eClaims: New Procedures for Controverted Cases October 10, 2013
In the coming months, the Workers' Compensation Board is phasing in its new eClaims system, which will greatly impact the manner in which carriers file denials on new claims. To help streamline the process and maintain all applicable defenses to new claims, the following is our recommended procedure for controverting claims.
1. Fact Gathering: Obtain a C-2F
Obtain a C-2 from the employer to ensure compliance with Workers' Compensation Law § 110. You should investigate the claim as you normally would prior to the implementation of eClaims as all of the prior defenses have been maintained. Note that the filing of a C-2 does not satisfy the carrier’s obligation to file a new First Report of Injury (FROI) or Second Report of Injury (SROI). However, the filing of a FROI will satisfy the employer’s obligation to complete a C-2F.
2. FROI-04 or SROI-04? Determine How You Wish to Deny the Claim
You will have to choose the procedural manner in which you wish to deny the claim. Based on prior presentations and the eClaims overview, carriers will have the option to issue a FROI with a denial (FROI-04) or to enter a FROI-00 initial report followed by a SROI-04 denial or SROI-PD partial denial form. If you wish to deny by FROI-04 under WCL § 25(2)(a), the denial should be issued within 18 days after the disability event or 10 days after the employer has knowledge of the alleged disability. If you opt to deny by SROI-04 under WCL § 25(2)(b), the denial is due by the later of the following dates: 10 days after the employer has knowledge of the alleged disability, 18 days after the disability event, or within 25 days of the Notice of Indexing.
3. Choose the Appropriate Defenses: Consult With Counsel
As attorneys will no longer be able to file paper C-7 forms, it is crucial to review the file with your defense counsel prior to filing your FROI-04 or SROI-04. These forms will have specific boxes for each applicable defense, including subsets of defenses such as “Accident Arising Out of and In the Course of Employment.” Discussing the claim in detail with counsel will be important to ensure that you raise all appropriate defenses in your FROI-04 or SROI-04. Also, send copies of your FROI/SROI reports to counsel for review.
4. Subsequent Filings: The PH-16.2 and OC-400.5
Finally, at this point, defense counsel will take the additional necessary steps to preserve your defenses. Just as you would have before eClaims, you need to file a PH-16.2 Pre-Hearing Conference Statement listing all appropriate witnesses and maintaining all defenses. In addition, any documentary evidence necessary to the defense of the claim should be filed as well. To fully maintain your defenses, counsel will additionally file an OC-400.5 form at or before the pre-hearing conference certifying all defenses.
For more information on these new procedures, please contact: