Practice tip: Beware of the L Code. Consider the timeline you have to file your first FROI form and always err on using the W code or the without liability code to allow ample time to properly investigate the claim.
If you are unsure of the extent of liability for a claim, Workers’ Compensation Law §21-a allows you to make temporary payments for compensation without prejudice and payments for prescribed medication for up to one year without admitting liability. WCL §21-a[1]
As of July 17, 2014, an eClaims process for WCL §21-a claims was implemented, which essentially extends the time to investigate the claim to determine whether a carrier will accept or deny a claim made in accordance with Subject No. 046-696 Notice Requirements for eClaims and WCL §21-a.
On or after January 1, 2019, carriers are required to indicate whether benefits are being paid with liability (L) and the claim is accepted or paid without liability (W) under WCL §21-a. These Agreement to Compensate Codes replace the former Claim Type Codes. When the carrier selects an Agreement to Compensate Code of W on the First Report of Injury (FROI) and/or W Code on the Subsequent Report of Injury (SROI), the carrier is accepting the case/paying without prejudice. Conversely, selecting the L Code on the FROI or SROI form means that the carrier is accepting the case and paying, with liability. The Board has developed a process and timeliness incorporating WCL §21-a in eClaims protocol.
The FROI-00 will likely be the first form filed when using the eClaims process. Beware that if you hit the L code to accept the claim with liability within the one year timeframe of investigation and then later determine that there is a basis to controvert and deny the claim, your opportunity to do so will be waived.
Should a claim be modified to rescind establishment of the claim, and remanded to a hearing for further development of the record on issues of causal relationship if a claimant fails to disclose a prior work-related claim to the same body part? In this example, a FROI-00 accepting liability was filed. The Board Panel concluded: “The carrier did not make payment without prejudice to preserve its right to controvert the claim; rather, the carrier waited to file a Notice of Controversy…which is untimely. The carrier failed to avail itself of the WCL Section 21-a safeguards and its acceptance of the claim was with prejudice.”
If you have any questions about this or any other issue, contact Shane E. Armstrong at (607) 723-0600 or any of the attorneys in our office. If you would like a training session on this or any area of the Workers’ Compensation Law, please do not hesitate to contact our firm. We represent clients throughout New York State and Pennsylvania.
This information is provided for general guidance only. This information should not be used as a substitute for consultation with legal counsel. Each case presents unique facts requiring individual analysis.
