Off the Job Injury or Illness
This pamphlet is a general and simplified presentation of Disability Benefits
provisions of the Workers' Compensation Law. 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 services.
Messages
from the Governor and Chairman
Introduction
to the Law
How to
File a Claim
Cash
Benefits
Who Is
and Who Is Not Covered?
Common
Questions
Privacy
Statement
A Message regarding Disability Benefits
A
Message from Governor Pataki
When the Disability Benefits Law
was enacted in 1949, it symbolized a coming together of labor and management to
meet the needs of the workforce. The law allows great flexibility to establish
individual disability benefits plans, and provides protection for workers
against the economic hardships of wage-loss from nonoccupational
accident or illness.
Rather than establish another
government agency, the Legislature placed responsibility for the administration
of the law within the Workers’ Compensation Board.
On behalf of the Workers’
Compensation Board, and as part of my Administration’s continuing commitment to
assist and protect the rights of injured workers, I am pleased to present the
Guide to New York State Disability Benefits.
A
Message from Chairman Wehner
Supplementing the Workers’
Compensation Law, the Disability Benefits Law ensures protection for workers by
providing for weekly cash benefits to replace, in part, wages lost because of
injuries or illnesses that do not arise out of and in the course of employment.
As Chairman, I am committed to honoring the original intent of the law to
provide a temporary safety net for workers, without unduly burdening the
State’s business community.
This pamphlet will give you the
basic information you need to file a claim and understand the process. If you
have any questions about the law, your rights, or your case, please contact the
nearest Workers' Compensation Board district
office.
Introduction
to the Disability Benefits Law
Disability benefits are temporary cash benefits paid to an eligible wage
earner, when he/she is disabled by an OFF THE JOB injury or illness. The
Disability Benefits Law provides weekly cash benefits to replace, in part,
wages lost due to injuries or illnesses that do not arise out of or in the
course of employment. Disability benefits are also paid to an unemployed worker
to replace unemployment insurance benefits lost because of illness or injury.
An employer is allowed, but not required, to collect contributions from its employees to offset the cost of providing benefits. An employee's contribution is computed at the rate of one-half of one percent of his/her wages, but no more than sixty cents a week.
If an employee has more than one job at the same time, with combined wages of more than $120.00 per week, the employee may request each employer to adjust the contributions in proportion to the earnings of each employment. The combined contributions may not exceed 60 cents per week. The request should be made as soon as the employee enters a second job.
Disability benefits include cash payments only. Medical care is the responsibility of the claimant. It is not paid for by the employer or insurance carrier.
Disability Benefits Plans
An employer may provide benefits under a Disability Benefits Plan (or one negotiated by agreement and accepted by the Chairman of the Workers' Compensation Board as meeting the requirements of the Disability Benefits Law). Benefits (rate, duration and waiting period) are payable as provided by the plan. In addition, the employer may pay the entire cost of the plan. There are some accepted plans under which employees are required to contribute more than 60 cents per week, buy only by agreement and provided the employees' contributions are reasonably related to the value of the benefits. Under an arrangement in which employees are required to contribute, the employer must add a contribution to make up the balance of the cost of the insurance.
How to
File a Claim
If you are currently employed, or if you have been unemployed for less than
four weeks from the date the disability began, file the claim with your
employer or insurance carrier, using the White form
DB-450. This form is available on-line, or you may obtain a copy from
the nearest district
office. Keep a copy of this form to submit again if your
claim is not paid promptly.
If you have been unemployed more than four weeks from the
date the disability began, file the claim with the Disability Benefits Bureau,
using the form
DB-300. Mail it to: Disability Benefits Bureau, Workers' Compensation
Board, 100 Broadway-Menands,
You must file your claim within 30 days after you become disabled. If you file late, you will not be paid for any disability period more than two weeks before the claim is filed. Late filings may be excused if it is shown that it was not reasonably possible to file earlier. No benefits will be paid if you file more than 26 weeks after your disability begins.
You must be under the care of a physician, chiropractor, podiatrist, psychologist, dentist, or certified nurse midwife in order to qualify for benefits. Your health care provider must complete and sign the "Health Care Provider's Statement" as proof of your disability.
However, if you depend for healing upon prayer through spiritual means alone in the practice of religion, you must be under the care of a duly accredited practitioner to qualify for benefits. In this situation, the practitioner must complete and sign the "Practitioner's Statement" (form DB-450.5) before mailing.
Before filing your claim, be sure that you have completed
and signed the "Claimant's Statement" and your health care provider
or practitioner has completed and signed his/her portion. Submit this
information promptly to avoid delaying your claim.
Cash
Benefits
Cash benefits are 50 percent of a claimant's average weekly wage, but no more than the maximum benefit allowed. The average weekly wage is based on the last eight weeks of employment. If counting the last week in which the disability began lowers the benefit rate, it is not included in determining average weekly wage. Effective May 1, 1989, the maximum benefit allowance for any disability is $170 a week. Benefits paid by the employer or insurance carrier are subject to Social Security and withholding taxes.
Benefits are paid for a maximum of 26 weeks of disability during 52 consecutive weeks. For employed workers, there is a 7-day waiting period for which no benefits are paid. Benefit rights begin on the eighth consecutive day of disability. For unemployed workers who are receiving Unemployment Insurance benefits and who become disabled more than four weeks (but within 26 weeks) after termination of employment, benefits are payable from the first day of the disability that disqualifies them from receiving Unemployment Insurance benefits. An employer must supply a worker who has been disabled more than seven days with a Statement of Rights under the Disability Benefits Law (form DB-271), within five days of learning that the worker is disabled.
Who Is
and Who Is Not Covered?
Who is Covered?
- Employees or recent employees of a "covered" employer, who have worked at least four consecutive weeks.
- An employer of one or more persons on each of 30 days in any calendar year becomes a "covered" employer four weeks after the 30th day of such employment.
- Employees of an employer who elects to provide benefits by filing an Application for Voluntary Coverage.
- Employees who change jobs from one "covered" employer to another "covered" employer are protected from the first day on the new job. Generally, an eligible employee does not lose protection during the first 26 weeks of unemployment, provided he/she is eligible for and is claiming unemployment insurance benefits.
- Domestic or personal employees who work 40 or more hours per week for one employer.
Who is Not Covered?
- A minor child of the employer.
- Government, railroad, maritime or farm workers. Ministers, priests, rabbis, members of religious orders, sextons, Christian Science readers.
- Corporate officers and persons engaged in a professional or teaching capacity in or for a religious, charitable, or educational institution of a "non-profit" character, and persons receiving rehabilitation services in a sheltered workshop operated by such institutions under a certificate issued by the U.S. Department of Labor.
- Persons receiving aid from a religious or charitable institution, who perform work in return for such aid.
- One or two corporate officers who either singly or jointly own all of the stock and hold all of the offices of a corporation that employs no other employees.
- Golf caddies.
- Daytime students in elementary or secondary school, who work part-time during the school year or their regular vacation period.
- Employees who change to jobs in an exempt employment or with a "non-covered" employer, and work in such employment for more than four weeks, lose protection until they work four consecutive weeks for a "covered" employer.
Note: A "noncovered" employer may elect at any time to provide disability coverage by filing an Application for Voluntary Coverage with the Chairman of the Workers' Compensation Board.
Common
Questions (Disability Benefits)
Q. What is a "day of disability?"
A. A "day of disability" is one on which the employee was prevented
from performing work because of disability and for which he/she has not
received regular wages or remuneration.
Q. If an employee engages in work for remuneration or
profit, even if done at home, while disabled, is he/she eligible for disability
benefits?
A. No. As long as he/she is performing any kind of work for remuneration or
profit, he/she is ineligible to receive benefits.
Q. Are the costs of medical care included?
A. No. Costs of medical care are not included under the statutory provisions of
the Disability Benefits Law. However, where an employer or a union or
association plan has been accepted as complying with the law, the worker is
entitled to the benefits as described by the plan. Contact your employer to
find out if it provides or participates in such a plan.
Q. May an employer/insurance carrier have an employee
claiming benefits examined by a health care provider designated by the employer/carrier?
A. Yes. The employee must submit him/herself at intervals, but not more than
once a week, to such examinations if requested. Exams are not paid for by the
employee and are held at a reasonable time and place. Refusal to submit to an
exam may jeopardize a claimant's benefits.
Q. After a claim is filed, how soon will it be paid?
A. If a claim is properly completed with the required statements, the first
payment should arrive within four business days after the 14th day of
disability or four business days after the receipt of the claim, whichever is
later. Benefits are payable every two weeks during the period of disability.
Q. Can a claimant collect Unemployment Insurance and
Disability Benefits for the same period of time?
A. No.
Q. If an employee quits his or her job,
may that employee receive Disability Benefits?
A. Termination of employment may affect an employee's right to Disability
Benefits.
Q. Can a claimant collect Disability Benefits for
disability caused by pregnancy?
A. Yes. If she is disabled because of pregnancy, she may be entitled to up to
26 weeks of benefits. Disability can occur at any time during pregnancy.
Q. What determines disability due to pregnancy?
A. Disability can only be determined and certified by a physician or certified
nurse midwife through the submission of medical reports. If a claimant becomes
disabled more than four to six weeks prior to the anticipated birth date, or is
disabled more than four to six weeks after the actual birth date, more detailed
information regarding the disability may be required. The medical reports
should describe specific symptoms, rather than just general prognosis. Note:
An elective sterilization procedure will not extend the payable period of
disability, since benefits are not payable for any period an individual is
unable to work due to elective surgery.
Q. Can an employee collect disability benefits if on
maternity leave?
A. Yes. If she is on a leave of absence without pay (i.e. maternity leave), and
becomes disabled within four weeks of the last day she actually worked, she is
entitled to benefits from the employer/carrier (if otherwise eligible). If the
disability begins more than four weeks from the last day actually worked and
she is claiming/receiving Unemployment Benefits, she is entitled to disability
benefits from the Special Fund for Disability Benefits (if otherwise eligible).
Q. Is there a limit on the number of weeks a claimant can
receive benefits?
A. Yes. There is a limit of 26 weeks of benefits during a period of 52 consecutive
calendar weeks or during any one period of disability. The amount of benefits a
claimant receives is dependent upon the length of time he/she is actually
disabled as certified by a physician. (If an employer has a separate Disability
Benefits Plan, more than 26 weeks of benefits may be paid, if so specified).
Q. What if a claimant is still disabled, but benefits
have stopped?
A. If he/she received less than 26 weeks of benefits, is still disabled, and
has not received a Notice of Rejection, he/she must submit further medical
evidence to his/her employer, insurance carrier or the Special Fund for
Disability Benefits. If he/she has received a Notice of Rejection, the claimant
may request a review of the rejection by completing its reverse side and
mailing it to the Disability Benefits Bureau at the Workers' Compensation
Board.
Q. Is a claimant entitled to Disability Benefits for an
injury incurred in an auto accident?
A. Yes. However, the amount of the disability benefits may reduce any no-fault
insurance benefits the claimant is eligible to receive.
Q. If a claim is rejected or not paid, may it be
reviewed?
A. Yes. If a claim is rejected or not paid, the employee should complete the
reverse side of the Notice of Rejection (sent by the employer/carrier/the
Special Fund, within 45 days of its receipt of the claim) and mail it within 26
weeks to the Disability Benefits Bureau. The address is located on the back of
the rejection notice, and in the back of this brochure. Where necessary, the
Board will obtain further information and may hold a hearing on the claim. Benefits
will be paid if a claim is determined proper and valid.
Q. If a claimant is entitled to or receiving Social
Security Retirement Benefits, may he/she still receive Disability Benefits?
A. Yes. If he/she is entitled to Disability Benefits, the fact that he/she is
eligible for or receiving old-age insurance benefits under the Social Security
Act does not affect his/her right to Disability Benefits.