Eligibility and Covered Injuries
New York law requires most employers to carry workers' compensation insurance, which provides benefits to employees who suffer work‑related injuries or illnesses. To qualify, the employee must prove the injury arose out of and in the course of employment. Occupational diseases, repetitive‑stress injuries, and injuries occurring off‑site but during work duties are also covered.
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Types of Benefits
Benefits fall into several categories, each with its own calculation method:
- Medical Benefits: All reasonable and necessary medical treatment related to the injury is paid in full.
- Temporary Total Disability (TTD): A wage‑replacement benefit equal to 66⅔% of the employee's average weekly wage (AWW), capped at the state maximum, paid until the employee can return to work.
- Temporary Partial Disability (TPD): If the employee can work in a limited capacity, the benefit is 66⅔% of the difference between the pre‑injury wage and the earnings while at work.
- Permanent Partial Disability (PPD): A lump‑sum or periodic payment based on a schedule that assigns points to loss of body parts or functions.
- Permanent Total Disability (PTD): A lifetime benefit of 66⅔% of AWW when the employee is permanently unable to work in any occupation.
- Death Benefits: Payments to surviving family members, including a funeral allowance and ongoing support.
Calculating the Average Weekly Wage
The AWW is derived from the employee's earnings during the 52 weeks preceding the injury, including overtime, bonuses, and commissions. The state sets a maximum weekly wage (e.g., $1,300 in 2024); any amount above that does not increase the benefit.
Payment Timelines and Process
After a claim is filed, the insurer must acknowledge receipt within 10 days and make an initial payment (often a medical advance) within 30 days. Ongoing benefits are paid bi‑weekly. If the claim is disputed, the employer or insurer must issue a written decision within 30 days of receiving the claim.
Appeals and Dispute Resolution
Employees may appeal a denied or reduced benefit to the Workers' Compensation Board (WCB) within 30 days. The process includes an informal conference, a formal hearing, and, if necessary, a review by the Appellate Division. Legal representation is allowed, and many claimants use attorneys specializing in workers' compensation.
Common Pitfalls
Failing to report the injury promptly, not keeping detailed medical records, or accepting a settlement without understanding future earnings impact can reduce benefits. Also, returning to work too early may trigger a loss of TTD payments.
Key Dates and Limits
| Action | Deadline | Notes |
|---|---|---|
| Injury report to employer | Within 30 days | Late reports may delay benefits |
| Claim filing with insurer | Within 30 days of injury | Essential for benefit eligibility |
| Employer/insurer decision | 30 days of claim receipt | Triggers appeal period if denied |
| Appeal to WCB | 30 days of denial | Starts informal conference |