 2nd report total incurred loss of $75,000
   3. 1st unit report—Correction not required because the calculated $58,000 net incurred loss is greater than the 1st report total incurred loss of $50,000

   The next step is to perform the loss allocation of the subrogation recovery between indemnity and medical. Based on the 30% for indemnity and 70% for medical subrogation and expense allocation, calculations are performed as follows:

   1. Indemnity—30% of the subrogation recovery (net of recovery expenses) is 30% x $42,000 = $12,600
   2. Medical—70% of the subrogation recovery (net of recovery expenses) is 70% x $42,000 = $29,400

   For the 3rd report correction, the reportable net paid and incurred losses are calculated as follows:

   1. Net Incurred Indemnity: $45,000 – $12,600 = $32,400
   2. Net Paid Indemnity: $45,000 – $12,600 = $32,400
   3. Net Incurred Medical: $55,000 – $29,400 = $25,600
   4. Net Paid Medical: $55,000 – $29,400 = $25,600

   In addition to reporting the revised loss amounts on the correction report, the appropriate Loss Condition Code — Type of Recovery Code must be reported as Code 03 (Subrogation-Only).

   It was determined above that a second report correction is required. The net incurred loss for the 2nd unit report is determined by comparing the originally reported loss amount at 2nd report to the net losses as of the 3rd report:

   1. Net Incurred Indemnity: Report $32,400 because it is less than the $35,000 reported on the 2nd report originally.
   2. Net Paid Indemnity: Report $22,000 (unchanged because it is less than the $32,400 net paid amount at 3rd report)
   3. Net Incurred Medical: Report $25,600 because it is less than the $40,000 reported on the 2nd report originally.
   4. Net Paid Medical: Report $25,600 because it is less than the $28,000 reported on the 2nd report originally.

   Because the Paid Indemnity was less than the calculated Net Paid Indemnity, the Paid Indemnity on the 2nd report level remains at $22,000.

   The above example shows this claim reported on a correction to a 2nd unit report to include the revised loss amounts and Type of Recovery Code 03. Because the claim was still open, the Claim Status remains 0 (Open).

When the claim involves a lump-sum representing the discounted or commuted value of a specific award or benefit, report the actual loss payment, including the lump-sum amount subdivided proportionally between indemnity and medical.

Report the applicable Lump-Sum Indicator on each claim as follows:

1. Paid Indemnity Amount

   Report the dollar amount of paid indemnity costs for the claim as of the valuation date. These losses consist of all paid benefits due to an employee’s lost wages or inability to work, including compensation paid to a deceased prior to death, burial expense, payments to the state, and employers’ liability losses and expenses. Allocated Loss Adjustment Expense (“ALAE”) for other than employers’ liability coverage must be excluded from indemnity losses. Subrogation recoveries must be subtracted from paid indemnity if the recovery applies to the indemnity loss. Refer to Item (10) of this Part for instructions regarding recoveries.

   Payments required by the New York State Workers’ Compensation Law in connection with certain types of injury shall be included in the paid indemnity loss amounts on the unit statistical report.

2. Paid Medical Amount

   Report the dollar amount of medical losses paid for the claim as of the valuation date. Paid medical must not include any claim expense. Subrogation recoveries must be subtracted from paid medical if the recovery applies to the medical loss. Refer to Item (10) of this Part for instructions regarding recoveries.

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

   Paid medical amounts for claims that are 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, should not be reported to the Rating Board.

Report the dollar amount of loss adjustment expense allocated and paid for each claim as of the valuation date. ALAE encompass the following costs to a carrier, which can be directly allocated to a particular claim:

1. Fees of attorneys or other authorized representatives where permitted for legal services, whether by outside vendors or staff representatives.

2. Court, Alternate Dispute Resolution and other specific items of expense such as:

   1. Medical examinations of a claimant to determine the extent of the carrier’s liability, degree of permanency or disability
   2. Expert medical or other testimony
   3. Autopsy
   4. Witness and summonses
   5. Copies of documents such as birth and death certificates, and medical treatment records
   6. Arbitration fees
   7. Surveillance
   8. Appeal bond costs and appeal filing fees

3. Medical cost containment expenses incurred with respect to a particular claim, whether by an outside vendor or done internally by a staff representative for the purpose of controlling losses, to ensure that only reasonable and necessary costs of services are paid. The expenses include:

   1. Bill auditing expenses for any medical or vocational services rendered, including hospital bills (inpatient or outpatient), nursing home bills, physician bills, chiropractic bills, medical equipment charges, pharmacy charges, physical therapy bills, and medical or vocational rehabilitation vendor bills
   2. Hospital and other treatment utilization reviews, including precertification/preadmission, concurrent or respective reviews
   3. Preferred provider network/organization expenses
   4. Medical fee review panel expenses
   5. Expenses that are not defined as losses and are directly related to the handling of a particular claim for services that are required to be performed by statute or regulation

Report the classification code under which the injured worker’s payroll or other exposure was assigned even if, at the time of injury, the worker may have been involved in an activity that would be classified differently. No claim shall be assigned to any classification unless payroll or other exposure has also been reported for that classification.

Report the type of injury code as defined under provisions of the New York State Workers’ Compensation Law corresponding to the carrier’s estimate, as of the valuation date, of the ultimate injury type of the claim. The injury type does not have to correspond to the type of benefit being paid as of the valuation date; e.g., if temporary total payments are being made on a claim that is reserved as a permanent partial case, report the claim as a permanent partial injury type.

1. Death – Code 01

   Report each death claim unless it has been established that the carrier has incurred no liability.

   The amount reported as incurred indemnity must include all paid and outstanding benefits, including compensation paid to the deceased prior to death, burial expenses and payments to the state.

   If there is compensation paid prior to the death of a claimant and there is later found to be no liability on the death claim, the loss is to be reported on the basis of the injury for which payments have previously been made.

   Refer to Section (h) below for rules concerning the computation of death claim loss amounts that are payable to the Aggregate Trust Fund.

2. Permanent Total Disability – Code 02

   Report as permanent total disability each claim that constitutes permanent total disability under the New York State Workers’ Compensation Law, or that, in the judgment of the carrier, will result in permanent total disability.

   Refer to Section (h) below for rules concerning the computation of permanent total claim loss amounts that are payable to the Aggregate Trust Fund.

3. Permanent Partial Disability – Scheduled Loss of Use – Code 10

   A Scheduled Loss of Use permanent partial loss is defined as any permanent injury that does not involve permanent total disability and has been classified, or is expected to be classified, by the New York State Workers’ Compensation Board as a Scheduled Loss of Use, in accordance with Section 15, Paragraph 3 Items (a) through (v) of the New York State Workers’ Compensation Law, or if a claim has settled prior to such classification but was expected to be classified as such. Refer to this link for more information: Schedule Loss of Use Award.

   The amount entered as incurred indemnity must include specific benefits and compensation for temporary disability, as well as scheduled loss of use award.

   Note: For Permanent Partial claims that include or are expected to include both a Scheduled Loss of Use award and a Non-Scheduled award, report the injury type that generated the higher incurred indemnity loss amount.

4. Permanent Partial Disability – Non-Scheduled – Code 11

   A non-scheduled permanent partial loss is defined as any permanent injury that does not involve permanent total disability and has been classified, or is expected to be classified, by the New York State Workers’ Compensation Board as a non-scheduled permanent partial disability claim, in accordance with Section 15, Paragraph 3 Item (w) of the New York State Workers’ Compensation Law, or if a claim has settled prior to such classification but was expected to be classified as such. Refer to this link for more information: Schedule Loss of Use Award.

   The amount entered as incurred indemnity must include specific benefits and compensation for temporary disability, as well as loss of earning capacity.

   Refer to Section (h) below for rules concerning the computation of permanent partial claim loss amounts that are payable to the Aggregate Trust Fund.

   Note: For Permanent Partial claims that include or are expected to include both a Scheduled Loss of Use award and a Non-Scheduled award, report the injury type that generated the higher incurred indemnity loss amount.

5. Temporary Injury – Code 05

   Report as temporary every case that involves, or is expected to involve, indemnity benefits, but does not constitute a death case, permanent total disability or any permanent partial disability as defined above.

6. Medical Only – Code 06

   Report as medical-only claims that involve medical costs only and for which no indemnity costs have been incurred or are expected to be incurred as of the valuation date.

   When reporting claims involving medical-only losses, incurred and paid indemnity loss amounts must be $0.

   Incurred medical losses 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 immediately reimburses the carrier for the treatment rendered to the employee, should 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.

7. Contract Medical – Code 07

   In conjunction with managed care or preferred provider organization programs in New York, medical costs incurred under a contract for medical services that cannot be allocated to individual claims must be reported in the aggregate as incurred medical and must be assigned to the governing classification. Contract medical costs, or medical costs incurred outside of the contractual arrangement, that are allocated to individual claims must be reported in connection with these claims and must not be included in the amount otherwise reported as contract medical.

8. Aggregate Trust Fund

   All death cases and designated permanent total and permanent partial disability cases are payable to the Aggregate Trust Fund as set forth in the New York State Workers’ Compensation Law. In determining the present value of the incurred loss amounts on these claims, the tables published in Bulletin 222C by the New York State Workers’ Compensation Board must be used. Refer to the New York State Workers’ Compensation Board for this Bulletin.

   When an award directing such payment has been made, include in the indemnity loss amount the fee charged by the Aggregate Trust Fund for the handling of such cases. This fee must not be included in the calculation of the present value of any case in which the final award has not yet been made.

   For all permanent total and permanent partial disability cases for which a life award is being made, but for which payments have not been designated for placement into the Aggregate Trust Fund, the tables shown below must be used in determining the present value for reporting under this Plan. For claims on policies effective prior to January 1, 2015, use Table-I. For claims on policies effective on or after January 1, 2015, Table I-M must be used for male claimants and Table I-F must be used for female claimants.

1999 United States Life Tables (U.S. Department of HHS) 3.5% Annual Rate of Interest

2007 United States Life Tables (U.S. Department of HHS) 3.5% Annual Rate of Interest

2007 United States Life Tables (U.S. Department of HHS)3.5% Annual Rate of Interest

Report the code that indicates the status of the claim as of the valuation date.

Open means that the carrier still expects to make further indemnity or medical payments on the claim (the exact nature of these payments is not known) or may not have determined as of the valuation date whether payments will be made in the future.

Reopened means that subsequent indemnity and/or medical payments have been made on a claim previously closed by the carrier or, due to a recent event, further indemnity and/or medical payments are expected and a reserve has been established for a claim previously closed by the carrier.

Closed means that the carrier does not expect to make any further indemnity or medical payment on the resolved claim.

Report claims covered entirely by contract medical with a closed claim status unless more payments are expected in addition to the contract amount.

Report the applicable code corresponding to the Act, Type of Loss, Type of Recovery, Type of Claim, and Type of Settlement for each individual claim.

An accident resulting in an injury to one worker with payments made under different coverages of the policy must be reported as one claim with all of the incurred amounts combined.

Example: If the entire loss is incurred under the provisions of both Part One and Part Two of the Workers’ Compensation and Employers’ Liability Insurance policy, the claim would be coded to Type of Claim (03) Workers’ Compensation, including Employers’ Liability. Refer to section (d) of this Part, Type of Claim, within this section.

General definitions of the loss conditions follow:

1. Act

   1. State Act or Federal Act Excluding USL & HW – Code 01

      A claim with benefits determined according to the state workers’ compensation law or federal compensation laws, excluding United States Longshore and Harbor Workers’ Compensation Act.

   2. USL & HW F-Classifications and USL & HW Coverage on Non-F Classifications – Code 02

      A claim with benefits determined according to the United States Longshore and Harbor Workers’ Compensation Act.

2. Type of Loss

   1. Trauma – Code 01

      An injury resulting in disability or death that is traceable to a definite compensable accident occurring during the employee’s present or past employment.  A traumatic injury cannot be classified as either a Cumulative Injury or an Occupational Disease Loss as defined below.

   2. Occupational Disease – Code 02

      Any abnormal condition or disorder other than a workplace injury resulting in a disability or death that is not traceable to a definite compensable accident occurring during the employee’s present or past employment. Any injury caused by repetitive exposure extending over time to a disease-producing agent or agents present in the worker’s occupational environment.

      Example: A granite worker presents a claim for the occupational disease of silicosis due to exposure to the disease agent silica.

      In order for a claim to be coded as an occupational disease case, it must have resulted from repetitive exposure extending over time. Claims that arise from single identifiable incidents should be coded as Trauma even though they may have been caused by inhalation, absorption, ingestion or other environmental factors.

   3. Cumulative Injury Other Than Disease – Code 03

      An injury that results in a disability or death and is not traceable to a definite compensable accident occurring during the employee’s present or past employment. The injury is understood to have occurred from, and has been aggravated by, a repetitive employment-related activity.

      Example: A cement mason or carpet installer presents a claim for injury to the knee caused by repetitive bending and kneeling on the job.

3. Type of Recovery

   1. No Recovery – Code 01
   2. Subrogation Only (Third Party) Code – 03

      A recovery that occurs when the carrier has received reimbursements from an entity, other than the employer, with legal liability due to circumstances for the injury.

      Refer to Item (10) of this Part regarding recoveries from subrogation and other third parties.

4. Type of Claim

   1. Workers’ Compensation Only – Code 01

      The entire loss is incurred under the provisions of Part One of the Workers’ Compensation and Employers’ Liability Insurance Policy

   2. Employers’ Liability Only – Code 02

      The entire loss is incurred under the provisions of Part Two of the Workers’ Compensation and Employers’ Liability Insurance Policy.

   3. Workers’ Compensation Including Employers’ Liability or Liability-Over – Code 03

      The loss is incurred under the provisions of Parts One and Two of the Workers’ Compensation and Employers’ Liability Insurance Policy.

   4. Liability Over – Code 04

      A particular Employers’ Liability coverage situation where a third party, who is being sued by an employee, in turn sues the employer on the grounds of negligence, or like theory.

      Example: A person operating a drill press is injured, and, although the injury is compensable, the worker brings suit against the manufacturer of the drill press on the grounds of faulty design or manufacture. The manufacturer then succeeds in suing the employer for damages on the grounds of faulty installation or maintenance of the drill press. The damages thus incurred to the employer, if covered under his workers’ compensation policy, are classified as liability-over, and are in addition to compensation payments made to the injured employee.

5. Type of Settlement

   Identify the type of settlement for the claim.

   1. Claim Not Subject to Settlement – Code 00
   2. Section 32 Settlement – Code 03

      The claim has been settled under Section 32 of the New York State Workers’ Compensation Law.  Code 03 is applicable to both closed claims and to open claims even when only a portion of the claim is subject to a Section 32 settlement.

   3. Dismissal or Take Nothing (Non-compensable) – Code 05

      The claim meets one or more of the following:

      1. Official ruling denying benefits on the entire claim.
      2. Claimant’s failure to file for benefits and no claim is established by the New York State Workers’ Compensation Board.
      3. Claimant’s failure to prosecute claim following carrier’s denial of the claim as of the valuation date of the claim.
      4. No reimbursement is sought for care provided within six months of the date the claim is filed and the claim has not been established by the New York State Workers’ Compensation Board.

   4. All Other Settlements – Code 09

Report the numeric state code of the governing jurisdiction that will administer the claim and whose statutes will apply to the claim adjustment process.

Refer to Part VI of this Plan for Jurisdiction State Codes.

Note: State Code “00” will no longer be accepted on any Unit Stat claim.

A catastrophe is defined as any accident (one occurrence) resulting in two or more reportable claims.

Report the two-digit sequential number for two or more claims resulting from the same occurrence. For each policy, the claims from the first such occurrence must be assigned a Catastrophe Number of “01,” claims from a second occurrence must be “02,” etc. up to “10.” After number “10” is assigned the next number in the sequence will reprocess to number “01”. When an occurrence results in only one claim being reported, zero-fill this field.

Exceptions:

1. Report Catastrophe Number 87 for all claims for a latent condition emanating from the rescue, recovery and clean-up operations at the World Trade Center site that were undertaken between September 11, 2001 and September 12, 2002, as defined in Article 8-A of the New York Workers’ Compensation Law (Chapter 446 of the Laws of 2006).

   Note: Catastrophe Number 87 will apply to both single and multiple claims.

2. Report Catastrophe Number 12 for all claims occurring on or after December 1, 2019 and before January 1, 2024 that are due to the COVID-19 pandemic.

   Note: Catastrophe Number 12 will apply to both single and multiple claims.

Report the code that corresponds to the type of organization, if any, that administers the applicable medical loss on the claim.

Report the 3 two-digit codes that represent respectively, the Part of Body, Nature of Injury and

Cause of Injury for each claim.

1. Part of Body: Report the code that identifies the injured body part for a given claim. The part of body that is injured and expected to be the most significant contributor to the cost of the claim.

2. Nature of Injury: Report the code that represents the nature of injury for a given claim.

3. Cause of Injury: Report the code that represents the cause of injury for a given claim.

Refer to Part VI of this Plan for the applicable codes.

Report the narrative description of the regular occupation of the claimant.

Report the unique alphanumeric Case Number assigned to each claim by the New York State Workers’ Compensation Board.

Note: The Case Number must be reported for every claim to which a number has been assigned by the New York State Workers’ Compensation Board.

Case numbers are not required for:

1. Jurisdiction State is not New York
2. Medical-only claims
3. Claims subject to the Volunteer Firefighters’ Benefit Law
4. Claims subject to the Volunteer Ambulance Workers’ Law
5. Claims that are only Employers’ Liability – Type of Claim 02
6. Claims that are only Liability-Over – Type of Claim 04
7. Claims that are subject to Federal Coverage
8. ALAE-only claims when no Case Number has been assigned

Report, in whole dollars, the claimant’s actual weekly wage amount at the date of injury upon which the indemnity benefits are based.

Note: This amount is NOT the effective weekly wage underlying maximum or minimum statutory benefits.

Report the incurred dollar amount (paid plus outstanding reserves) for the claimant’s legal representation during the settlement of the claim as of the valuation date.

Report the incurred amount (paid plus outstanding reserves) for the employer’s legal representation during the settlement of the claim as of the valuation date.

Report the arithmetic totals of the amounts reported for Number of Claims, Incurred Indemnity, Incurred Medical, Paid Indemnity, Paid Medical, ALAE Paid and Claimant Attorney Fees and Employer Attorney Fees, if reported.

In the case of corrections and subsequent reports, the totals shown must be the revised totals.