When an employer or its insurance carrier contests a New York workers’ compensation claim, a hearing is one possible next step, but not every dispute reaches one. The Workers’ Compensation Board first identifies the disputed issues, and some disputes resolve through additional paperwork, new medical records, or the carrier withdrawing its objection before anyone testifies. If a hearing is held, a Workers’ Compensation Law Judge reviews the medical evidence and hears testimony when needed. The judge then issues a decision that either side may challenge through Board review and, later, an appeal to court.
At K L Sanchez Law Office, P.C., Queens workers’ compensation attorney Keetick L. Sanchez helps injured workers throughout New York City respond when an insurance carrier challenges their claim. If the case moves to a hearing, she helps clients prepare their testimony and address the issues the judge needs to decide.
This guide explains which records can help support a contested claim, what to look for in a hearing notice, and how to respond if you disagree with a decision. Call K L Sanchez Law Office, P.C. at (646) 701-7990 for a free consultation.
What Does It Mean When a Workers’ Comp Claim Is Contested?
A claim is “controverted” when the insurance carrier formally disputes the injured worker’s right to benefits. The carrier may argue that the injury did not happen at work or that the worker is not injured to the extent claimed. The carrier files a notice of controversy with the Workers’ Compensation Board using Form FROI-04 or SROI-04. Disputes over specific medical treatments or payments can also arise after a claim has been accepted.
The carrier’s denial does not end the claim. The Workers’ Compensation Board reviews the disputed issues and decides if the injured worker is entitled to benefits.
Why Do Employers and Carriers Contest Claims?
Carriers often dispute whether the injury happened at work or whether it is connected to your job duties. A causation dispute is common when the injury developed gradually or when you have a prior condition in the same body part. Carriers also question employment status, because Workers’ Compensation Law § 2(3) and (4) define who counts as an employer and an employee, and the carrier may argue the injured person falls outside those definitions. Late notice to the employer is another possible reason for a dispute.
A different situation arises when the employer has no coverage at all. Workers’ Compensation Law § 50 requires employers to secure compensation through the State Insurance Fund, a policy from an authorized insurer, or approved proof of financial ability to pay. When an employer fails to secure compensation, Workers’ Compensation Law § 11(1) lets the injured worker choose between a compensation claim and a court suit for damages against that employer.
Does Every Contested Claim Go to a Hearing?
Not every claim dispute leads to a full hearing with witness testimony. When an insurance carrier formally controverts a claim, the Board schedules a pre-hearing conference once it receives a medical report about the injury. The conference can resolve the dispute or identify what still needs to be decided.
A Workers’ Compensation Law Judge can schedule a later hearing if additional evidence or testimony is needed. For disputes about whether your injury was work-related or reported on time, K L Sanchez Law Office, P.C. can review the carrier’s objection and help you prepare a response to the Board.
Workers’ Compensation Attorney in Queens – K L Sanchez Law Office, P.C.
How Does the Board Handle a Disputed Claim in New York?
The Board’s next steps depend on what the carrier disputes and which records are already available. For a formally controverted claim, the process can involve these stages:
- Notice of dispute: The carrier files its objection and explains why it contests the claim.
- Board review of the issues: The Board compares the claim forms, employer reports, and carrier filings to identify what is disputed.
- Medical and documentary evidence: Treating doctors’ reports, carrier exam reports, wage records, and accident reports are added to the file.
- Conference and next steps: At the pre-hearing conference, the judge or conciliator identifies unresolved issues and decides what testimony or other evidence is needed.
What Issues Does the Board Decide?
The Board decides whether the accident arose out of and in the course of employment, meaning it was connected to the worker’s job and occurred during work-related activity. It also decides causal relationship, which is whether the medical condition you are being treated for stems from the work incident.
Other frequent issues include whether you gave the employer timely notice and the degree of disability you have. Disputes over your average weekly wage are also common, since that figure drives the amount of any wage benefit.
What Happens if the Carrier Requests an Independent Medical Exam?
An independent medical examination (IME) is an exam performed by a doctor the carrier selects, not your treating doctor. The IME doctor reviews relevant records, examines you, and prepares a report on the medical issues in dispute, such as the cause of your injury or the degree of disability.
That report goes into the Board file alongside your treating doctor’s reports, and the judge weighs both. When the opinions conflict, the judge may request more information or allow testimony from the doctors, often through a deposition. Attend the scheduled exam, and let your lawyer know if anything prevents you from going. Attorney Keetick L. Sanchez can review the IME findings alongside your doctor’s reports and help you address the medical issues the carrier disputes.
What Happens at a New York Workers’ Compensation Hearing?
At a New York workers’ compensation hearing, a Law Judge reviews the issues that remain in dispute. The judge considers the records already in the Board’s file and hears each side’s position. Some questions can be decided from those records, while others require testimony or more evidence. The proceeding is more informal than a court trial, and some hearings are brief.
Who Is Present at the Hearing?
The Workers’ Compensation Law Judge runs the hearing and controls what becomes part of the record. You attend when the Board requires your participation, and your attorney can appear with you or on your behalf when permitted. The carrier participates through a claims representative or defense attorney.
Witnesses may testify, including coworkers or an employer representative when the dispute involves how the injury happened. Interpreters can be provided for workers who need one. The Board offers virtual hearings statewide, but injured workers and lay witnesses must appear on video when testifying. An unrepresented worker without access to video technology may be allowed to testify by phone in limited circumstances. Follow the instructions in your hearing notice.
What Happens During Testimony and Questioning?
When testimony is needed, you describe how the injury happened, your job duties, your symptoms, and your treatment. The carrier’s attorney may then ask questions, and the judge may question you or any other witness to clarify the facts.
If your description of the injury differs from your medical records, the carrier may use that difference to challenge your account. Reviewing those records before the hearing can help you prepare to address it.
Is One Hearing Enough?
One hearing may not be enough to resolve a contested claim. The judge can schedule additional hearings when more testimony is needed or when the evidence involves several disputed issues.
Some cases also require depositions of the treating doctor or the IME doctor before the judge rules. These additional steps can extend the time needed to reach a decision. If a hearing is scheduled, K L Sanchez Law Office, P.C. can review the attendance instructions, check if witnesses are expected to testify, and address outstanding medical deposition requests.
What Evidence Helps Prove a Contested Claim?
Strong evidence connects the injury to your work. If you are seeking lost wage benefits, medical opinions can also explain how the injury affects your ability to work. Workplace records can support your account of what happened. Useful evidence includes:
- Treating doctor’s reports: Explain causation and work restrictions.
- Accident and incident reports: Document when and how the injury happened.
- Employer and coworker information: Support the account of the injury.
- Medical records and prior history: Show the timeline and address preexisting conditions.
- Notice to the employer: Shows the injury was reported.
A treating doctor’s report is stronger when it clearly explains how the work incident caused or worsened the condition. Vague language leaves room for the carrier’s doctor to offer a competing explanation.
The evidence needed depends on the type of injury and what the carrier disputes. For a slip and fall at work, an accident report or witness account can help show how the injury happened. Claims involving work-related stress, anxiety, or PTSD can rely on mental health treatment records to show the condition and its connection to work. If important records are missing or the medical evidence does not address the disputed issue, K L Sanchez Law Office, P.C. can help identify what additional proof may be needed.
How Does the Judge Decide a Contested Claim?
Once the judge has enough evidence to decide an issue, the Board sends the parties a written decision explaining the findings and any benefits awarded. Not every ruling closes the case. Questions about future treatment or the extent of a lasting disability can be addressed later.
What Outcomes Are Possible?
The judge may find the claim established, partly established, or disallowed. For example, the judge may establish a claim for a shoulder injury but not a back injury if the evidence does not support both.
If the claim is established, the Board determines what medical and wage benefits are owed.
For the most serious injuries, Workers’ Compensation Law § 15(1) provides wage benefits for permanent total disability at 66⅔% of the worker’s average weekly wage, subject to the maximum weekly benefit rate. Payments continue for as long as the total disability lasts.
How Long Does a Decision Take?
The time needed for a decision depends on the case and whether it follows the expedited hearing process. In an expedited controverted case, the judge can announce the decision when the evidence closes at the hearing. If the record closes later, after depositions or other ordered documents are submitted, the judge must issue a decision within five business days of the record closing.
If your claim is still pending after a hearing, K L Sanchez Law Office, P.C. can review the case record and explain what evidence or decisions are still outstanding.
Can You Appeal a Workers’ Comp Decision in New York?
If either side disagrees with a Law Judge’s decision on a contested claim, they can ask a Board panel to review it. After the panel issues its decision, an appeal to court may also be available. The table below explains the review options and filing deadlines.
| Stage | Who Reviews | What Happens | Filing Requirement |
|---|---|---|---|
| Law Judge decision | Workers’ Compensation Law Judge | Decides disputed issues using the evidence in the case | Not applicable |
| Board panel review | Three-member Board panel | Reviews the record; may affirm, modify, rescind, or send back | Within 30 days of the filing of the judge’s decision |
| Full Board review | Full Board | Reviews panel decisions; required in certain cases and discretionary in others | Apply within 30 days after notice of filing the panel decision |
| Court appeal | Appellate Division, Third Department | Reviews the Board’s decision | Within 30 days after the Board’s decision is served on the parties |
How Does Board Panel Review Work?
Under Workers’ Compensation Law § 23, either side can request Board panel review within 30 days after the Law Judge’s decision is filed. A party represented by an attorney or licensed representative must use Form RB-89. The request explains which findings are being challenged and why.
The panel reviews the existing record rather than holding a new hearing, so the evidence submitted before the judge’s decision matters most. If the panel is not unanimous, a party may apply for full Board review.
Can You Appeal to the Appellate Division?
A Board panel decision can be appealed to the Appellate Division, Third Department, within 30 days after the decision is served on the parties. You do not have to request a full Board review before appealing to court. The court reviews whether the Board’s decision is supported by the record and the law. A further appeal to the New York Court of Appeals may be possible in limited circumstances.
Missing an appeal deadline can prevent you from challenging the decision. Call K L Sanchez Law Office at (646) 701-7990 to discuss a decision you want reviewed.
Do You Need a Queens Workers’ Compensation Attorney?
A Queens workers’ compensation attorney can help when the carrier disputes causation, schedules an IME that conflicts with your doctor’s opinion, or challenges your account of the accident. At a hearing, your attorney can address legal arguments while you answer questions if testimony is needed.
If the judge’s decision needs to be challenged, an attorney can request Board review or pursue an appeal to court when appropriate. Attorney fees in workers’ compensation cases are subject to Board approval under Workers’ Compensation Law § 24, and an approved fee is deducted from a compensation award rather than paid upfront.
Workers’ compensation also affects your options for bringing a lawsuit after a workplace injury. For most covered work injuries, workers’ compensation benefits are the exclusive remedy against an employer that has secured the required coverage. Workers’ Compensation Law § 29(6) also makes workers’ compensation the exclusive remedy for an injury caused by a coworker’s negligence in the same employment. However, you may have a separate claim against a third party, such as a property owner, contractor, or equipment manufacturer, while receiving benefits. Our workers’ compensation attorney Keetick L. Sanchez can review how the injury occurred and assess whether another party could be held legally responsible.
New York law also protects workers who seek benefits. Workers’ Compensation Law § 120 bars an employer from firing or otherwise treating you worse for claiming or trying to claim benefits unless the employer shows another valid reason.
Legal Help for Contested Workers’ Compensation Claims in Queens
While the Board resolves a contested claim, wage benefits can be delayed and some medical bills can remain unpaid. Missing a hearing or appeal deadline, or failing to provide requested evidence, can delay the case or limit your options.
If your claim remains disputed or you disagree with a Law Judge’s decision, Attorney Keetick L. Sanchez can review the reasons for the dispute and assess what benefits are at stake. As your Queens workers’ compensation lawyer, she can prepare the appropriate response or request for Board review based on the issues in your case.
Call K L Sanchez Law Office, P.C. at (646) 701-7990 to schedule a case evaluation. Our office is located at 37-06 82nd St #304, Jackson Heights, and serves clients throughout Queens and New York City. We offer assistance in English and Spanish.
Frequently Asked Questions
Does every contested workers’ comp claim go to a hearing?
Some disputes can be resolved after the Board reviews the paperwork. When an insurer formally challenges a claim, the Board schedules a pre-hearing conference once a medical report is on file, but that does not mean witnesses will need to testify at a later hearing.
Will I get paid while my claim is being contested?
Not necessarily. If the carrier disputes your claim, wage payments can be delayed, and medical bills can remain unpaid while the case is reviewed. If the Board later awards benefits, you can receive wage payments owed for an earlier period.
Can my employer fire me for filing a workers’ comp claim?
Not simply for filing a claim. New York law prohibits retaliation, but an employer can still terminate employment for a separate, lawful reason. If you believe you faced retaliation, you have two years from the incident to file a discrimination complaint with the Board using Form DC-120. Call K L Sanchez Law Office, P.C. at (646) 701-7990 to discuss a possible retaliation complaint.
Do I have to attend the hearing in person?
Not always. Many hearings take place online, so you can attend remotely. If you testify at a virtual hearing, you must appear on video, although the Board can allow an unrepresented worker without video access to testify by phone. Check your hearing notice for instructions.
How long do I have to report a work injury?
For an accident injury, you have 30 days to notify your employer in writing. For an occupational disease, the two-year period begins when you become disabled or when you knew or should have known the illness was work-related, whichever is later. The Board can excuse late notice in certain circumstances.
What if my employer has no workers’ compensation insurance?
You still have legal options. If your employer failed to carry coverage required by law, you can pursue a workers’ compensation claim or sue the employer for damages. The employer’s ability to pay is one factor to consider when choosing between these options. Call K L Sanchez Law Office, P.C. at (646) 701-7990 to discuss the employer’s coverage and which option may be appropriate for your case.
