New York Codes, Rules and Regulations › Title 12 - DEPARTMENT OF LABOR › Chapter V - Workers' Compensation › Subchapter C - Medical Treatment and Care › Part 325 - Medical And Surgical Care And Treatment › Subpart 325-6 - Reimbursement for workers' compensation claims paid by health insurers; arbitration of disputed requests for reimbursement › Section 325-6.12 - Decisions of the arbitrator; awards; interest

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The arbitrator shall make a decision in
					 writing no later than 30 days after completion of a hearing. The decision shall
					 contain a dollar amount of an award or a denial of the claim, and shall specify
					 the basis of the decision on the form prescribed by the dispute forum for such
					 purpose. The decision may include any stipulation made by the parties,
					 including stipulations as to payment of fees. The decision shall be delivered
					 to each party in accordance with section
					 325-6.15(b) 
					 of this Subpart.
(b) In the event
					 the arbitrator's decision is in favor of the health insurer in the full amount
					 requested, the amount of the award shall be increased by the amount of any
					 filing fee, or any additional fee paid by the health insurer including any fee
					 for manual searches as provided in section
					 325-5.6(b) 
					 of this Part, except attorney's fees, for oral hearings. In the event the claim
					 for reimbursement is denied in full, the arbitrator shall make an award in
					 favor of the carrier for any filing fees or additional fees, except attorney's
					 fees, paid by the carrier. In all other cases, the arbitrator shall, in his or
					 her discretion, determine whether such fees shall be allocated and the manner
					 of such allocation provided, however, that in all cases in which the
					 arbitrator's decision is based in whole or in part upon objections or documents
					 received and accepted by the arbitrator as newly-discovered evidence pursuant
					 to section
					 325-6.11(c) 
					 of this Subpart, and is entirely or partly in favor of the party which served
					 the objections or documents untimely, any filing fees shall be chargeable to
					 such party in whole or in part. In any such case the arbitrator, when
					 allocating such fee, shall consider the extent to which the other party may
					 have been prejudiced by the prevailing party's failure to serve the objections
					 or documentation in a timely manner. If payment is made to the health insurer
					 after the time within which the carrier was required to object or making
					 payments has expired and the carrier submits proof of payment after the health
					 insurer has served a request for arbitration, the arbitrator shall make an
					 award to the health insurer for any filing fees paid by it.
(c) If the arbitrator determines that the
					 carrier's objection to or non-payment of the reimbursement or the health
					 insurer's request for arbitration was frivolous or was not made in good faith,
					 he or she may impose in his or her discretion a penalty of no greater than
					 $1,000 against the party whose position was frivolous or not made in good
					 faith. Such determinations shall be limited to instances where the objection to
					 non-payment or request for arbitration had no basis in fact, or was not
					 warranted by existing law or good faith argument for the extension,
					 modification, or reversal of existing law. Any penalty shall be issued in the
					 form of an arbitrator award payable to the opposing party by the party whose
					 position was deemed frivolous or not made in good faith.
(d) Within 15 days of the date of the
					 arbitrator's decision, either party may serve a request for reconsideration by
					 serving a written request for reconsideration on the opposing party and by
					 serving two copies of the written request with proof of service of the request
					 for reconsideration and an additional filing fee of $150 on the dispute forum.
					 The party seeking reconsideration shall have the burden of establishing that
					 the original decision is incorrect as a matter of law or fact. The party
					 opposing reconsideration shall have fifteen days to serve its written response
					 on the serving party and two copies on the dispute forum. Such reconsideration
					 shall be conducted by the arbitrator who issued the underlying decision. The
					 arbitrator shall issue a written decision on the request for reconsideration in
					 accordance with subdivision (a) of this section. The arbitration decision,
					 including payment of arbitrator's awards and reimbursement of filing fees,
					 shall not become final for purposes of subdivision (e) of this section during
					 the pendency of a request for reconsideration and shall be stayed during the
					 pendency of such request for reconsideration. If the arbitrator determines that
					 the request for reconsideration was frivolous, he or she may impose in his or
					 her discretion a penalty of no greater than $1,000 against the party seeking
					 reconsideration. The proceeds of the penalty shall be paid in equal parts to
					 the dispute forum and the other party. In no case shall the arbitrator impose
					 the additional filing fee for a request for reconsideration on the party
					 opposing reconsideration.
(e)
					 Awards shall be paid to the prevailing party no later than 30 days after
					 service of the decision upon the parties. Any awards remaining unpaid after
					 said 30-day period shall draw simple interest from 30 days after the making of
					 the award at the rate provided in section 5004  of the Civil Practice Law and
					 Rules.