Workers’ Comp Benefits Stopped in New York?
When workers’ comp benefits stop in New York, the payment almost always ends before the explanation arrives. The check does not show up, the carrier does not call, and the reason turns out to be buried in a filing you never saw.
Nearly all of it comes down to four things: a report from an examining doctor the carrier hired, a gap in your treating provider’s medical filings, missing job search documentation, or a formal denial of the claim.
Benefits stopped? Call Lewis & Lewis, P.C. at (716) 854-2100. Free consultation, answered 24 hours a day.
This is Stage 2 of the New York Workers’ Compensation Resource Center.
Why did my workers’ comp payments stop with no notice?
Because the carrier is generally allowed to stop paying and argue about it afterward, and because most triggers are administrative rather than dramatic.
| What happened | What it means for you |
| Your provider’s report is overdue | New York expects progress reports at intervals of no more than 90 days. A gap gives the carrier an opening to suspend payment |
| The wrong provider type signed the report | Only certain provider types can give an opinion the Board will accept on causation or degree of disability |
| An examining doctor hired by the carrier disagreed | A report finding you less disabled, or fully recovered, is often filed the same week payments stop |
| Job search documentation was not filed | Partially disabled claimants who have been directed to show labor market attachment must document the search |
| Your disability classification changed | Moving from total to partial disability changes the rate, and sometimes the entitlement |
| The claim was formally controverted | The carrier filed a Form C-7 disputing the claim outright |
Emily F. Janicz on the pattern she sees:
“People need to have medical evidence signed by a particular provider type. They need to have a comment on their level of disability every 90 days. And if the insurance company starts just paying without telling them why they’re paying or what they need to do to continue to be paid, they’ll often lapse in what they actually need. And the insurance company will then, after the fact, say, ‘Well, we never should have paid you that. We don’t want to have paid you for that.’ And they’ll argue about it at a hearing even though they voluntarily did something.”
That last part surprises people the most. A carrier that paid voluntarily for a year can turn around and ask a judge to call those payments an overpayment.
What is an independent medical examination, and how independent is it?
Attorney Emily Janicz
An IME is an examination performed by a doctor the insurance carrier chooses and pays for, and the name oversells it.
“They’re called independent medical examinations, and there’s nothing independent about it. They are consultants hired by the insurance company. So why they call them independent medical examinations, I don’t know.” Emily F. Janicz, partner
You are generally required to attend when one is properly scheduled, and it is not the same thing as treatment from the Board-authorized provider you chose. What you are not required to do is walk in unprepared.
What are your rights at an IME in New York?
More than most claimants realize. Under Workers’ Compensation Law § 137 and the Board’s regulations:
- You must receive written notice of the examination in advance, and a copy goes to the Board at the same time.
- You may bring someone with you. The claimant may be accompanied by a person of their own choosing, and the notice is supposed to tell you so.
- You or the examiner may record the examination. If the examiner intends to record, the notice has to say that.
- You are entitled to a copy of the report. The examining doctor must send it to you, your attorney, your treating provider, the carrier, and the Board on the same day and in the same way.
- If the carrier requested the exam, the carrier pays, and your travel costs are reimbursable.
What should you say at an examination?
Answer honestly and describe a normal day rather than your easiest hour. Exams are short, notes are brief, and a claimant who minimizes pain out of habit gets a report that reflects the minimizing. Do not guess at dates or medical history, and do not perform. Assume everything from the parking lot onward can end up in the report.
How do IME reports get challenged?
By examining the doctor’s actual qualifications and the basis for the opinion, which is where a lot of these reports come apart.
“Often they’re retired, and they’re doctors that never practiced in New York State. They might have a license to practice in New York State, but they practiced in another state. They might be an orthopedic doctor, but somebody whose practice was hips and knees, evaluating a back. So we often end up cross-examining those doctors and getting down to the details of what their actual experience is, and using that to make arguments about their credibility.” Emily F. Janicz, partner
A claimant cannot do that alone. Cross-examining a carrier’s examining physician is a scheduled proceeding with its own rules, and it is one of the clearest reasons to have counsel by this point.
Sent to an exam and unsure what happens next? Call (716) 854-2100 for a free case review.
What does it mean when the insurance carrier controverts your claim?
It means the carrier has formally disputed your claim by filing a Form C-7, the Notice That Right to Compensation Is Controverted. The claim is now contested, and it will be decided through hearings and testimony rather than paid voluntarily.
A controverted claim is not a rejected claim. It is a claim headed to litigation.
“If your claim is denied, you need an attorney, because the insurance company is going to hire an attorney to argue your claim at the Workers’ Compensation Board. So there’s going to be a series of hearings and testimony to prove whether or not you were injured at work. And since the insurance company is going to have an attorney there representing them, you need an attorney there representing you.” Emily F. Janicz, partner
What follows is covered in Stage 3, the claims process and hearings, including how decisions are issued and how they are appealed.
Can the carrier blame a prior injury for your condition?
It can try, and the mechanism has a name: apportionment. Apportionment divides responsibility for your current condition between the work injury and something that came before it, which reduces what the carrier owes.
“There’s a concept in workers’ comp called apportionment, where if a portion of what is wrong with you is caused by something pre-existing, a prior injury, there may be some division of responsibility. But it’s a very complicated, fact-specific question that often we can avoid.” Emily F. Janicz, partner
Notice the last clause. Apportionment does not apply automatically because you have a history, and one limit matters a great deal: a prior condition that was not itself disabling, that never kept you from doing your job, generally does not support apportionment at all.
Expect the argument to arrive as a medical opinion rather than a letter.
“The insurance company is always going to try to do whatever they can to minimize what they have to pay. But particularly in apportionment, they will often seek independent medical examinations where the doctors will say that as much as possible is related to a pre-existing condition or prior injury.” Emily F. Janicz, partner
What is labor market attachment, and why did it stop my benefits?
Labor market attachment is proof that you are looking for work you can physically do. If you have a partial disability and the Board has directed you to show attachment, the documentation obligation is real, ongoing, and heavier than almost anyone expects.
“People have to document that they’re looking for work if they have been directed to demonstrate an obligation to show attachment to the labor market under the workers’ compensation law if they have a partial disability, and it’s voluminous what the injured worker has to show. It can be an obligation that can span several years.” Emily F. Janicz, partner
The Board accepts several ways of showing it, and most claimants use more than one:
- A timely, diligent, and persistent independent job search, documented with employer names, contact details, and dates
- Working with New York State Department of Labor re-employment services or a One-Stop Career Center
- Active participation in vocational rehabilitation through ACCES-VR, the state’s Adult Career and Continuing Education Services program, or another Board-approved program
- Active participation in a job retraining program
- Full-time attendance at an accredited school pursuing work within your restrictions
The Board’s labor market attachment guidance sets out what counts. Efforts are recorded on Board forms C-258 and C-258.1.
One important limit works in your favor. Since the 2017 reform, a claimant already receiving benefits when classified with a permanent partial disability does not have to keep demonstrating attachment. The obligation bites hardest on claimants still in temporary partial status, which is exactly where most people are when the benefits stop.
What should you do the week your benefits stop?
Five things, in this order, and none of them require you to know the law.
Do not wait to see if the next check arrives. Every week of silence is a week of evidence not being built.
Get your treating provider current. Ask when the last report was filed and whether it stated your degree of disability. This one call resolves a surprising share of cut-offs.
Collect everything the carrier sent you. Every letter, every form number, every envelope, including the ones you did not understand. The form number in the corner usually explains what happened.
Do not give a recorded statement without advice. A carrier asking for one after benefits stop is building a record, not gathering facts.
Call a lawyer. The consultation is free, and the Board does not charge you for having representation. Fees in a New York comp case are set and approved by a judge and come out of the benefits recovered, not out of your pocket.
Emily on what changes once someone else is carrying it:
“A big advantage beyond monetary compensation is having somebody there that’s been through it, to give you that reassurance that you don’t need to be so worried, you don’t need to be so stressed. We can help you walk through any paperwork that needs to be filled out. We can help deal with medical denials. We can handle the communication with the insurance company so you don’t have to, and you don’t have to second guess if you did or didn’t say the right thing to somebody.”
Call (716) 854-2100 and describe what showed up in the mail. We will tell you what it is.
Questions from claimants whose benefits stopped
Will I get back the payments I missed while this gets sorted out?
Often yes. When a judge finds you were entitled to benefits for a period the carrier did not pay, the award typically covers that period retroactively. That is one reason the delay hurts less than it feels like it does, and one reason it is worth fighting rather than absorbing.
The carrier says I was overpaid and wants the money back. Can they do that?
They can raise it, and judges do sometimes credit a carrier for an overpayment against future benefits. Whether it was your fault matters, and voluntary payments are treated differently from payments made under a mistake of fact. Do not repay anything or sign anything acknowledging a debt before someone reviews the file.
Can I go back to my own doctor if the carrier’s exam said I am fine?
Yes. The examining doctor’s report is evidence, not a decision, and it does not replace your treating provider or end your treatment. Your provider’s continuing reports are what put a competing opinion in front of the judge.
My employer offered me a light duty job I do not think I can do. What happens if I turn it down?
Refusing work within your medical restrictions can cost you benefits, so the question is whether the offer really is within your restrictions. Get your treating provider’s written opinion on the specific duties before you answer, and get advice before you decline.
Get it moving again
You do not have to know which rule got broken. Bring what you have and someone here will find it.
Lewis & Lewis, P.C. has been protecting injured workers’ rights across Western New York for over 80 years, from offices in Depew, Buffalo, Niagara Falls, Batavia, Olean, and Jamestown. No attorney here has ever worked for an insurance carrier.
Call (716) 854-2100 or contact the firm online for a free consultation.
More reading on denials, cut-offs, and disputes
- Workers’ Compensation Denied? Here’s What You Need to Know
- Form C-7 and the Contested Workers’ Comp Claim
- Challenging Your Employer-Selected IME in Niagara County
- Can You Get a Workers’ Compensation Second Opinion?
- How the 90-Day Rule Can Affect You
- Can I Be Fired After Filing for Workers’ Compensation in NYS?
- Avoiding Questionable Behavior While on Workers’ Compensation
- Are You Allowed to Travel While on Workers’ Compensation?
- Avoiding Workers’ Compensation Fraud
- What Happens When You Quit Your Job on Workers’ Compensation?
- The NY Workers’ Comp Drug Formulary
- Getting Medical Marijuana Covered by Workers’ Comp in NYS
- Can a Workers’ Compensation Case Be Reopened?
- How Long Can a Workers’ Compensation Claim Stay Open?
- How Long Can You Be on Workers’ Compensation in New York State?
- Why Your Maximum Medical Improvement Rating Is Premature for Olean Healthcare Workers
- Does FMLA Run Concurrently With Workers’ Compensation?
- Can I Collect SSDI and Workers’ Compensation at the Same Time?
- Differences Between Workers’ Compensation and Disability
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