Workers’ Compensation provides benefits to an employee who suffers a personal injury or death arising out of, and in the course of, his or her employment. If the employee suffers an injury resulting in death, his or her dependents may receive the benefits.
The focus of Workers’ Compensation benefits is to compensate for the loss of the ability to work, as opposed to pain and suffering, which is actionable through a civil tort claim. Therefore, the benefits are focused mostly on losses stemming from the inability to work. If the injury is so severe that it interferes with “ordinary pursuits of life,” such as having children or bodily disfigurement, then such loss may be taken into consideration when determining whether there should be an increased award in compensation.
New Jersey’s Workers’ Compensation system focuses on determining how much a person is prevented from doing after he or she is made as “whole” as possible following an injury. The three kinds of benefits available under Workers’ Compensation in New Jersey are 1) medical benefits, 2) temporary disability benefits, and 3) permanent disability benefits.
Medical Benefits
Medical benefits are those related to medical diagnosis and treatment. The treatment can be as minor as the assignment of a brace, to as major as a hospital stay. Medical benefits can also range in time, depending on how much treatment is needed. If an employee is diagnosed as having a permanent disability that requires ongoing medical treatment as a result of the workplace injury, for example, he may get medical benefits for life
Generally, the employer controls the medical care provider. Employees who choose their own providers without getting authorization from their employer may be forced to pay for those expenses. Some exceptions apply, however, if the employer only provides “ineffective and unreasonable treatment,” fails to provide any treatment at all, or if it is impossible to notify the employer before getting treatment. In addition, employers may refuse to pay excessive medical bills, paying instead the “reasonable and usual fees which are charged and prevail in the same community for the same physicians, surgeons, and hospital services.
It is quite standard for an employer to require the employee to undergo a physical examination in order to receive medical benefits. Employees who refuse may lose their right to compensation. Additionally, if employees refuse to accept reasonable treatment and their condition worsens as a result, their award of medical benefits may diminish. For example, in one case a woman was found to be 100% disabled from psychosis, but that 75% of the disability resulted from her obstinate refusal to accept medical aid from her employer. As a result, she was only given 25% of the available benefits.
Temporary Disability Benefits
Temporary disability benefits are those that compensate an employee until he or she is restored as fully as the injury will allow and can return to work. To become applicable for these benefits, an employee must be disabled from working for a full seven days (including weekends and holidays) from the injury. These days do not need to immediately follow the injury and do not need to be consecutive. Once the seven-day requirement is met, the employee can begin collecting benefits as long as he or she is unable to work and is under a doctor’s care. This applies retroactively to the seven-day period after the injury.
Typically, the temporary disability benefit consists of 70% of the employee’s gross average weekly wage but is tax-free. This number is capped, but the cap is adjusted from year to year. The benefit will last either until the employee is able to go back to work, or until he or she has improved as much as the injury will allow, which is known as reaching maximum medical improvement (MMI).
There are several ways in which a work-related injury may not result in temporary disability benefits. For example, employers may offer “restricted duty” work for an injured employee. If the employee thus returns to work but takes on lighter work, which the injury permits, he or she will not be entitled to continue receiving temporary disability benefits. Employees who receive paid sick leave through their employers, which provides full wages as opposed to 70%, also do not qualify for temporary disability benefits, unless they are school employees. Lastly, it is critical that the disability is what causes the loss of income, not some other factor. For example, courts in New Jersey have held that if an employee quits his job and does not seek other work, and then afterward claims temporary disability based on a work-related injury, he may not receive benefits.
Permanent Disability Benefits
Permanent disability benefits can come in two forms: 1) partial, or 2) total. To establish partial disability, an employee must prove a permanent impairment caused by a work-related injury and based on objective medical evidence. The impairment must be one that “restricts the function of the body or of its members or organs. The employee does not need to show a reduction in earnings. Minor injuries, such as lacerations, minor sprains and scars will not typically suffice as a partial permanent disability. Impairments can be either physical or psychiatric.
In New Jersey, an employee can prove permanent injury by satisfying two prongs: 1) showing demonstrable objective evidence of a functional restriction of the body, and 2) showing that he or she has suffered a material lessening of his working ability, or that his disability is otherwise significant and not just the result of a minor injury.
Medical examinations for permanent disability benefits, however, may not be taken until 6 months after the employee’s authorized medical treatment ends, and no later than 6 months after the employee returns to work. This is to ensure the permanency of the employee’s condition. The examination will also take into account how strenuous the employee’s line of work is
For permanent total disability, an employee must show a total permanent impairment with no reasonable expectation for marked improvement. An employee can qualify by showing a medical evaluation stating 100% disability, or by satisfying a statutory provision. For example, statutory provisions for permanent total disability include loss of both hands, both arms, both feet, both legs, or both eyes, or any two thereof. Preexisting conditions do not count.
