Updated Claim Conciliation Procedure for Additional Sites of Injury and Consequential Injuries
By Rosalind Asch-Hobeck
In December 2024, the Board rolled out a new process to speed up decisions on additional and consequential injuries. Now, when a Request for Further Action by Legal Counsel (Form RFA-1LC) includes prima facie medical evidence (PFME) for an unestablished injury or condition, the Board will issue a Proposed Decision confirming PFME. At that point, the insurer has a few options: accept the condition; request an independent medical examination (IME); cross-examine the treating provider, or submit arguments on the record.
Enhanced Record Development on Mechanism of Injury
Due to concerns raised about needing a clearer way to establish how the injury happened, the Board has refined the process. Once the PFME Proposed Decision is issued, the case will be set for a hearing about 75 days later. At this hearing, the insurer must provide any evidence the Proposed Decision requires. Plus, both sides will have the chance to ask the claimant brief questions about how the injury occurred. If the IME doesn’t dispute the injury or condition, the judge can decide to establish the additional injury site at that time. If the IME challenges the injury’s connection to work and depositions are needed, the judge will allow extra time to depose doctors.
In most cases, the Board expects to wrap things up within one or two hearings, unless there’s a strong reason for more delay.
Important Deadlines and Requirements
The case file must include a Claimant’s Notice of Independent Medical Examination (Form IME-5) or proof of a scheduled testimony date by the time the Proposed Decision becomes final. If not, the Board may consider that a waiver of the insurer’s right to an IME or to cross-examine the claimant’s provider. If an insurer needs broader medical record access, they should request it well ahead of the hearing to avoid delays.
While the Board’s new process marks a shift from how hearings and disputes have traditionally been handled, the goal is to streamline case resolution, reduce litigation, and keep things moving more efficiently. Success will largely depend on both sides cooperating, as delays in obtaining key information have been a persistent issue. By implementing these changes, the Board aims to address existing bottlenecks and create a more structured, predictable approach to resolving claims.
Caveat for claimants
Lack of cooperation in providing requested information, records releases when required and failure to attend IME exams can lead to delays and determinations against interest.
Caveats for the insurer
Missing deadlines for obtaining an IME, doing due diligence for discovery if the need is apparent and arranging depositions may lead to waivers of defenses.
If you found this information helpful, you might also be interested in reading about New York Governor proposes changes to medical treatment options for injured workers.
