The WTC Health Program is delaying the effective date for the component of the policy and procedures relating to recoupment from lump sum settlements of workers’ compensation cases. The policy was originally scheduled to apply to any lump sum settlement entered into after September 1, 2013. The recoupment policy will now apply to proposed settlement agreements filed with the New York Workers’ Compensation Board (NY WCB) on or after October 1, 2013. Any proposed settlement filed with the NY WCB on or after October 1, 2013, and which releases an employer/insurer’s liability for any future medical expenses must be reviewed by the WTC Health Program or the parties may be financially responsible for treatment expenses. The effective date for the policy as it relates to active workers’ compensation cases where the claimant has not filed a lump sum settlement remains September 1, 2013.
General Recoupment Scheme
1. The WTC Health Program will seek to recoup from medical providers of the WTC
Health Program and from WC insurers. The Program does not anticipate that it will be
necessary to seek recoupment directly from individual WTC responders, unless the
Responder accepts a lump sum settlement from WC and the settlement either releases
or has the effect of releasing the WC insurer from its obligation to pay future medical
expenses. 42 U.S.C. § 1395y(b)(2)(B)(iii) incorporated in 42 U.S.C. § 300mm-41(b)(1).
2. If the primary payer seeks to shift costs onto the WTC Health Program, and the
Program cannot recover WC payments voluntarily, it may seek double damages from
the payer in a recoupment action.
This means that if either a medical provider or a Responder receives payment from a WC insurer for services already paid for by the WTC Health Program, the Program has a duty to reduce further payments or recoup funds from that medical provider who received funds from the WC insurer.42 U.S.C. § 300mm-41(b)(1).
3. If evidence suggests that a WC insurer has improperly shifted WC costs onto the WTC
Health Program, the Program may recommend that a recoupment action be filed
against an insurer, even if the insurer has already paid the claim. 42 U.S.C. § 1395y(b)(2)(B)(iii) incorporated in 42 U.S.C. § 300mm-41(b)(1).
Click here to read the entire WTC Health Fund Policy Statement
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Jon L. Gelman of Wayne NJ is the author NJ Workers’ Compensation Law (West-Thompson) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson). For over 4 decades the Law Offices of Jon L Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.
