Posts by Albert Talone

The Workers’ Compensation Fraud Act makes it a fourth-degree felony to “purposely or knowingly” make false or misleading claims, representations, or submissions concerning any fact “material” to a workers’ compensation claim for the purposes of wrongfully obtaining benefits. The Act has been in force in New Jersey since 1998.

A “material fact” is any fact that a reasonable person would recognize as relevant to your workers’ compensation case, as distinguished from an insignificant or unimportant detail.

Example Case

For example, in the 2014 case Bellino v. Verizon Wireless, Verizon accused former employee Natalie Bellino of workers’ compensation fraud. Verizon maintained that several of her statements to both her treating and examining conditions were allegedly false, incomplete, or misleading and argued that she did not disclose every medication she’d been taking to each doctor she saw. They also argued that Bellino did not report all prior treatment of her injured back and hand to each doctor and failed to prevent that she had a substance abuse problem in the past or that she’d been taking Suboxone to prevent relapse. They also claimed that she failed to disclose her prior psychiatric treatment and issues fully.

Bellino argued she never purposefully or knowingly provided false or misleading information. She said she tried to answer all doctor questions truthfully but that she’d seen multiple doctors several times and wasn’t always sure of the times or dates of previous treatments. She also disagreed with the characterization of her statements contained in several doctor reports. …

It would be nice to receive pain and suffering compensation when you are injured at work. Unfortunately, pain and suffering is not part of any workers’ compensation claim.

The creation of workers’ compensation was meant to serve as a “grand bargain” between employers and employees. The idea is that employers would cover certain types of expenses for an injured employee without question, but in return, employees would lose the right to sue employers for negligence.

The ability to sue a person for negligence leads to pain and suffering compensation, also known as a personal injury lawsuit.

What Workers’ Compensation Covers 

Under workers’ compensation, your medical bills are covered for any visit relating specifically to your work-related injury. If you are temporarily or even permanently disabled, workers’ compensation replaces a portion of your lost wages, though it does not replace all of them. 

This is not to say there aren’t some cases wherein injured workers could, theoretically, obtain pain and suffering compensation. 

If a third party was involved in your injury and that third party was not your employer, you could receive workers’ compensation and sue that third party. The third party would then be required to pay the portion of your lost wages not already covered by workers’ compensation and for pain and suffering damages.

Can you sue the workers’ compensation insurance company for delaying medical treatment payment or authorization?

The third-party lawsuit exemption does not include the insurance carrier. 

For example, in the 2012 case Stancil …

If your employer can prove you were drunk or high at work, you may lose your workers’ compensation benefits. 

However, in New Jersey, employers can only raise this defense to a workers’ compensation claim if they can prove “by a preponderance of the evidence” that your work-related injuries were caused solely by your intoxication. 

Mixed-Cause Injuries 

An example of how this law may work in your favor comes from the  2006 case Tlumac v. High Bridge Stone, decided in the New Jersey Supreme Court. 

The Thlumac case revolved around James Tlumac, who drove a tractor-trailer for High Bridge Stone. At the time of his accident, he had worked 12 days in a row and had logged a total of 230 hours. His wife had recently suffered a broken hip, increasing his family responsibilities and causing him to lose sleep. 

At 8:00 PM, he was up on the roof of his house, doing some repairs and drinking a beer. He was up at 2:15 AM for work. His wife made coffee and saw no signs of intoxication. But he was in an accident, and his blood alcohol level was slightly over the legal limit at 0.087. 

Tlumac’s attorney showed that his exhaustion, roadway conditions, mental state, and other factors had far more to do with the accident than his intoxication and awarded him workers’ compensation. 

Drug Testing After an Injury

In New Jersey, employers do not have the right to drug test you just because you’ve been injured unless you …

Workers’ compensation insurance companies in New Jersey will often offer a settlement when you reach Maximum Medical Improvement (MMI). They usually do not wish to keep paying out for medical expenses or to keep issuing weekly checks indefinitely, especially if it doesn’t look like you’re going to be able to return to work anytime soon.

But how do you know when you are receiving a fair offer? After all, you know the insurance company is a lot more interested in saving money than in helping you. Lowball offers are common and should be expected early in the process.

While you should have a New Jersey workers’ compensation law firm like ours evaluate any settlement offer before accepting it, there are some general guidelines you can use to determine whether or not your settlement is fair. 

Ask yourself the following questions.

What does the offer include?

Your offer should include coverage for the following:

• 100% of your past unpaid medical bills.
• Compensation for your unpaid lost wages.
• Compensation which addresses future medical bills, lost wages, and other expenses.

It is very common for insurance companies to ignore future needs on their first offer, or to offer a sum so paltry that it couldn’t even get you through a year. 

If you don’t think the money is going to meet your needs, reach out to our law firm ASAP so we can discuss your claim.

Does the offer take all of the evidence into account?

Are they paying attention to all of …

New Jersey workers’ compensation law has provisions for when a condition worsens. Much will depend on which condition is worsening and when it is worsening.

Here are a few scenarios.

Condition Worsens While Your Case is Ongoing

If your case is open and ongoing, workers’ compensation insurance should still actively pay your medical bills. Your medical needs should be met, regardless of what they are.

You might expect questions about how and why the condition worsened, and you should be ready to answer them as best you can. 

Sometimes, of course, your doctor needs you to need specific medical care, and the workers’ compensation company rejects that care as “not medically necessary,” especially if the one advocating for a higher level of care is your second-opinion doctor. In such cases, working closely with a New Jersey workers’ compensation lawyer is useful. 

Condition Worsens After You Settle

If your condition gets worse after you settle, you may be able to reopen your workers’ compensation claim so long as you are asking for additional treatment for the same work-related injury. 

You must provide concrete, objective medical evidence that your condition has worsened. Unfortunately, “increased pain” is not enough—pain is subjective, and the medical industry isn’t very good at dealing with it as it is. 

The Initial Injury Exacerbates a Pre-Existing Condition

New Jersey law recognizes that an exacerbated pre-existing condition is a valid issue. Compensation may be pro-rated in some cases, but not all. In some cases, exacerbating a pre-existing condition could …

Most workers’ compensation cases run smoothly and are very routine. 

Every now and then, we end up with a case where a workers’ compensation insurance company is acting in bad faith. When you see signs of this happening to you, it’s time to involve a New Jersey workers’ compensation attorney.

Here are seven signs to look out for. 

#1) Unreasonable Delays

There is a short delay period for temporary disability payouts known as the “waiting week.” That’s the first seven days of your disability period. The Department of Labor holds that first payment until your unpaid leave continues for a total of 22 days or more. Once you meet that 22-day cut-off, you receive a retroactive payout for the first seven days.

If you don’t get your benefits on the second week, or if your workers’ compensation insurer refuses to pay your doctor bills promptly, the insurer may delay your payments in the hopes of somehow undermining your claim. 

#2) Denying Legitimate Claims

Is your insurer making false accusations, trying to claim you weren’t injured at work, or spinning a story that has nothing to do with the incident report you submitted?

They may deny claims to see if they can make you give up and go away. This often happens in severe injury cases where the claim is especially expensive. 

#3) Denying Requests for Necessary Medical Care

We all know that a doctor’s definition of “medically necessary care” and an insurance company’s don’t always …

Suicide is a difficult subject, and we don’t discuss it lightly.

Nevertheless, suicide is a subject that can come up in New Jersey workers’ compensation cases. Under most circumstances, a self-inflicted injury or death is not compensable, but exceptions exist. 

It doesn’t come up often, but this workers’ compensation law provision is worth knowing about.

The 1945 case Konazewska v. Erie R.R. Co. established a 4-part test that said an employee’s suicide was not compensable unless:

1. It’s the direct result of a physical injury.

2. The worker was possessed of an uncontrollable impulse to commit suicide or is in a delirium of frenzy.

3. The worker did not consciously intend to kill themselves.

4. They do not recognize the consequences of self-destruction. 

The 1980 case Kahle v. Plochman involves a suicidal worker.  Rosalie Kahle was injured during her employment at a mustard plant. She sustained back and left leg injuries and suffered from chronic pain and depression. She was permanently partially disabled. She could never return to work and suffered complications from her accidents.

Eventually, she ended her own life. Her husband requested dependency death benefits for himself and his children, alleging that her suicide directly resulted from her work-related injuries. 

During this case, the court ruled that a chain-of-causation test is “a more realistic and reasonable standard” than the 4-part test. Kahle established that “an employee’s death by suicide is compensable where the original work-connected injuries result in the employee’s becoming dominated by a disturbance of mind …