N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 380-5.4

Current through Register Vol. 46, No. 45, November 2, 2024

Section 380-5.4 - Acceptance or denial of claim

(a) Once the carrier or self-insured employer receives a completed request for paid family leave with the necessary certification as identified in Subpart 380-4 of this Part, the carrier or self-insured employer must pay the claim or deny the claim within 18 days. In the event a completed request is received more than 18 days before the occurrence of a qualifying event, the carrier or self-insured employer shall send payment to the employee within 5 days following the qualifying event.

(1) The chair may prescribe the format of a denial for request for paid family leave, and with the first payment or denial, the carrier or self-insured employer must provide contact information, including a contact person's name or office, mailing address, email, and contact phone number, as well as any form identifiers prescribed by the chair such as name, number or bar code. A paid family leave denial must state the reason, repeat any relevant information filed in the request for paid family leave, and include any other information considered by the carrier in making the decision.

(2) Unless the employee requests to receive correspondence by regular mail, the carrier or self-insured employer may send the denial and accompanying information by email.

(3) Whenever a claim for paid family leave is the responsibility of the special fund for disability benefits pursuant to section 213 of the Workers' Compensation Law, the chair may waive the special fund for disability benefits' obligation to pay or deny within 18 days.

(b) The carrier or self-insured employer may deny the claim without prejudice for the following reasons:

(1) incomplete claim package; or

(2) insufficient certification or proof of eligibility.

(c) If the claim is denied without prejudice due to an incomplete claim package, the carrier or self-insured employer must notify the employee of each piece of required information, as identified in the request for paid family leave (currently form PFL-1) and sections 380-4.2, 380-4.3, and 380-4.4 of this Part, which is missing from the employee's request for paid family leave. If the claim is not refiled within 30 days from when leave was first taken, the carrier or self-insured employer may deny the claim.

(d) The carrier or self-insured employer may deny the claim for the following reasons:

(1) employee has not been employed by the employer for a sufficient length of time to be eligible for benefits;

(2) employee is not an employee of the employer;

(3) employee is not an employee of a covered employer;

(4) the family member that the employee is seeking leave to care for is not a covered family member under subdivision (20) of section 201 of the Workers' Compensation Law; or

(5) the amount of leave requested exceeds the statutory maximum benefit period for family leave or disability benefits under article 9 of the Workers' Compensation Law;

(6) the amount of family leave requested exceeds the statutory maximum or the family leave needed as stated in the medical certification of the employee or the qualifying event was foreseeable and the employee failed to provide the employer with notice as required in Subpart 380-3 of this Part. In such a case, the carrier may issue a partial denial of any excess leave or a partial denial for 30 days when the qualifying event was foreseeable and the employee failed to provide the employer with notice. All benefits requested that have not been denied must be paid within the statutory time frame;

(7) the employee requesting leave is the perpetrator of domestic violence or child abuse against the care recipient; or

(8) the claim was not timely made;

(9) the employer did not have coverage on the date family leave began;

(i) when the board has identified a carrier as providing coverage, the carrier shall pay family leave benefits to the employee without prejudice while the dispute regarding coverage is resolved. Whenever a claim for paid family leave is the responsibility of the special fund for disability benefits pursuant to section 213 of the Workers' Compensation Law, the chair may waive the special fund for disability benefit's obligation to pay without prejudice;

(ii) when a basis for a denial is lack of insurance coverage, the insurance carrier shall provide the board with a copy of the denial.

(e) Failure of the employer to complete, or inadequate completion by the employer, of the employer section on the request for paid family leave is not a valid basis for denial by the carrier.

(f) If the employee is eligible to receive benefits at the time of submission of the request for paid family leave with the carrier, the carrier or self-insured employer must accept the claim and make payment to the employee within 18 days. In addition to any other applicable penalties, any benefits paid after 18 days shall draw simple interest from 10 days after notice was given, at the rate provided in section 5004 of the Civil Practice Law and Rules.

(g) The employee and carrier or self-insured employer should make every effort to informally resolve a denial of benefits.

(h) The carrier or self-insured employer shall make all reasonable efforts, consistent with the principles set forth in Executive Order 26, issued October 6, 2011, to communicate with respect to the paid family leave claim in the language identified by the employee on the request for paid family leave form.

(i) The insurance carrier on the first date of paid family leave taken by the employee will be deemed the insurance carrier for the whole period of paid family leave for a 52 week period from the first date of leave taken, except that when an employee changes employers with a different insurance carrier, the existing carrier's coverage of the employee is terminated and the employee must become eligible under the new covered employer's coverage.

N.Y. Comp. Codes R. & Regs. Tit. 12 §§ 380-5.4

Adopted New York State Register July 19, 2017/Volume XXXIX, Issue 29, eff. 7/19/2017