N.Y. Comp. Codes R. & Regs. tit. 12 § 363.13

Current through Register Vol. 46, No. 41, October 9, 2024

Section 363.13 - Rejection of claim

(a) Notice of denial of claim. If the employer or carrier denies an initial claim for disability benefits, the employer or carrier must notify the employee of such denial in a manner prescribed by the chair within 18 days of receipt of the proof of disability and must thereafter notify the employee of rejection within 45 days of receipt of the proof of disability.

(b) Notice of rejection of claim. A Notice of Total or Partial Rejection of Claim for Disability Benefits (in the format prescribed by the Chair) sent to the claimant within 18 days of receipt of proof of disability shall satisfy the employer or carrier's obligation to send a notice of denial of claim pursuant to subdivision (a) of this section.

(c) Unless supported by an examination pursuant to Workers' Compensation Law § 217(2), and upon 7 days' notice to the employee, no inquiry pursuant to Workers' Compensation Law § 208(1) shall be made prior to the expiration of the medical certification or twelve weeks from the date of disability, whichever is sooner. Any inquiry made thereafter must be made no more than two weeks prior to the date of expiration of the proof of disability. Such inquiry shall include a clear and prominent statement of the deadline of at least 2 weeks for responding and consequences of failing to respond. Disability caused by or in connection with a pregnancy shall be presumed for the four weeks prior to the child's estimated due date and for the six weeks after giving birth or eight weeks after delivering by Cesarean section.

(d) The carrier or self-insured employer may deny the claim without prejudice for the following reasons:

(1) incomplete Notice and Proof of Claim for Disability Benefits; or

(2) insufficient certification of disability.

(e) If the claim is denied without prejudice due to an incomplete claim package, the carrier or self-insured employer must notify the employee of each piece of required information, as identified on the Notice and Proof of Claim for Disability Benefits (in the format prescribed by the Chair), which is missing from the employee's claim for benefits. If the claim is not refiled within 30 days from when leave was first taken, the carrier or self-insured employer may deny the claim.

(f) The carrier or self-insured employer may deny the claim for the following reasons:

(1) employee has not been employed by the employer for at least 4 consecutive weeks and has not carried eligibility from their prior employer;

(2) employee is not an employee of the employer or employee's disability began more than 4 weeks after their employment terminated;

(3) employee is not an employee of a covered employer;

(4) the amount of leave requested exceeds the statutory maximum benefit period under Article 9 of the Workers' Compensation Law;

(5) the amount of leave requested exceeds the leave needed as stated in the medical certification of the employee;

(6) the claim was not timely made, and claimant did not show it was not reasonably possible to timely file required notice and proof of claim (e.g., delay of medical provider, or claimant was incapacitated);

(7) the employer did not have coverage on the date leave began:

(i) when the Board has identified a carrier as providing coverage, the carrier shall pay benefits to the employee without prejudice while the dispute regarding coverage is resolved. Such payments are subject to reimbursement by the carrier identified following the dispute regarding coverage. Whenever a claim for benefits is the responsibility of the special fund for disability benefits pursuant to section 213 of the Workers' Compensation Law, the chair may waive the special fund for disability benefits' obligation to pay without prejudice;

(ii) when a basis for denial is lack of insurance coverage, the insurance carrier shall provide the Board with a copy of the denial;

(8) disability arose out of and in the course of the employee's employment as evidenced by a workers' compensation claim number, if available, or by providing the employer's name and date of accident or date of disablement.

(g) Failure of the employer to complete, or inadequate completion by the employer, of the employer section on the Notice and Proof of Claim for Disability Benefits is not a valid basis for denial by the carrier.

(h) If the employee is eligible to receive benefits at the time of submission of the Notice and Proof of Claim for Disability Benefits with the carrier, the carrier or self-insured employer must accept the claim and make payment to the employee within 18 days. In addition to any other applicable penalties, any benefits paid after 18 days shall draw simple interest from 10 days after notice was given, at the rate provided in section 5004 of the Civil Practice Law and Rules.

(i) Request for review. If an employee desires a review of any action on their claim, they shall file with the chair the notice of rejection of their claim, the request for review and a statement giving specific reasons for such request. Determination of such contested claim shall be made in accordance with the provisions of section 221 of the Workers' Compensation Law. If the insurance carrier or self-insured employer fails to respond to an inquiry from the Workers' Compensation Board relating to a request for review, the claim shall be deemed approved.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 363.13

Amended New York State Register May 10, 2023/Volume XLV, Issue 19, eff. 1/1/2024