What Is Workers' Compensation?

New Jersey law requires that all employers, including governmental entities, provide specified compensation benefits to employees who are injured while working or who suffer from a disease which is attributable to the work effort, a condition of employment, or exposure in the course of employment.

Who Pays The Workers' Compensation Benefits?

Workers' Compensation benefits are not paid by the State of New Jersey unless, of course, the employer happens to be the State itself.  Generally speaking, private insurance companies provide coverage for the compensation an employer is obligated to furnish.  However, some larger businesses and governmental employers have been approved by the State to operate as self-insureds.

What benefits are available?

 In non-fatal cases, an injured worker is entitled to only three (3) types of benefits:  1) medical treatment, 2) temporary disability and 3) permanent disability compensation .  When the work accident or exposure results in death, dependency benefits are provided which include weekly compensation to eligible dependents, payment of burial expenses up to $3,500.00, and satisfaction of medical expenses.

1) Medical Benefits.

The workers' compensation insurance carrier or self-insured employer is obligated to cover 100% of the reasonable and related charges for medical treatment necessary to cure the work injury or occupational disease.  However, the law gives the insurance carrier or self-insured employer the primary right to select the treating physician(s) they will be obligated to pay.  Except in emergency circumstances, prior approval or authorization for treatment must be obtained from the employer or insurance company.  If a physician has been authorized to render treatment, the insurance company or employer is legally responsible to pay for only such treatment or diagnostic testing ordered or prescribed by the authorized physician(s).  However, in denied claims, where no medical attention is authorized, the Workers' Compensation Court has the power to order coverage for unauthorized care if it is determined that the claim should not have been denied and the unauthorized treatment charges are reasonable, necessary and related to the work injury or disease.  Again, you must remember that the workers' compensation carrier/employer will not voluntarily pay for any bills for treatment or tests which were not provided or prescribed by the authorized physician or someone/place they sent you to.

Will private health insurance cover unauthorized medical charges?

Most private health insurance policies contain an exception clause which expressly excludes medical bills for work injuries or occupational diseases.  Before incurring unauthorized charges, you should always review your private health policy.  In denied workers' compensation claims, private insurance will normally pay for treatment if a letter of denial is furnished from the workers' compensation insurance carrier or self-insured employer.  Where a private plan picks up medical bills, usually a lien is then asserted against the workers' compensation claim and the Court will have to decide whether reimbursement is permissible.

Is there a limit on how much medical treatment is payable by the workers' compensation carrier or self-insured employer?

There is no dollar limit on the amount of medical bills, provided the charges are reasonable, related and necessary for cure.  Nevertheless, an injured worker is not customarily entitled to ongoing treatment for as long as symptoms persist. The insurance company is only responsible for curative medical treatment, i.e. care or diagnostic testing which is designed to lead to a permanent improvement.  Once an injured worker reaches a plateau of recovery or so-called "maximum medical improvement", continued authorized care is not the legal responsibility of the insurance carrier or self-insured employer despite the fact that symptoms persist.  After maximum medical improvement has been achieved, periodic treatment charges become the responsibility of private health insurance or the individual worker, unless otherwise ordered by the Workers Compensation Court.

What if I do not like the physician authorized to treat me by the insurance company or my employer?

The selection of the authorized physician is very rarely overturned by the Compensation Court because of personality problems or personal preferences.  In extenuating circumstances, the carrier or employer may be persuaded to provide a different authorized physician.  Absent voluntary re-designation of the authorized physician, the Compensation Court will only order the provision of a new doctor where there exists clear and convincing evidence that the treatment being rendered by the carrier's designated doctor is incompetent, wholly inadequate, or detrimental.  Only in unusual cases can this be proven.

What should I do with medical bills I receive?

In claims which have been accepted by the compensation carrier or self-insured employer, medical bills should be turned over to the insurance carrier or employer for payment.  However, if you receive the same unpaid bill more than two (2) times, a copy should be presented to our office and continue to be sent to us as received in the future.  Upon receipt, these bills are forwarded to the appropriate party with a request for payment.  We then assume the bill has been taken care of unless we received a subsequent identical bill from you which shows additional action is needed.

2) Temporary Disability Benefits.

Claimants who are disabled because of a work injury or disease are entitled to temporary disability benefits at 70% of their gross average weekly wage at the time of the accident provided the disability extends beyond seven (7) days and a doctor, invariably the authorized treating physician, certifies that the disability is in fact due to a work injury or disease.  Benefits do not have to be paid for disabilities of seven (7) days or less, but this initial week is paid once the disability extends beyond the first week.  [Note Well: This is NOT N.J. State Temporary Disability, which is paid for lost time from work due to non-occupational injuries or illnesses.  If you collect N.J. State TDB, a lien will be placed on your workers' compensation recovery from which the lien will be repaid.]

In calculating the gross average weekly wage, the Court will take the average of gross wages for the 26 weeks preceding the date of accident, or date of last exposure in an occupational disease case. Tips and other gratuities are included  in wages so long as there exists sufficient credible documentation as to the amounts received during the relevant 26 weeks.

Temporary disability compensation extends for as long as there is medical proof of work related incapacitation and the claimant is under active medical treatment. The workers' compensation carrier or self-insured employer will stop the payment of temporary disability compensation on the date when any one of the following events occurs:

(a) The claimant is released to return to work by the doctor;

(b) The claimant returns to work, with or without medical approval;

(c) The claimant stops active medical treatment or refuses to attend a medical examination or consultation reasonably requested by the insurance company or employer; or

(d) The claimant reaches maximum medical improvement irrespective of whether he/she is medically released to return to any gainful employment.

In order to carefully document one's continued right to temporary disability benefits, we suggest that you routinely obtain disability notes from the authorized treating physician.

What if the authorized treating physician releases me to return to light duty or restricted duty work, but my employer refuses to take me back under those terms?

It is important for you to make the treating physician aware of the type of work you are required to perform. If you are released to return to work at light duty or restricted duty, you must obtain a written note which fully sets forth the doctor's work restrictions.  If an employer refuses to provide suitable work, and active medical treatment is continuing, the law requires continuation of temporary disability benefits until the work restrictions are lifted or medical treatment ceases.

What if I am released to return to work, but I personally do not believe I can do the job?

Without credible medical evidence of ongoing work incapacitation due to the work injury, the Court will not require the payment of temporary disability benefits.  Therefore, as previously stated, it is essential that you make the treating physician fully aware of the nature of your employment duties and any problems you foresee carrying out those duties at the time return to work is considered.

3) Permanent Disability Benefits.
 
After curative medical treatment has concluded and maximum medical improvement has been achieved, an assessment will be made to determine whether the work injury has resulted in some partial permanent disability or total permanent disability.  Doctors who are qualified to rate permanent disability will be asked to examine you and render reports expressing their opinion on the nature and extent of permanent disability. These examinations must be performed to enable the Court to determine a claimant's entitlement to compensation for permanent disability.  For each type of evaluation we order (i.e., orthopedic, neurologic, neuropsychiatric, etc.), the insurance company/employer is absolutely entitled to their own "independent medical examination". In certain cases, re-evaluations are necessary and must be kept to resolve a given case.  Refusal or repeated failure to attend a permanent disability evaluation will most likely result in the assessment of missed appointment charges and eventual dismissal of your claim. Injuries which involve "minor" sprains or strains do not usually qualify for permanency compensation.  Only where there is objective medical evidence of disability and material restrictions on activities of daily living, will the Court enter an Award or Approve a Settlement.

How is permanent disability determined and paid?

Permanent disability benefits are not paid permanently except in cases of total disability, and they are not based on future lost income.  Permanent partial disability is awarded in accordance with a pre-determined Schedule of Benefits which allows fixed amounts of compensation depending upon the percentage of permanent disability sustained to the injured part of the body.  For instance, 10% disability of the hand for 2006 injuries entitles an individual to $4,508.00, 15% of the leg is $8,694.00, 25% of the whole person is $31,458.00, and so forth. Based upon the respective opinions of the permanent disability evaluators on both sides, the diagnosis and treatment involved, and your testimony as to ongoing symptoms and restrictions, the degree of disability related to your case will be awarded either by Settlement or Judgment of the Court.

The money awarded to compensate you for permanent disability must be paid over the course of a designated number of weeks commencing on (retroactive to) the date of accident or date you last received temporary disability compensation.  Thus, some portion of your permanency award may be payable into the future if your award calls for a large number of consecutive weekly payments.  We will go over the manner in which your particular award will be paid once it is handed down or approved.

What if I am totally permanently disabled from working?

In cases of total permanent disability, you are entitled to continuing weekly benefits at your temporary disability rate for at least 450 consecutive weeks, and possibly till death.

How long do workers' compensation claims normally take to resolve?

In virtually all claims, the Court cannot enter an award or approve a settlement until permanent disability has been fully evaluated.  Consequently, workers' compensation claims remain pending on the Court's Docket until medical treatment has concluded and the permanency evaluations have been completed.  As a rule of thumb, claims cannot be settled or otherwise resolved (except for dismissals for lack of prosecution or failure to cooperate) until at least six (6) months following the end of medical treatment.  That is typically the earliest date a case can be presented to the Court for judgment or settlement approval.  Thus, during the time medical treatment is being rendered or sought, it is not possible to resolve a workers' compensation claim, except on a dismissal basis.

Is my spouse entitled to compensation benefits?

No, a spouse is not entitled to benefits except where the injury or occupational disease results in death to the injured worker.  In that event, spouses and other dependents are entitled to dependency benefits.

Are my transportation expenses to and from medical treatment and evaluations covered under the law?

With few exceptions, transportation expenses are not reimbursable.

Am I entitled to compensation for time spent attending permanency evaluations and/or court?

Because you have brought a claim before the Division of Workers' Compensation, it is considered your obligation to cooperate in the prosecution of your claim.  This includes attendance at medical evaluations and necessary court hearings.  Therefore, you will not receive compensation for time spent attending to these matters.

How often should I expect to hear from my attorney?

While you are under active, authorized medical treatment and receiving payments of temporary disability benefits voluntarily sent by the workers' compensation insurance carrier/employer, there is no action to be taken by this firm except to keep updating your file and remain vigilant should a problem arise.  In fact, in this phase of your case, you will probably keep us more informed of events than vice-versa.  However, once a problem is communicated by you, or you reach the point of undergoing permanency evaluation(s), we will then take the necessary steps to move your case forward in the legal arena.  Naturally, you should expect to be advised of all noteworthy developments.

What should I do to assist my attorney?

It is not necessary for you to contact us each and every time you see the doctor or therapist.  However, it is absolutely essential that you keep our office advised of all doctors you see, all diagnostic testing you undergo, all emergency room visits and hospital admissions, and any other information relevant to the preparation and presentation of your case.  We should also be notified when you are released to return to work, when you in fact return to work, or when you have reached maximum medical improvement.  Keeping us current on your medical and work status will enable us to move forward at each juncture and avoid needless delays.  Naturally, we should always be informed regarding any communications received from the insurance carrier or employer, particularly if a bona fide offer is made towards permanent disability benefits. 

File updates from you need not be communicated directly to the attorney handling your file, rather they should be directed to the workers' compensation paralegal and secretary.  These individuals are well trained and quite experienced in handling such matters and will keep your file documented and your attorney apprised.  In addition, it is always helpful for you to communicate any questions you have to our fine support staff as most issues can be dealt with by them promptly.

How are file costs handled?

This firm has a policy of advancing most of the file costs which are necessary for the preparation and presentation of workers' compensation cases.  At the conclusion of each case, we seek reimbursement for the firm's out-of-pocket expenses.  However, we never advance money to a client against their recovery, as this is an unethical practice which creates a conflict of interest.