Medical Benefits Under The New Jersey Workers' Compensation Act

Posted on July 18, 2008 by Frank Crivelli

We haven’t spoken about the New Jersey Workers’ Compensation system in a little while and there is still a great amount of information regarding the available benefits that all public safety officers and first responders should be made aware of. With that being said, let’s talk a little about medical benefits under the New Jersey Workers Compensation Act. 

Under the New Jersey Workers’ Compensation system, the injured employee is entitled to reasonable and necessary medical treatment to cure and relieve the effects of the injury, illness, or condition that occurred either on the job or as a result of the job. In New Jersey, due to the fact that the employer is responsible for payment of 100% of the injured worker’s medical treatment associated with the workplace injury, the employer has the right and ability to control treatment. What this means, is that the employer or the employer’s workers’ compensation insurance carrier will select the doctors that will treat the injured worker for his or her injury. 

When the injured worker is treated by medical physicians that have been chosen by the employer or the employer’s insurance company, this treatment is commonly referred to as “Authorized Treatment”. However, if the injured employee receives treatment for his or her workplace injuries from physicians, doctors, or hospitals that have not been chosen or authorized by the employer or the employer’s insurance company, this particular treatment is referred to as “Unauthorized Treatment”. 

The New Jersey Workers’ Compensation Act only requires employers to make payment for “authorized treatment” in a New Jersey workers’ compensation case. Therefore, should an injured employee obtain treatment from physicians or medical providers that have not been chosen by their employer or their employer’s insurance company, he or she may be responsible for paying these medical bills out of his or her own pocket.

It is important for an injured employee to understand that the only medical treatment that has to be provided under The New Jersey Workers’ Compensation Act is treatment that is medically necessary to cure and relieve the effects of the injury or condition. Palliative medical treatment does not have to be provided by the employer. Palliative medical care has been described as medical care or treatment that concentrates on reducing the severity of pain associated with the injury, rather than halting or delaying the progression of the injury itself. To clarify, palliative medical treatment is care that provides pain relief only. It is not medical care or treatment that will improve the medical condition of the injured worker.

Medical treatment under the New Jersey Workers Compensation Act must continue until one of two events occurs; the employee is returned to work, or in the alternative, a doctor declares that the employee has reached maximum medical improvement or “MMI”. When one of these two events occurs, medical benefits and temporary total disability benefits will cease, and the injured employee’s claim will move to the establishment of a permanent disability rating and thus the settlement of the case. We will discuss permanent disability and partial total disability in a later entry.   

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Sick Leave Injury (SLI)--The Common Reasons for Denial of Benefits

Posted on July 2, 2008 by Frank Crivelli

As you may remember from the June 27, 2008 blog entry, injured New Jersey Public Safety Officers may be entitled to receive Sick Leave Injury benefits or “SLI” benefits due to their inability to report for duty due to illness, injury, or infirmity that occurred on the job. This particular entry is written by Michael P. DeRose, a paralegal with our office that is in charge of our firm’s SLI appeal unit. Michael has been involved with SLI appeals for several years and has authored hundreds of appeals on behalf of injured Police, Fire and Corrections Officers. Michael is temporarily leaving our firm this fall to attend law school. However, he will continue to lead our SLI appeal unit from Michigan given the advances in technology and telecommunications. We look forward to his return as a summer intern and eventually as an attorney at law.

In certain circumstances, SLI benefits are issued in lieu of temporary total disability benefits associated with the NJ Workers’ Compensation Act. The initial threshold for a Public Safety Officer to receive SLI benefits is governed by N.J.A.C. 4A:6-1.6.  As mentioned in previous blog entries, SLI benefits allow a Public Safety Officer to receive 100% of his or her base weekly wage notwithstanding overtime pay, for a period of one calendar year beginning on the date the injury occurred. As any injured officer knows, when he or she is unable to report for duty for a certain length of time, it is much more beneficial to receive SLI benefits as opposed to temporary total disability benefits. Thus, it is important for all Public Safety Officers in New Jersey to be familiar with the common reasons offered by the appointing state agency for denial of SLI benefits.

The most common reason for denying an officer’s application for SLI benefits is the presence of a preexisting injury to the same body part upon which the application for benefits is based. For example, if an officer injures his or her lumbar spine in 2005 and then re-injures the lumbar spine in 2008, he or she will be denied SLI benefits associated with the 2008 injury. The grounds for said denial is that he or she aggravated a preexisting injury (the injury that occurred in 2005). However, state agencies tend to take advantage of this provision, often unjustifiably denying SLI benefits. For example, if that same officer who injured his or her lumbar spine in 2005 suffers an injury that caused a herniated disc in his or her thoracic spine in 2008, the individual cannot be denied benefits on the premise that he or she aggravated a preexisting injury. Never the less, state agencies routinely attempts to blanket the injury as a “back injury” and therefore will deny the application for SLI benefits. Counterfeit denials such as these are precisely the reason why it is important to act swiftly and speak to your union representative about appealing the state’s decision.

The next provision commonly utilized by the state agencies when denying SLI applications is refusing to pay benefits on the grounds that the individual’s injury was not “work-related.” This may sound asinine due to the fact that law enforcement personnel can only apply for SLI benefits when injured on the job, however we repeatedly see denials based on this premise. A state Agency will often justify denying benefits stating that the Public Safety Officer was not “aware of his or her work environment at all times,” thus, resulting in his or her injury. Once again, if such a reason based on this theory of negligence is stated as the basis for the denial of benefits, act swiftly to appeal the decision.

After reading countless denial letters issued by state agencies, I would be remiss if I did not mention one more reason typically posited for an applicant’s SLI denial. This reason pertains to a “delay in reporting the injury to the appropriate authority”. As anyone who has been injured is aware, on certain occasions, an injury does not manifest of become known to the Public Safety Officer until a day or two after the incident which caused the injury. Once again, state agencies frequently utilize this factor to its advantage in denying benefits. However, the New Jersey rule governing SLI requires the injured Public Safety Officer to report the injury pursuant to “occurrence or discovery.” Therefore, it is commonplace for a Public Safety Officer to be denied SLI benefits when he or she reports an injury pursuant to discovery, despite comporting with the governing administrative rule. Once again, a Public Safety Officer that finds themselves in this situation is entitled to SLI benefits so long as the circumstances surrounding his or her injury do not conflict with the remaining provisions of the code.

In sum, when a Public Safety Officer is denied SLI benefits, do not panic. Many applicants are initially denied benefits as the individual with the responsibility of issuing benefits and denying applications may not be entirely familiar with the specific situation as it applies to the applicable administrative code. It is important to assert your rights and act promptly to appeal the denial. This can most likely be accomplished by contacting your union representative. The matter will then be handled by the union’s attorney who will issue a formal appeal on your behalf. Bear in mind that the injured Public Safety Officer only has 20 days to notify the state of his or her intent to appeal the denial of benefits. The 20 day clock begins to run upon receipt of the official SLI denial letter. So once again, subsequent to receipt of a denied SLI application, act swiftly and assert your rights to receive the benefits you are entitled to as New Jersey Public Safety Officer.

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