Out of State coverage, possible scenarios

COVERED


Employee lives in NY, accident was in NY and claim is filed in NY.

Employee lives in NY, accident out of state but claim filed in NY.

Employee lives in NY, assigned temporarily to work out of state, accident occurs out of state and claim filed in NY.

Salespersons controlled and directed from NY but works out of state and claim filed out of state.

Salespersons controlled and directed from NY but works out of state and claim filed in NY.

Sales persons controlled and directed from out of state hired in NY claim filed out of state. Assuming that the insured has no other operations in that other State and the State Fund Policy has been endorsed accordingly.

Sales persons controlled and directed from out of state hired in NY claim filed in NY.

Employee lives out of state, performing work in NY, hurt in NY but filed claim in NY.

Truckers who keep their trucks out of state, accident in NY and claim filed in NY.



NOT COVERED


Employee lives in NY, accident out of state and claim filed out of state.

Employee lives out of state, assigned temporarily to work out of state, accident occurs out of state.

Employee hired in NY for specifically out of state work, accident happens out of state and claim filed out of state.

Employee lives out of state, performing work in NY, hurt in NY but filed claim out of state.

Truckers who keep their trucks out of state, accident in NY and claim filed out of state.

Truckers who keep their trucks out of state, temporarily working out of state, accident out of state, claim filed out of state.

OSHA new Recordkeeping Requirements

1. ALL EMPLOYERS must follow the serious injury rule and….

• Contact OSHA within 8 hours of a work related fatality.
• Contact OSHA within 24 hours of a work related in-patient hospitalization, amputation or loss of eye.

For more information on reporting a fatality or severe injury click here.

2. EMPLOYERS WITH 11 OR MORE EMPLOYEES must maintain OSHA recordkeeping forms….

• OSHA 300 log along with a claim report must be kept in your OSHA records. If you are unsure an incident is OSHA recordable use OSHA Recordkeeping Advisor.
• OSHA 300a must be posted for all employees to view from Feb 1 to April 30th of each year.
• Only employers in exempt industries can be exempt from this portion of the recordkeeping regulation. (See Partially Exempt Industry list).

3. EMPLOYERS WITH 20 TO 249 EMPLOYEES in certain industries employers must also annually file the OSHA 300a through OSHA.gov….

In addition to the rules listed above, employers with 20-249 employees per establishment (see definitions below for establishment) and are in OSHA’s list of high risk industries are required to electronically file their OSHA 300a forms annually.  The high risk industry list includes construction, manufacturing, utilities, department stores, general merchandise stores, general freight trucking, warehouse and storage, waste management services, and other high risk industries.  A complete list of OHSA’s high risk industries can be found at this link: https://www.osha.gov/recordkeeping/NAICScodesforelectronicsubmission.html

2016 data in Form 300A must be submitted by July 1, 2017, and again by July 1, 2018. Beginning in 2019 and every year thereafter, the information must be submitted by March 2.

4. EMPLOYERS WITH 250 OR MORE EMPLOYEES must electronically submit to OSHA injury and illness information from OSHA Forms 300, 300A, and 301 through OSHA

Form 300A must be submitted by July 1, 2017, and must submit information from all forms (300A, 300, and 301) by July 1, 2018. Beginning in 2019 and every year thereafter, the information must be submitted by March 2.

 

Forms, instructional videos, incident rate calculators, and interactive tools can be found in the Recordkeeping section of the Keevily Portal to help answer your questions about this OSHA regulation.

 

 

Establishment: The electronic reporting requirements are based on the size of the establishment, not the firm. The OSHA injury and illness records are maintained at the establishment level. An establishment is defined as a single physical location where business is conducted or where services or industrial operations are performed. A firm may be comprised of one or more establishments. To determine if you need to provide OSHA with the required data for an establishment, you need to determine the establishment's peak employment during the last calendar year. Each individual employed in the establishment at any time during the calendar year counts as one employee, including full-time, part-time, seasonal, and temporary workers.

 

 

You have three options for reporting the serious event:

By telephone to the OSHA Area Office nearest to the site of the work-related incident. By telephone to the 24-hour OSHA hotline (1-800-321-OSHA or 1-800-321-6742). Electronically, using the event reporting application that will be located on OSHA's public website.

Your Workers Comp Team

Ivana Molinari, WC Claims Assistant - (914) 269-9459
Demeika Wheeler, WC Claims Assistant - (914) 269-9441
Mary Dennis, WC Claims Assistant - (914) 412-0511
Richard Whitehill, WC Actuarial Specialist - (914) 412-0509
Janice Robinson, WC Sr. Claims Specialist - (914) 412-0572
Genevieve Keller, WC Claims Manager - (914) 412-0563
Barry Hartglass, WC Supervisor - (914) 412-0550

Information Needed to File a claim:

Policyholder Information:

- Active policy number *
- Mailing address and contact information *
- E-mail Address *
- Nature of Business *

Injured Worker/Employee/Claimant Information:
- Name and Social Security Number *
- Personal information, such as date of birth and gender *
- Contact information, such as mailing address * and telephone number
- Did employee give notice of accident/illness, If so, to whom? *
- Injured employee’s supervisor’s name

Employment information:
- Date of hire
- Wage information
– The injured employee’s gross avg weekly wage *
- Job title *
- Employee’s usual days worked *
- Time employee starts work
- Date stopped working (the last day the injured employee was at work and ceased work activities because of this injury/illness)
- Last day paid (The last calendar day the employee earned wages.)
- How long employer will pay the employee? (Will the employer pay the employee for any lost time due to the injury/illness?)
- Return-to-work information, date and rate employee returned to work

Accident/Illness and Injury Information:
- Date of the accident/illness or injury *
- What was employee doing at the time of injury? *
- How did the accident occur? *
- Where did the accident/illness happen? *
- Nature of the injury, such as laceration or fracture *
- Body part(s) injured *
- Cause of injury *
- Any witnesses? If so, who?
- Names, addresses, contact information for medical providers and/or hospitals from whom the injured worker received treatment
- If employee received medical care, on what date? *

*Required field

Keevily Safety Programs deliver significant upfront premium discounts of 20%.

What are Safety Groups?
Our NY Workers' Compensation Safety Groups are Workers' Compensation insurance programs that are underwritten by the New York State Insurance Fund (NYSIF). A State Fund Safety Group is a cost-plus plan for Workers' Compensation Insurance producing low-cost non-profit coverage for groups of employers with similar operational hazards. As an incentive to Group Members to practice safety, the State Fund returns generated savings in the form of dividends to the Group Members. Hence, every dollar saved by a prevented or properly managed claim is a whole dollar returned to Group Members.
While dividends are not guaranteed, Keevily has paid out consistently for more than 35 years with an average payment of between 20-25%
Eligible members are entitled to a substantial competitive advance discount and to also participate in group dividends.
For more information regarding our Safety Group Program, contact us directly at
800-523-5516.

What is Workers’ Compensation Fraud?

Claim fraud can be
broken down into
two categories:

1.Claimant fraud

2.Provider fraud.

Claimant Fraud

Claimant fraud occurs when a worker knowingly makes a false or misleading statement for the purpose of obtaining workers’ compensation benefits.  The most common type of claimant fraud is when a worker exaggerates his condition in order to continue benefits relating to the work related accident they suffered.

Claim fraud can also occur when an employee files a claim for an accident that did not occur, injuries that do not exist or injuries that are not work related.

Types of Claimant Fraud to be aware of:

•Malingering – when an injured worker recovers from their injuries, however, continues to receive benefits.

•Receiving benefits while employed elsewhere – an employee who files a workers’ compensation claim and collects benefits while claiming they are unable to work and works another job without reporting income/work status.

•Non-work related injury – when an employee claims he/she was injured at work, however the injury occurred while not engaged in work activities.

•Non-injury claim – when an employee fakes an injury in order to collect workers’ compensation benefits.  This often occurs after a layoff or plant closing announcement or rumor.

•Multiple claims – an employee who files multiple workers’ compensation claims for the same injury.

•Prescription drugs – when prescriptions are misused for illegally resale.

Provider Fraud

Provider fraud occurs when doctors, medical practices or medical laboratories charge excessive fees for medical services performed or charges for work never performed.  Provider fraud can also occur if the provider convinces the employee to file a workers’ compensation claim in lieu of unemployment benefits claiming the individual can make more money.  A less obvious form of provider fraud could be unnecessary tests or treatment, even if the injury is legitimate and some form of treatment is needed. 

Types of Provider Fraud to be aware of:

• False billing – when a doctor, clinic or lab bills for services not performed.

• Kickbacks – a medical provider who pays or receives compensation for a patient referral.

• Self-referrals – a medical provider who inappropriately refers patients to clinic or laboratory in which the provider has a financial interest

• Upcoding – a provider who bills for a more expensive treatment or service than what was performed.

• Unbundling – a provider that performs a single service and bills it as a series of separate procedures.

• Over-utilization – a provider administers and bills for unnecessary medical services.

• Product switching – a provider or pharmacy that bills for one type of product but dispenses a cheaper version.

Nine Elements of Common Law Fraud.

In order to prove fraud certain requirements must be met before a prosecution can be pursued.  Below are the nine elements in the Law that are necessary to prove fraud:

1. Representation – the simplest type of representation is an affirmative statement of a fact made directly by the person claiming the false claim.  It can also be a statement that one has no knowledge of a fact or issue or an intentional understatement or overstatement of cost or value.

2. Falsity – to prove fraud the representation must not be true.

3. Materiality – a “material representation” is one that would be likely to affect the conduct of a reasonable person with regards to transaction that is subject of the claim.

4. The Speaker’s Knowledge of Falsity or Reckless Disregard of the Truth – the person making the statement must either know the statement was false, or be aware that they lack the knowledge as to its truth or falsity.  Showing the representation was made recklessly without the knowledge of the truth or falsity can also prove fraud.

5. Intent that Representation be Acted Upon – the intent of the speaker must be to mislead or deceive the hearer.

6. Hearer’s Ignorance of Falsity - the hearer was not aware that the statement was false.

7. Reliance – the hearer must rely on the speaker’s representation.

8. Hearer’s Right to Rely – the hearer has a right to rely on the speaker’s representation.

9. Damages – damages are considered “general” and “punitive”.  General damages are the amount paid as a result of the fraudulent representation.  Punitive damages are provided by a showing of egregious conduct on the part of the defendant.