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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 …

Many of our clients who are injured on the job also have child support obligations at the time of their injuries. Some are also child support recipients. It’s natural to wonder how your child support might impact your disability benefits.

Here’s what you need to know.

If You Are Paying Child Support

If you have a regular child support payment then the New Jersey Child Support enforcement office can take your payment right out of your benefit amounts, just like they were able to take them out of your paycheck. You will still continue to owe child support.

Of course, this can prove financially difficult for some of our clients, as they are now only receiving 70% of their wages, but their child support amount remains the same. 

Depending on when you are expected to recover and how well you are expected to recover, you may be able to apply for a modification of child support that lowers your payment amount based on the amount of money that is actually coming into your bank account every week. To do this you would have to file a motion with the family court. It may be a good idea to look into taking this step sooner rather than later so that your child support does not go into arrears.  

If you owe back child support then a lien will be attached to your case. The arrears will have to get paid right out of your workers compensation settlement. That’s statutory, which means …

In New Jersey, you have a right to workers compensation, even if you have a pre-existing or chronic condition. Under New Jersey law, employers are considered to have  hired you “as you are,” which means that they took you with all the conditions you came to them with. 

In fact, you are entitled to compensation for the exacerbation if the workplace injury made your pre-existing condition worse. 

Here’s what you need to know about how a pre-existing condition could impact your claim.

Your employer could dispute causality.

Even though employers may not deny your claim on the basis of the existence of a pre-existing condition, you nevertheless will have to prove that the condition was “aggravated, accelerated, or combined with the pre-existing disease or infirmary to produce the disability for which compensation is sought.” (Sexton v. County of Cumberland). 

This means you’ll have to prove that there was true medical exacerbation, and you’ll have to prove the exacerbation was solely the result of your work-related activities. The claim must be based on the exacerbation, and not on the old injury. There are many ways to do this, including medical records, medical tests and images, and witness testimony. We may also have to bring in expert witnesses. 

Denying that an injury or death is work-related is a go-to strategy for most employers. As your workers compensation attorneys we’re here to help you prove otherwise. 

Your compensation amount may be smaller. 

New Jersey law does allow workers compensation insurance …

False allegations of workers compensation fraud are quite common. There are some people who would like you to believe that every time someone files a workers compensation claim they’re committing some form of fraud.

Workers compensation companies get to deny claims they believe to be fraudulent, so they’re more than a little incentivized to make fraud allegations. The person so accused faces not only the prospect of absorbing all of their medical bills and lost wages themselves, but the possibility of jail time. Under Section 34:15 – 57.4 of the New Jersey Revised Statute, fraud is a felony. 

Workers compensation fraud is not limited to workers. Employers also commit their own forms of workers compensation fraud, including by failing to carry workers compensation insurance in the first place and by misclassification of employees. Nevertheless, this post specifically addresses allegations of worker fraud.   

Types of Fraud

If a worker does commit fraud there are generally four ways that it happens.

• Misrepresenting their job status while continuing to collect benefits.
• Filing claims for injuries that did not occur on the job.
• Misrepresenting a physical condition for benefits.
• Misrepresenting preexisting conditions or previous trauma or treatments.

In an era where more workers work remotely we might expect to see more denials based on certain types of fraud. For example, we might see more instances of denials on the basis that the worker’s injury did not occur on the job.

Handling Fraud Allegations

As your New Jersey workers compensation attorneys we can …