INJURED IN THE LINE OF DUTY?

Transcription

1 INJURED IN THE LINE OF DUTY? A Volunteer Firefighter s and Ambulance Worker s Guide to New York State Benefits New York State Workers Compensation Board

2 i NYS Workers Compensation Board Privacy Statement All documents the Workers Compensation Board has about your case are private. Under workers compensation law, only the parties to your claim may receive information from your case file. Beyond you and your attorney or representative, the parties who may see information include your employer and your employer s attorney your employer s workers compensation insurance carrier and its attorney That insurance carrier may share information with health care providers it hires to examine you. Your health care providers will have to share your health information with that insurer when they bill for their services. Anyone who obtains a court order authorizing access to your claim information is also included. Your information may also be shared with government entities if they are processing a claim for benefits or investigating fraud. No one may disclose your information to anyone who is not authorized to see it. You may give written permission to anyone you choose to access your claim information, in two ways. 1. File an original Form OC-110A, Claimant s Authorization to Disclose Workers Compensation Records. This is available from under Forms, or by calling File an original notarized letter or form where you authorize a particular person or entity to see your claim information. You may submit an authorization at any time. It s always helpful to share a copy of that document with the person you authorize to see your records. Some people authorize their spouse or child to access their records when they initially file for benefits. Prospective employers may not ask you for information about your workers compensation claims before hiring you, or in connection with assessing fitness or capability of employment.

3 ii NYS Workers Compensation Board Table of Contents Privacy Statement...i What Benefits are Available to Volunteer Firefighters or Ambulance Workers?... 1 How to File a Claim... 1 Who is Covered?... 2 What is In the Line of Duty... 2 What is Not In the Line of Duty... 3 Cash Benefits... 4 Death Benefits... 5 Waiver Agreements... 5 Disability Classifications... 6 Rehabilitation and Social Work... 6 Medical Care... 7 Hearings and Appeals... 8 Common Questions... 8 District Offices and Phone Numbers The VAW-3, VF-3, and OC-110a3 forms follow the text of this document. This pamphlet is a general and simplified presentation of Workers Compensation provisions and procedures. It is not a substitute for the law or legal advice. The Workers Compensation Board does not discriminate on the basis of race, color, national origin, sex, religion, age, disability or sexual preference in employment or the provision of service. Workers compensation fraud is a Class E felony, punishable with up to four years imprisonment, $5,000 individual/$10,000 corporate fine, and five years probation. Subsequent conviction is a Class D felony.

4 1 NYS Workers Compensation Board What Benefits are Available to Volunteer Firefighters or Ambulance Workers? The Volunteer Firefighters and Volunteer Ambulance Workers Benefits Laws provide cash benefits and/or medical care for volunteer members who are injured or become ill in the line of duty. Recognizing the unselfish service of volunteer firefighters and volunteer ambulance workers, laws designed to protect volunteers who are injured, or who become ill, in the line of duty were enacted in 1957 and 1989, respectively. The local political subdivision pays for this insurance, and cannot require the volunteer member to contribute to the cost of coverage. Weekly cash benefits and medical care are paid by the subdivision s insurer, in accordance with the applicable law. The Workers Compensation Board is a state agency that administers these laws, and if disputes arise, adjudicates them through a quasi-judicial proceeding. In a volunteer firefighter s or ambulance worker s benefits case, no one party is determined to be at fault. The amount that a claimant receives is not decreased by her carelessness, nor increased by the company s fault. A volunteer member loses his right to benefits if the injury results solely from his intoxication from alcohol or drugs, or from the intent to injure himself or someone else. How To File A Claim Obtain form VAW-3 (ambulance workers) or VF-3 (firefighters), the Claim for Benefits, from the nearest Board office, the Board s website, or from the fire or ambulance district or company. Notify one of the following individuals within 90 days of the injury. This may be in the form of a signed copy of a VAW-1 or VF-1: Clerk of the board of supervisors of the county; Town or village clerk; Secretary of the fire or ambulance district or company; or Comptroller or chief financial officer of the city. Mail a completed VAW-3 or VF-3 to the Board District Office nearest you. Claims must be filed within two years of an accident or two years from the date a death occurs. You will be notified by mail if a hearing on your case is necessary.

5 2 NYS Workers Compensation Board Who is Covered? All New York State volunteer firefighters are entitled to benefits under the law if they are active volunteer members of a fire company of a county, city, town, village or fire district and are injured in the line of duty. Most New York state volunteer ambulance workers are entitled to benefits under the law if they are active volunteer members of an ambulance company and are injured in the line of duty. Volunteer ambulance companies that are not under contract with a county, city, town, village or other political subdivision, or that do not wish to become special improvement districts of towns, may provide optional coverage to their workers. What is In the Line of Duty for Volunteer Firefighters? Any of the following activities, pursuant to orders or authorization: Participation at a fire, alarm of fire, hazardous material incident, or other emergency situation that triggers response by the fire company or its units; Travel to, from and during fires or other calls to which the company responds; travel in connection with other authorized activities; Some duties in the firehouse, such as construction, repair, maintenance and inspection; Inspection of property for fire hazards or other dangerous conditions; Fire prevention activities; Attendance at fire instructions or fire school; instruction at training; Participation in authorized drills, parades, funerals, inspections/reviews, tournaments, contests or public exhibitions conducted for firefighters; Attendance at a convention or conference as an authorized delegate; Work on or testing of fire apparatus/ equipment, fire alarm systems and fire cisterns; Meetings of the fire company; Pumping water or other substances from a basement or building; Inspection of fire apparatus prior to delivery; Response to a call for general ambulance service by a member of an authorized emergency rescue and first aid squad; Participation in a supervised physical fitness class; or Fund-raising activities (noncompetitive events).

6 3 NYS Workers Compensation Board What is In the Line of Duty for Volunteer Ambulance Workers? (continued) Travel to, work at, and travel from an accident, alarm of accident or other duty to which the ambulance company has responded; travel in connection with other authorized activities; Personal assistance rendered to another ambulance company; Performance of duties at the ambulance facility or elsewhere, directly related to the prevention of accidents or disasters or the delivery of emergency health care; Instruction or being instructed in ambulance duties; attendance at a training school or course of instruction for ambulance workers; Attendance at, or participation in, any noncompetitive training program; Attendance at, or participation in, authorized drills, parades, funerals, inspections or reviews; Attendance or work at meetings of the ambulance department or company, or any organized unit thereof, at the ambulance facility or other regular or special headquarters of the department, company or unit; Work in connection with the construction, testing, inspection, repair or maintenance of the ambulance facility and the fixtures, furnishings and equipment thereof, and the ambulance vehicles, ambulance apparatus and equipment used by the ambulance department, ambulance company, or other unit; Practice for, or participation as a contestant or an official in any competitive tournament, contest or public exhibition conducted for ambulance workers intended to promote the efficiency of the ambulance department, ambulance company or any unit; Inspection of ambulance vehicles and ambulance apparatus prior to delivery under a contract or purchase, or performing duties related to the delivery; Attendance at a convention or conference of ambulance workers or officers as the authorized delegate or representative of the ambulance department, ambulance company or any unit; or Work in connection with a fund-raising activity of the ambulance company, not including competitive events where volunteer ambulance workers are competitors. Participation, including practice, in any recreational or social activity, other than noncompetitive fund-raising activities; Work rendered in service of a private employer, public corporation or special district; Work rendered while on leave of absence or suspended from duty, or work that the volunteer was ordered not to perform; or What is Not In the Line of Duty? Competitive events where volunteer members are competitors, such as baseball, basketball, football, bowling, tugs of war, donkey baseball, donkey basketball, boxing, wrestling, contests between bands or drum corps, or other competitive events where volunteer members compete, that involve physical exertion on the part of the competitors.

7 4 NYS Workers Compensation Board Cash Benefits Benefits are payable when the volunteer company responds as a unit, regardless of whether the injury occurred in the service of the home area or an aided area. Total disability, schedule loss or death benefits are fixed according to the statute. In determining weekly benefits for other types of injuries, the loss of earning capacity is based on the ability of the person to perform the work usually and ordinarily performed in his/her regular employment. Earning capacity is the capability of a volunteer member to perform on a 5-day or 6-day basis the work normally done in regular employment at the time of injury, or other work that could be considered a reasonable substitute if there is no employment. Every volunteer member is considered to have an earning capacity. The Board determines the reasonable earning capacity, considering the work that he/ she could reasonably be expected to obtain and for which he/she would be qualified by age, education, training and experience. Benefits are payable from the first day of disability, with no waiting period. Necessary medical care is provided without regard to the length of the disability. Schedule of Benefits for Volunteer Firefighters and Ambulance Workers Date of Accident Weekly Maximum Total / Partial Disability July 1, 1992 and after $400 / $400 July 1, June 30, 1992 $400 / $350 July 1, June 30, 1991 $400 / $280 Note: The maximum benefit for volunteer firefighters and volunteer ambulance workers classified as totally and permanently disabled is $400 per week, regardless of the date that the injury occurred. In the event of death or disability due to disease or malfunction of the heart or coronary arteries, the claim must be decided within 90 days from the time the claim is received by the Board.

8 5 NYS Workers Compensation Board Death Benefits If a volunteer firefighter or ambulance worker dies from a compensable injury, the surviving spouse and/or minor children (or other dependents as defined by law if there are none), are entitled to continuing weekly cash benefits, depending on the date of death. A minor child is under age 18, or under 25 if enrolled in an accredited educational institution. In no instance may the weekly benefit amount exceed the legal maximum, regardless of the number of dependents. Surviving spouses who have not remarried and have no dependent children are entitled to the following weekly benefits: Firefighters, for benefits paid after Jan. 1, 2006 $887 per week if death occurred on or after July 1, Ambulance Workers, for benefits paid after Jan. 1, 2006 $887 per week if death occurred on or after July 1, Surviving spouses with dependent children are entitled to smaller weekly cash benefits. Children are also entitled to weekly cash benefits. Weekly benefits for surviving spouses who remarry after January 1, 2006, and have no dependent children are replaced by the following lump sum benefit: Firefighters $92,219 if death occurred on or after July 1, Ambulance Workers $ if death occurred on or after July 1, Weekly benefits for surviving spouses who remarry and have dependent children are replaced by smaller lump sum benefits. Children continue to receive weekly benefits. Funeral expenses are payable up to a maximum of $6,700, if the death occurs on or after January 1, If a volunteer firefighter dies from injuries received in the line of duty as the direct result of firefighting, the $6,700 maximum is not applicable. A lump sum benefit of $56,000 is paid to the surviving spouse, or to the estate if there is no surviving spouse, after Jan. 1, These are in addition to all other benefits provided. If a beneficiary claiming death benefits as a dependent or spouse of a volunteer member dies before a determination in his/ her favor is made on the claim, all weekly benefits due from the date of death of the volunteer member up to the date of death of the eligible beneficiary will be paid to the executor or administrator of his/her estate. Waiver Agreements Claimants can reach a settlement agreement with the insurer for the benefits the claimant will receive. In exchange, the claimant will waive his right to future benefits. Waiver agreements are entirely voluntary and are not effective until approved by the Board. The Board will approve an agreement unless it is unconscionable, unfair or improper as a matter of law, is the result of an intentional misrepresentation of material fact, or within 10 days of submitting the agreement one of the interested parties asks the Board to disapprove the agreement.

9 6 NYS Workers Compensation Board Disability Classifications An injured volunteer member s health care provider will give an opinion on the extent of the disability. Cash benefits are directly related to the following disability classifications: Permanent Total Disability: The volunteer member s earning capacity is permanently and totally lost. Temporary Total Disability: The injured volunteer member s earning capacity is lost totally, but only on a temporary basis. Temporary Partial Disability: The earning capacity is lost only partially, temporarily. If the loss of earning capacity is 75 percent or greater, the volunteer member receives the maximum amount, determined by the date of accident. If the loss of earning capacity is between 50 and 75 percent, the benefit rate is $ per week. If the earning capacity loss is between 25 and 50 percent, the benefit rate is $30 per week. If the earning capacity loss is less than 25 percent, no cash benefits are paid. Permanent Partial Disability: Part of the volunteer member s earning capacity has been permanently lost. Benefits are payable at the same rates as Temporary Partial Disability, except for Schedule Loss. Schedule Loss: This is a special category of Permanent Partial Disability, and involves loss of eyesight or hearing, or loss of a part of the body or its use. Compensation is limited to a certain number of weeks, according to a schedule set by law. For instance, 25 percent loss of use of an arm is equal to 78 weeks (1/4 of 312 weeks). Disfigurement: Serious and permanent disfigurement to the face, head or neck may entitle the volunteer member to compensation up to a maximum of $20,000, depending upon the date of the accident. Rehabilitation and Social Work Rehabilitation programs offer special services designed to eliminate the disability if possible, or to reduce or alleviate the disability to the greatest degree possible; help an injured worker return to work when possible; or aid a person with a residual disability to live and work at her maximum capability. The Board s Rehabilitation staff includes counselors, social workers, a consultant physiatrist, and claims examiners to coordinate and follow-up on medical and vocational rehabilitation services. Rehabilitation is voluntary except in limited circumstances. Injured workers should contact the rehabilitation unit at the Board to determine if they are required to participate. There are four general types of services. Vocational Rehabilitation programs help people whose disability keeps them from returning to their former jobs. These services may provide guidance to help the claimant determine the best way to return to work. Selective Placement programs help claimants who are left with a permanent disability, and who need a job that will fit their abilities. Medical Rehabilitation programs include exercise and muscle conditioning, under the supervision of a physician, to restore a person to maximum usefulness. Only physicians may recommend a medical rehabilitation program. Social Services, which are provided by a staff of social workers, are designed to assist an injured volunteer member with family or financial problems that interfere with rehabilitation. Claimants who participate in one of the rehabilitation programs continue receiving cash benefits, based on the extent of the disability. Claimants who return to work but cannot earn the same wages because of an injury may be entitled to compensation benefits at a reduced rate.

10 7 NYS Workers Compensation Board Medical Care An injured or ill volunteer member will have his health care for that condition paid. This care is covered whether or not you lose time from work. It is also paid in addition to any benefits you get for missed wages. Health care providers must be authorized by the Board. The Board has lists of providers who are authorized to treat you. You can find a doctor on the Board s web site, or by calling You can receive care from any of these providers, or from your own doctor, if he or she is registered. The providers will send the bills directly to the insurer and the Board. Do not pay any bills unless the Board disallows your case. You may also receive reimbursement for travel to and from a health care provider s office. If specific medical services are disputed, the insurer must pay any undisputed portion. It must also explain in writing why the services were not paid, and request any information needed to pay them. Your doctors may ask you to sign Form A-9. This states you ll pay the bills if the Board does not allow your claim, or if you drop your case before it s accepted. Preferred Provider Organizations If the insurer has a network of providers to care for injured workers, you must use those providers. This is called a Preferred Provider Organization (PPO). The insurer must notify you of this. If you aren t satisfied with the care you receive from the PPO, you may select an authorized provider outside the PPO after 30 days of treatment. Types of Services Covered Medical Osteopathic Dental Podiatric Psychological (by referral) Chiropractic Treatment Surgery Hospital Care Laboratory Tests Prescribed Drugs Nursing Services Surgical Appliances Prosthetic Devices Preauthorization is sometimes required. You re not responsible for a copayment. If you must use an insurer s network pharmacy, the insurer must tell you how you should use it. Those pharmacies are paid directly. You will not be responsible for any charges. Diagnostic Networks Insurers may also require you to use its network of facilities for diagnostic tests. Make sure to tell your doctors and other providers if the insurance carrier requires you to use its network for diagnostic test. Pharmacy Charges You can go to any pharmacy, unless the insurer uses a network. Make sure the pharmacist knows you have a workers compensation case, because many will bill the carrier directly, rather than you. However, the pharmacy can ask you to pay for the prescription up front. The insurer must reimburse you within 45 days. The pharmacy can only charge you the amount specified by law, so even if you pay in advance, you will be fully reimbursed. Exceptions 1. Testing: The insurer may not demand you use a network provider for a diagnostic test in a medical emergency. It may not demand you use a network that does not have a provider or facility within a reasonable distance, which is one mile from your home or employment in an urban setting, and ten miles in a suburban or rural setting. 2. Pharmacy: The insurer may not demand you use network pharmacies if it is not reasonably possible in a medical emergency. You don t need to use network pharmacies if they don t offer mail order or aren t located a reasonable distance from you, either.

11 8 NYS Workers Compensation Board Hearings and Appeals The Board may hold hearings before a workers compensation law judge. The judge may take testimony, review medical and other evidence, and will decide if the claimant is entitled to benefits. If the claim is determined compensable, the judge determines the amount and duration of the compensation award. Either side may appeal the decision within 30 days of the filing of the judge s decision, by applying in writing for Board review. If the application is granted, a panel of three Board members will review the case and either affirm, modify or rescind the judge s decision, or restore the case to the judge to further develop the record. If the panel decision is not unanimous, any interested party may apply in writing within 30 days for a full Board Review. The full Board must review and either affirm, modify or rescind that decision. Appeals of Board Panel decisions may be taken to the Appellate Division, Third Department, Supreme Court of the State of New York, within 30 days. The decision of the Appellate Division may be appealed to the Court of Appeals. Note: If a law judge s decision is appealed, the insurer does not have to pay wage benefits while a Board Panel reviews the case. However, compensation payments and medical bills must be made if the Board Panel upholds the claimant s award, even if an appeal is made to the Appellate Division. In addition, the uncontested portion of a judge s award is paid even if a review application is filed. Claimants always have the right to an attorney or licensed representative, who may not ask for or accept a fee from the claimant. The legal fee is determined by a law judge or Board Panel, and is deducted from a compensation award. Common Questions Q. If an activity is authorized by the proper authority, is it covered? A. Not necessarily. The ambulance or fire officer may authorize an activity, but if it is not provided for in the law, it may not be compensable. Q. Must the claimant lose time in regular employment for the disability to be covered? A. Not necessarily. The disability is compensable if there is loss of earning capacity, or loss of use or partial use of a bodily member, eye or hearing. Q. If a volunteer firefighter or ambulance worker receives remuneration or a gratuity in the performing a duty or activity covered under the law, can he still sustain a compensable injury in the line of duty? A. No. The following are not remuneration or a gratuity: Reimbursed expenses for meals, lodging, necessary travel or a mileage allowance; and accepting transportation, food, drink, shelter, clothing and similar items while on duty. Q. Must a notice of injury be in writing? A. Yes. The volunteer member, or a representative, must sign the notice. However, the Board may excuse the failure to give written notice on any of the following grounds: for sufficient reason notice could not have been given; a member of a body in charge of, or any officer of, the ambulance or fire company/district had knowledge within 90 days of the injuries or death; the political subdivision, ambulance company or insurance carrier was not prejudiced by a delay in giving such notice; the cause of disablement or death was not known to be the result of service performed in the line of duty as a volunteer member in sufficient time to comply with the notice requirement.

12 9 NYS Workers Compensation Board Common Questions (cont d) Q. How much medical care is provided for a compensable injury? A. Necessary medical care is provided as long as the injury and recovery process require. Q. Is medical care provided even when time is not lost from work? A. Yes. Q. When does medical care require prior authorization? A. Prior authorization by the political subdivision, fire or ambulance company liable for the payment of benefits (or its insurer) is necessary for certain types of care, such as nursing, and for other services that significantly increase costs. Q. Is the volunteer member reimbursed for purchasing necessary medicine or prescribed drugs? A. Yes. The claimant must obtain receipts and submit them to the political subdivision, company, or insurance carrier involved. Q. What happens when a claim is contested by the insurer? A. To contest a claim, an insurer must file a notice of controversy with the Board within 18 days after the disability begins or within 10 days of learning of the accident, whichever is later. The carrier must give the reasons why the claim is not being paid. The issue is resolved by a law judge at a prehearing conference or a hearing. Q. May a closed case be reopened? A. Yes. The Board may reopen a closed case, subject to time limitations set forth in the statute, upon application of any party. The application must set forth the basis for the requested reopening. However, a claim that has been totally settled by a waiver agreement cannot be reopened by the Board. Q. May a volunteer firefighter or ambulance worker render emergency service with another district or company? A. Yes. If a volunteer member offers individual service to another company in New York outside the area regularly served by the member s company or district, and after such services are accepted by the officer in command at the scene, the responsibility for benefits resulting from an injury in the line of duty will fall to the fire or ambulance company (and its political subdivision) that accepted the voluntary service. Q. What is the penalty for making a false claim to obtain benefits? A. Such a person is guilty of workers compensation fraud, a class E felony.

13 10 NYS Workers Compensation Board Board Services Customer Service Advocate for Injured Workers Health Care Provider Advocate for Business Fraud Referral Hotline Disability Benefits Board Offices Albany District Office 100 Broadway - Menands Albany, NY Binghamton District Office State Office Bldg., 44 Hawley Street Binghamton, NY Brooklyn District Office 111 Livingston Street Brooklyn, NY Buffalo District Office Ellicott Square Building 295 Main Street - Suite 400 Buffalo, NY Hauppauge District Office 220 Rabro Drive, Suite 100 Hauppauge, NY Hempstead District Office 175 Fulton Avenue Hempstead, NY Manhattan District Office 215 W. 125th Street New York, NY Peekskill District Office 41 North Division Street Peekskill, NY Queens District Office st Avenue Jamaica, NY Rochester District Office 130 Main Street West Rochester, NY Syracuse District Office 935 James Street Syracuse, NY P-30 (8/12) Send claims-related mail to: NYS Workers Compensation Board PO Box 5205 Binghamton, NY