01. 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 NYCIRB 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 5.b. 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 16.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 18 of this part for instructions on the use of Catastrophe Number.

  6. Recoveries from subrogation, Special Funds 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 9 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.

 

02. Update Type

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

Code Description
R Original first reports and revised data on correction reports
P Previously reported data (used only on subsequent and correction reports)

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

 

03. Claim Number

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 NYCIRB 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 NYCIRB on unit statistical reports must be the same claim number reported in the NYCIRB 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).

 

04. Accident Date

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.

05. Incurred Losses

Report all loss amounts on a gross basis prior to any reimbursement of indemnity and/or medical payments by the insured 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. 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 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 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:
 
     
  • Payments in no-dependent death cases
  • 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 of 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 9 in this part for instructions regarding Recoveries.
 
  (4) Final Awards
 
    Where a final award has been made by the Workers' Compensation Board, the total incurred compensation must be in agreement with such award, except under the following circumstances:
 
    (a) 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.
 
    (b) 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.
 
    (c) 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, refers to an official ruling by the Workers' Compensation Board, specifically holding that a claimant is not entitled to benefits under the provisions of the New York Workers' Compensation Law. If 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, if 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 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.
 
 
      Where the carrier has appealed an award, it must report the full amount of such award.
 
    (d) 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 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 Workers’ Compensation Board or other body having jurisdiction over workers compensation claims.
 
  1. 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 Health Care Reform Act.

    Incurred medical amounts from claims not required to be reported to the Workers' Compensation Board, as defined in Section 110 of the New York 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 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.

 

06. Expenses Excluded From Losses

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

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

  • 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.

07. 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 Adj ustment Expenses (LAE)

    Employers liability losses must include allocated loss adjustment expenses, as defined in Item 12 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 Workers' Compensation Board

    Expenses for impartial examinations ordered by the 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

 

08. Fraudulent Claims

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

  • The claim has been ruled (or officially declared) fully fraudulent by a court decision or a ruling of the Workers’ Compensation Board.

  • The claim, or a portion of the claim, has been deemed to be partially fraudulent by a court decision or a ruling of the 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.
    • Ruling or declaration of fraud prior to 1st Report: The claim is considered non-compensable and is not to be reported.

    • Ruling or declaration of fraud subsequent to 1st Report: A correction report(s) must be filed, reducing the incurred cost of the claim to zero. This must be done for reports impacting the current and up to six prior experience modifications.
       
  2. Reporting Partially Fraudulent Claims

    When a claim, in which a portion of the 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.


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

      • Ruling or declaration of fraud subsequent to 1st Report: 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. This must be done for reports impacting the current and up to six prior experience modifications.

      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 (1st report), $40,000 (2nd report), and $60,000 (3rd report). Subsequent to the 3rd 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 2nd and 3rd reports. Correction reports must be submitted for the 2nd and 3rd reports. As the net incurred cost is higher than the $10,000 reported in the 1st report, no correction report is needed for the 1st 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.

Code Description
00 The claim does not involve fraud
01 Partially Fraudulent: a portion of the claim has been deemed fraudulent by the courts or ruling of the Workers’ Compensation Board
02 Fully Fraudulent: the entire claim has been found to be fraudulent by the courts or ruling of the Workers’ Compensation Board

09. Recoveries - Subrogation - Third Party Cases - Special Funds

(1) In all cases where there has been recovery of loss due to subrogation, or where the injured worker or his dependents have recovered from a third party, the loss amount reported must be the net incurred loss.
 
(2) For subrogation cases, the net incurred loss is defined as 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. When the recovery expenses exceed the amount recovered, report the gross incurred loss instead of the net incurred loss. When the allocation of the recovery to indemnity and medical is not known, the net incurred loss must be divided between indemnity and medical loss in the same proportion as the original gross incurred indemnity and medical amounts.
 
(3) For cases involving recovery by the injured employee or his dependents, the net incurred loss must be:
 
  (a)   the deficiency, if any, between the outstanding compensation provided by the Workers' Compensation Law
        and the net amount of recovery actually collected by the claimant, and
 
  (b)   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.
 
(4) When recovery by the injured worker or his 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 Special Funds (Special Disability Fund and Reopened Case 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 loss amounts to determine the total net liability for the case.
 
(5) When reimbursement by a third party or a subrogation recovery is received by the carrier subsequent to the first reporting of the claim, but within one year after the 5th report due date, a correction report(s) must be filed with the NYCIRB reducing the incurred cost on the claim to the net incurred loss as defined above. This must be done for reports which would impact the current and up to six prior experience modifications. If an anticipated recovery becomes known by the carrier, or a recovery is paid to the carrier as of the 6th report valuation date or subsequent, all adjustments are reported at the next valuation date.   Refer to Rule 4.B.2.c. of the New York Experience Rating Plan Manual.

 
Correction reports are required only for prior reports that reflected an amount higher than the net incurred cost.  
 
 
  Example: Consider a claim that has been reported as $10,000 (1st report); $40,000 (2nd report); $60,000 (3rd report). A subrogation recovery is in the amount of $25,000 and recovery expense is $3,000. The net incurred cost of the claim is the latest value minus the recovery, plus recovery expenses ($60,000 - $25,000 + $3,000 = $38,000). The net incurred cost ($38,000) is less than the claim value reported at the 2nd and 3rd reports. A corrected 2nd and 3rd report must be submitted. As the net incurred cost is higher than the $10,000 reported in the 1st report, no correction report is needed for the 1st report.    Refer to Part V for further instructions regarding correction reports.
 

 
(6) In all cases where a claim has been determined to be eligible for reimbursement to the carrier from a Special Fund (such as Special Disability Fund, Reopened Case Fund, etc.), the gross incurred costs of the claim (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) must be reduced by the amount of any payment or anticipated recovery from such fund. The net incurred cost of the claim must be reported on statistical reports that would impact the current and up to six prior experience modifications.   Refer to Rule 4.B.2.b. of the New York Experience Rating Plan Manual.
 
Correction reports are required only for prior reports which reflected an amount higher than the net incurred cost.
 
  Example:
 
Consider a claim that has been reported as $10,000 (1st report); $40,000 (2nd report); $60,000 (3rd report). A recovery from the Special Disability Fund is in the amount of $25,000. The net incurred cost of the claim is the latest value, minus the recovery ($60,000 - $25,000 = $35,000). The net incurred cost ($35,000) is less than the claim value reported at the 2nd and 3rd reports. Corrected 2nd and 3rd reports must be submitted. As the net incurred cost is higher than the $10,000 reported in the 1st report, no correction report is needed for the 1st report.

 

10. Lump - Sum Claims

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 according to indemnity and medical.

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

Code Description
Y The claim has been settled by an agreement between the insurer and claimant for a specified amount representing a discounted or commuted value.
N The claim has not been settled with a lump-sum agreement.

 

11. Paid Losses

  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 or Special Funds recoveries must be subtracted from paid indemnity if the recovery applies to the indemnity loss.

    Payments required by the 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 or Special Funds recoveries must be subtracted from paid medical if the recovery applies to the medical loss. Refer to Item 9 of this part for instructions regarding recoveries.

    Paid medical amounts must include surcharges on hospital and related services imposed pursuant to the New York Health Care Reform Act.

    Paid medical amounts for claims that are not required to be reported to the Workers’ Compensation Board, as defined in Section 110 of the New York Workers’ Compensation Law, should not be reported to the Rating

12. Allocated Loss Adjustment Expense (ALAE) Paid Amount

Report the dollar amount of loss adjustment expense allocated and paid for each claim as of the valuation date. ALAE encompasses 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:

    • Medical examinations of a claimant to determine the extent of the carrier’s liability, degree of permanency or length or disability
    • Expert medical or other testimony
    • Autopsy
    • Witnesses and summonses
    • Copies of documents such as birth and death certificates, and medical treatment records
    • Arbitration fees
    • Surveillance
    • Appeal bond costs and appeal filing fees
  1. 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:

    • 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
    • Hospital and other treatment utilization reviews, including precertification/preadmission, concurrent or retrospective reviews
    • Preferred provider network/organization expenses
    • Medical fee review panel expenses
  1. 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.

13. Classification Code

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 class.

Report the type of injury code as defined under provisions of the New York 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 g. 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 Workers' Compensation Law, or that, in the judgment of the carrier, will result in permanent total disability.

    Refer to Section g. 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, or if a claim has settled prior to such classification but was expected to be classified as such..

    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, or if a claim has settled prior to such classification but was expected to be classified as such.

    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.

    Medical losses must include surcharges on hospital and related medical services imposed pursuant to the New York Health Care Reform Act.

    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 Workers' Compensation Board, as defined in Section 110 of the New York 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 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 Workers’ Compensation Law. In determining the present value of the incurred loss amounts on these claims, the tables published by the Workers' Compensation Board must be used. Bulletin 222B must be used for cases with accident dates on and after September 1, 1983 and before January 1, 2001, and Bulletin 222C must be used for cases with accident dates on and after January 1, 2001.  Refer to the New York State Workers’ Compensation Board for these bulletins.

    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.
TABLE I
Life Awards—Permanent Total and Permanent Partial Disabilities
 
Age Present
Value
Age Present
Value
Age Present
Value
Age Present
Value
Age Present
Value
Age Present
Value

11 25.580 26 23.524 41 20.330 56 15.767 71 10.291 86 5.088
12 25.461 27 23.352 42 20.068 57 15.419 72 9.919 87 4.818
13 25.339 28 23.175 43 19.801 58 15.069 73 9.547 88 4.560
14 25.215 29 22.991 44 19.527 59 14.714 74 9.176 89 4.315
15 25.090 30 22.802 45 19.247 60 14.356 75 8.807 90 4.082
                       
16 24.963 31 22.607 46 18.961 61 13.994 76 8.439 91 3.861
17 24.835 32 22.406 47 18.670 62 13.630 77 8.073 92 3.651
18 24.706 33 22.199 48 18.372 63 13.264 78 7.707 93 3.453
19 24.573 34 21.987 49 18.069 64 12.896 79 7.345 94 3.265
20 24.436 35 21.768 50 17.758 65 12.526 80 6.988 95 3.087
                       
21 24.296 36 21.544 51 17.441 66 12.155 81 6.640 96 2..917
22 24.151 37 21.313 52 17.117 67 11.782 82 6.303 97 2..755
23 24.002 38 21.077 53 16.787 68 11.408 83 5.978 98 2.598
24 23.846 39 20.834 54 16.452 69 11.034 84 5.667 99 2..444
25 23.689 40 20.585 55 16.111 70 10.662 85 5.371 100 2.289
1999 United States Life Tables (U.S. Department of HHS)
3.5% Annual Rate of Interest

 

TABLE I - M
Life Awards - Permanent Total and Permanent Partial Disabilities (Male)
 
Age Present
Value
Age Present
Value
Age Present
Value
Age Present
Value
Age Present
Value
Age Present
Value

11 25.363 26 23.263 41 20.024 56 15.511 71 9.945 86 4.741
12 25.236 27 23.093 42 19.758 57 15.170 72 9.553 87 4.468
13 25.105 28 23.917 43 19.486 58 14.824 73 9.164 88 4.206
14 24.973 29 22.733 44 19.210 59 14.473 74 8.779 89 3.956
15 24.840 30 22.543 45 18.928 60 14.117 75 8.400 90 3.718
                       
16 24.706 31 22.347 46 18.641 61 13.755 76 8.027 91 3.491
17 24.572 32 22.144 47 18.349 62 13.390 77 7.660 92 3.275
18 24.436 33 21.935 48 18.051 63 13.020 78 7.300 93 3.071
19 24.299 34 21.719 49 17.749 64 12.646 79 6.948 94 2.878
20 24.160 35 21.496 50 17.442 65 12.268 80 6.604 95 2.696
                       
21 24.020 36 21.266 51 17.132 66 11.887 81 6.268 96 2.523
22 23.878 37 21.030 52 16.818 67 11.504 82 5.943 97 2.361
23 23.733 38 20.787 53 16.499 68 11.118 83 5.627 98 2.206
24 23.583 39 20.539 54 16.175 69 10.729 84 5.321 99 2.058
25 23.427 40 20.284 55 15.846 70 10.338 85 5.025 100 1.914
 

 

TABLE I - F
Life Awards - Permanent Total and Permanent Partial Disabilities (Female)
 
Age Present
Value
Age Present
Value
Age Present
Value
Age Present
Value
Age Present
Value
Age Present
Value

11 26.053 26 24.178 41 21.230 56 16.959 71 11.276 86 5.475
12 25.950 27 24.020 42 20.988 57 16.620 72 10.860 87 5.155
13 25.844 28 23.857 43 20.739 58 16.275 73 10.443 88 4.847
14 25.735 29 23.689 44 20.486 59 15.922 74 10.027 89 4.551
15 25.623 30 23.515 45 20.227 60 15.564 75 9.614 90 4.268
                       
16 25.510 31 23.335 46 19.962 61 15.200 76 9.205 91 3.998
17 25.393 32 23.150 47 19.691 62 14.831 77 8.800 92 3.741
18 25.274 33 22.960 48 19.414 63 14.457 78 8.400 93 3.497
19 25.152 34 22.764 49 19.130 64 14.077 79 8.005 94 3.266
20 25.025 35 22.562 50 18.840 65 13.692 80 7.618 95 3.049
                       
21 24.895 36 22.355 51 18.544 66 13.302 81 7.238 96 2.844
22 24.760 37 22.141 52 18.241 67 12.907 82 6.866 97 2.652
23 24.622 38 21.922 53 17.931 68 12.509 83 6.503 98 2.473
24 24.478 39 21.697 54 17.614 69 12.101 84 6.150 99 2.305
25 24.331 40 21.466 55 17.290 70 11.690 85 5.807 100 2.149
 
2007 United States Life Tables (U.S. Department of HHS)
3.5% Annual Rate of Interest

 

15. Claim Status

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

Code Description
0 Claim is Open
1 Claim is Closed
2 Claim is Reopened

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.

16. Loss Condition Code

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 paragraph d., Type of Claim, within this section.

General definitions of the loss conditions follow:

  1. Act
    • 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.

    • USL&HW F - Classes and USL&HW Coverage on Non - F Classes - Code 02
      A claim with benefits determined according to the United States Longshore and Harbor Workers’ Compensation Act.
       
  2. Type of Loss
     
    • 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.

    • 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.

    • 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
     
    • No Recovery - Code 01

    • Special Disability Fund (Second Injury Fund) Only - Code 02
      The Special Disability Fund provides for reimbursement to employers or carriers when a subsequent injury is caused by, or made substantially greater due to, the combined effects of physical impairment, previous accident, disease or congenital condition after a specified number of weeks are paid by the employer or carrier.

    • 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.

    • Subrogation With Special Disability Fund (Third Party) - Code 04
      A recovery that occurs when the carrier receives reimbursement from both the Special Disability Fund and a third party.

      Refer to Item 9 in this Part regarding recoveries from subrogation, the Special Disability Fund and other third parties.

      Note:   In any case for which the Special Disability Fund has been held legally liable for reimbursement of payments beyond the first 260 weeks, only the indemnity and medical corresponding to the first 260 weeks must be reported on the unit statistical report. If the Special Disability Fund has not been held legally liable for reimbursement of payments beyond the first 260 weeks, the full indemnity and medical losses incurred must be reported.

      Recovery from the Special Disability Fund only applies to an injury or illness with a date of accident or date of disablement prior to July 1, 2007.
       
  4. Type of Claim
     
    • 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.

    • Employers Liabiilty Only - Code 02
      The entire loss is incurred under the provisions of Part Two of the Workers Compensation and Employers Liability Insurance policy.

    • 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.

    • 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.
    • Claim Not Subject to Settlement - Code 00

    • Section 32 Settlement - Code 03
      The claim has been settled under Section 32 of the New York 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.

    • Dismissal or Take Nothing (Non - Compensable) - Code 05
      The claim will generate no payments or reserves due to one or more of the following:
      • Official ruling denying benefits
      • Claimant’s failure to file for benefits
      • Claimant’s failure to prosecute claim following carrier’s denial of the claim
         
    • All Other Settlements - Code 09
       

17. Jurisdiction State

Report the numeric state code of the governing jurisdiction that will administer the claim and whose statutes will apply to the claim adjustment process when that state is not New York.

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

Report the two-digit sequential number for 2 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. 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).

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

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

19. Managed Care Organization Type

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

Code Description
00 Not Administered by an approved Managed Care or Preferred Provider Organization
01 Administered by an approved Managed Care Organization
03 Administered by an approved Preferred Provider Organization

20. Injury Description Code

Report the 3 two-digit codes that represent respectively, the Part of Body, Nature of Injury and Cause of Injury for each claim. Refer to Part VI for the applicable codes.

21. New York State Workers' Compensation Board Case Number

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 Workers’ Compensation Board.

Case numbers are not required for:

  • Jurisdiction State is not New York
  • Medical-only claims
  • Claims subject to the Volunteer Firefighters’ Benefit Law
  • Claims subject to the Volunteer Ambulance Workers’ Law
  • Claims that are only Employers Liability-Type of Claim 02
  • Claims that are only Liability-Over-Type of Claim 04
  • Claims that are subject to Federal Coverage
  • ALAE-only claims when no Case Number has been assigned

22. Claimant Weekly Wage

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.

 

23. Claimant Attorney Fees Incurred - Optional

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.

24. Employer Attorney Fees Incurred - Optional

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.

25. Totals

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.