Is an Employer Entitled to Reject a Workers’ Compensation Claim in NJ?

February 27, 2023

Even Though Employers May Argue Some Qualified Reasons To Deny A Workers’ Compensation Claim, in Some Cases, There May Be Grounds For Refuting the Rejection

Is an Employer Entitled to Reject a Workers' Compensation Claim in NJ?Believe it or not, the mere act of filing a workers’ compensation claim doesn’t guarantee that your benefits will be given to you. Yes, an employer in New Jersey can deny a workers’ compensation claim if they believe it is unjustified or if the injury is not covered under the state’s workers’ compensation law. However, if the employer denies the claim, the worker can challenge the denial by filing a claim with the New Jersey Division of Workers’ Compensation. An administrative law judge will then review the case and decide the outcome of the workers’ compensation claim.

It’s important to note that in New Jersey, workers’ compensation is a no-fault system, meaning that an employee does not need to prove that the employer was at fault for the injury to receive benefits. However, the damage must have occurred during employment and must be covered under the state’s workers’ compensation law. If the workers’ compensation claim is accepted, the employee may be eligible for medical expenses, temporary disability benefits and permanent disability benefits.

Valid Grounds For Denying a Workers’ Compensation Claim in NJ

Several valid justifications exist for denying a workers’ compensation claim in New Jersey. Suppose the injury is not covered under the state’s workers’ compensation law. In that case, the employer may deny the claim if it did not occur in the course of employment or if it is not covered under the state’s workers’ compensation law.

If the employee did not report the injury within a reasonable time frame, the employer may deny the claim if the damage was not written in a timely manner. In New Jersey, employees must report the injury to their employer within 90 days of the date of the accident. The employer might deny the claim if the employee had a pre-existing injury or condition that contributed to the current injury.  For example, if someone with a back problem has been told not to lift heavy boxes or other items, disregards the indication, and hurts their back, their claim might be denied.

If the injury was sustained while the employee was performing duties that weren’t work-related, the employer might deny the claim. For example, if an employee were to injure their hand while attempting to fix their car because it won’t start, the injury does not qualify for workers’ compensation. The employer may deny the claim if the employee committed fraud or made false statements concerning the workers’ compensation claim, such as altering details of the accident or convincing coworkers to fabricate eyewitness accounts.

If the injured party refuses to work part-time after the incident when they are cleared to do so by their medical team, their benefits can be denied. Similarly, if the employee does not use a doctor from the given list provided by the employer, their benefits could be in jeopardy. One is also considered ineligible for workers’ compensation benefits when the accident was caused by “willful negligence.”  The four possible actions of willful negligence are the illegal use of a controlled substance, intoxication, deliberate acts or omissions, or reckless behavior.  The burden of proof is on the employer to deny compensation benefits.

Alternatives if There is Bad Faith in the Denial

Explore the Options if There is Bad Faith in the Workers' Compensation Denial in Monmouth County, NJInstead of submitting a formal claim, you can request an informal hearing with a Division of Workers’ Compensation judge. After reviewing evidence and medical records, they will recommend how to proceed. The result of this process is non-binding. It is similar to mediation; the goal is to decide on a settlement between you and the insurance company.

The New Jersey Division of Workers’ Compensation will receive your formal claim and accompanying evidence to review your situation.  Your workers’ compensation attorney can meet with you to discuss your claim and help you to submit it. A formal hearing is akin to a trial.  You and your attorney will submit evidence from experts, witnesses, medical reports, physical therapists, and cross-examination.  If you win, your employer’s insurance must pay your claim.

What are the Employer’s Options If a Claim Is Denied?

If an employee’s workers’ compensation claim is denied, the employer’s attitude should be empathetic and understanding toward the employee. The employer should also make sure to follow the proper procedures for appealing the denied claim and provide the necessary support to the employee throughout the process.

It’s important to remember that the employee is likely in a difficult situation, potentially dealing with an injury or illness that has affected their ability to work. The employer should take steps to ensure that the employee is aware of their rights and options and provide any resources or information that may be helpful. Additionally, the employer should maintain a professional and neutral stance throughout the process, avoiding any actions that could be interpreted as retaliation against the employee for filing the claim.

Is There Room For an Appeal in the Process?

Yes, you can appeal a workers’ compensation decision in New Jersey. The New Jersey Division of Workers’ Compensation provides a process for appealing a decision related to workers’ compensation benefits. If you disagree with a decision made by a workers’ compensation judge or the New Jersey Division of Workers’ Compensation, you have the right to file an appeal. The appeal must be filed within 20 days of the date of the decision and must include a written statement explaining the reasons for the appeal. This hearing is different in that no new evidence or testimony is presented.  This trial is designed to review the previous hearing and ensure that the decision was lawful, legitimate, and unbiased.

Employee Tips to Avoid a Denial of Your Workers’ Compensation Claim in New Jersey

Injured employees who want to ensure that their workers’ compensation claim is not denied should take the following steps. Injured employees should report their injury to their employer immediately after it occurs. This can be done in writing or orally, but it is best to provide a written report to ensure that the injury is documented. Seeking prompt medical attention is a must. This is important for their health and establishing a clear connection between the injury and the workplace.  They must use the healthcare providers given to them by their employer.

Steps to Follow if a Workers' Compensation Claim is Denied in NJEmployees should complete and submit a Workers’ Compensation Claim Form to the New Jersey Division of Workers’ Compensation as soon as possible after their injury. This form can be obtained from the employer, the Division of Workers’ Compensation, or an attorney.

Cooperating with their employer and the insurance carrier in processing their claim can make the process easier. This includes attending medical exams and providing any requested information.  It does not include accepting the denial of your benefits.  You have a right to receive the benefits to which you are entitled.  Cooperating does not mean receiving substandard medical support.

It is a good idea to keep detailed records of all medical appointments, expenses related to the injury, and other relevant information. This can be helpful if an appeal is necessary.

Talk to Our Workers’ Compensation Team to Protect Your Rights After a Claim Denial in Monmouth County NJ

An attorney can help you navigate the workers’ compensation claim process and ensure that your claim is filed correctly and on time while helping you negotiate a fair settlement.  Your attorney can help you obtain the medical treatment you need to recover from your injury, including referrals to specialists and rehabilitation services. You don’t want to do this on your own, especially when you are injured and need to focus on your recovery. If your claim is denied, they can help you appeal the decision and present your case to a judge.

Our clients are our greatest motivation at Chamlin, Uliano, & Walsh.  We want to ensure your rights are upheld and will work with you to make that happen in Holmdel, Middletown, Howell, Long Branch, Freehold, and throughout Southern New Jersey.  Being injured or ill is stressful.  You have concerns about costly healthcare, and piling bills can hinder your much-needed recovery.  Our job is to put our experience to work and get you the best possible outcome.

To learn more, please call us at (732) 440-3950 or complete our online form for your free initial consultation.  Time is of the essence and we look forward to helping you today.

Categorised in: Workers' Compensation