Version 1.1
New Jersey Private Plan
Claims Manual
Version 1.1
TABLE OF CONTENTS
INTRODUCTION ............................................................................................................. 1
CHAPTER 1 - NEW JERSEY TEMPORARY DISABILITY PROGRAM .......................... 3
CHAPTER 2 - COVERAGE AND LIABILITY
Private Plan Coverage May Vary ........................................................................... 4
Last Employer Is Liable ......................................................................................... 4
Concurrent Employment ....................................................................................... 4
Fourteen Days of Extended Coverage .................................................................. 5
Liability Determined by Date the Disability Began ................................................. 5
Vacation Pay Extends Employment ...................................................................... 5
Governmental Employers ..................................................................................... 5
Determining Liability for Relapses ......................................................................... 6
Overlapping Disabilities ......................................................................................... 7
Late Filing of a Claim ............................................................................................ 7
Return to Work on Part-Time Basis ...................................................................... 8
Partial Return to Work 8
Labor Disputes ...................................................................................................... 9
CHAPTER 3 - MEDICAL ISSUES
Disability Date ..................................................................................................... 10
First Date of Treatment ....................................................................................... 10
Licensed Medical Practitioners ........................................................................... 10
Independent Medical Examinations .................................................................... 10
Pregnancy Claims ............................................................................................... 11
Acceptable Medical Basis for Denial ................................................................... 11
Morbidity Table ................................................................................................... 12
Requesting Updated Medical Information ........................................................... 13
Light Duty ............................................................................................................ 13
Illegal Drugs and Alcohol .................................................................................... 13
Self-Inflicted Injury .............................................................................................. 13
Cosmetic Surgery ............................................................................................... 14
Elective Surgery .................................................................................................. 14
Deceased Claimants ........................................................................................... 14
CHAPTER 4 - HOW TO CALCULATE STATUTORY BENEFITS
Base Week ......................................................................................................... 15
Base Year ........................................................................................................... 15
Earning Requirements ........................................................................................ 15
Wage Information from Prior Employers ............................................................. 16
Calculating the Weekly Benefit Rate ................................................................... 16
Alternative Base Year I ........................................................................................ 16
Alternative Base Year II ....................................................................................... 17
Calculating Benefits When Claimant in Concurrent Employment with Two
Private Plan Employers ............................................................................ 17
Version 1.1
Calculating Benefits When Claimant in Concurrent Employment with One Private
Plan Employer and One State Plan Employer .......................................... 17
Maximum Duration of Benefits ............................................................................ 18
Money From Another Source Is Not Part of 26 Week Maximum .......................... 18
Waiting Week ...................................................................................................... 18
CHAPTER 5 - BENEFIT CHECKS AND WITHHOLDINGS FROM BENEFITS
Checks Must Be Payable to the Claimant ........................................................... 20
Tax and Other Withholdings from Benefits .......................................................... 20
CHAPTER 6 - DENIALS AND OVERPAYMENTS
Reasons for Denial ............................................................................................. 22
Termination from Job .......................................................................................... 22
Denial Procedure ................................................................................................ 22
Appeals ............................................................................................................... 23
Overpayments..................................................................................................... 23
CHAPTER 7 - WORK-RELATED DISABILITIES
Contested Workers' Compensation Claims ......................................................... 24
Occurrence of Second Disability ......................................................................... 25
Private Plan Liable for Up to 26 Weeks in Addition to Workers’
Compensation Benefits ............................................................................ 25
Claim Not Compensable Under Workers’ Compensation Law ............................. 26
Private Plan Benefits Payable for Work-Related Disability When
Employed by Two Employers ................................................................... 26
Further Information on Workers’ Compensation Program.................................... 27
CHAPTER 8 - REDUCTION OF BENEFITS
Sick Pay or Regular Weekly Wage From the Employer ....................................... 28
Vacation Pay ....................................................................................................... 28
Limitation (h) ....................................................................................................... 28
Calculating the Reduction of Benefits Due to Sick Pay and Vacation Pay ............ 29
Other Types of Monies Received (in alphabetical order):
Federal Disability Benefits ................................................................................... 31
Maintenance and Cure Benefits .......................................................................... 31
Military Veteran’s Pension ................................................................................... 31
New Jersey State, County or Municipality Sick Leave ......................................... 31
No-Fault Auto Insurance Benefits ....................................................................... 32
Payment in Lieu of Notice ................................................................................... 32
Pensions ............................................................................................................. 32
Severance Pay .................................................................................................... 33
Social Security Disability Benefits ....................................................................... 33
Social Security Retirement Benefits .................................................................... 33
Supplemental Benefits, or Gifts........................................................................... 33
Temporary Disability Benefits from Another State ............................................... 34
Unemployment Benefits ...................................................................................... 34
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CHAPTER 9 - SEMI-ANNUAL AND ANNUAL REPORTS ............................................ 35
CHAPTER 10 – FAMILY LEAVE INSURANCE PROGRAM ......................................... 36
APPENDIX .................................................................................................................... 38
REVIEW OF SIGNATURE REQUIREMENT FOR PROCESSING CLAIMS .................................. 39
SEVERENCE PAY VS. PAYMENT IN LIUE OF NOTICE .............................................................. 40
MEDICAL PRACTITIONERS ......................................................................................................... 41
A QUICK GUIDE TO DEALING WITH LLC’S ................................................................................ 42
A QUICK GUIDE FOR PAYMENT OF PREGNANCY CLAIMS ..................................................... 43
CHANGES TO CALCULATING BENEFITS ................................................................................... 45
CONTINUED PAY AND OTHER BENEFITS IMPACT LIST ........................................................... 46
“SAMPLE” NOTICE OF TEMPORARY DISABILITY CLAIM DECISION ........................................ 47
CONCLUSION .............................................................................................................. 48
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https://myleavebenefits.nj.gov
INTRODUCTION
This manual has been prepared by the New Jersey Department of Labor and Workforce
Development, Private Plan Compliance Section, as a guide to the processing of New
Jersey short-term non-work-related temporary disability claims. It is intended for use by
insurance companies, employers, union welfare funds, and claims consultants who
process and pay New Jersey temporary disability claims under approved Private Plans.
This manual describes the benefits and eligibility conditions for approved Private
Plans that are equal to the State Plan in every way. If a Private Plan is more liberal
than the State Plan, the more liberal provisions in the Private Plan must be used to
process actual claims. The material in the manual is based on the New Jersey
Temporary Disability Benefits Law (N.J.S.A. 43:21-25 through 43:21-56), the New Jersey
Administrative Code (N.J.A.C. 12:18-1.1 through 12:18-3.9 and 1:12A-1.1 through 1:12A-
15.2), and portions of the New Jersey Unemployment Compensation Law, Workers'
Compensation Law, State Income Tax Law, and No-Fault Automobile Insurance Law.
Decisions issued by the New Jersey Supreme Court and Superior Court, policies
established by this Department, and our own experience in the area of short-term disability
claims processing also served as a basis for this material.
This manual is published for informational purposes only, and does not have the effect of
law, regulation or ruling.
For more information on the material in the manual, or for additional copies, please
contact:
New Jersey Department of Labor and Workforce Development
Division of Temporary Disability and Family Leave Insurance
Private Plan Operations
PO Box 957
Trenton, NJ 08625-0957
Phone: (609) 292-2720
Fax: (609) 292-2537
E-mail: ppmclaim@dol.nj.gov
To view this manual online or for additional information about Temporary Disability and
Family Leave Insurance, visit the Division’s website at:
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The following Department of Labor and Workforce Development publications may be
viewed online:
New Jersey Temporary Disability Benefits Law –
https://myleavebenefits.nj.gov/labor/myleavebenefits/about/laws
New Jersey Administrative Code - Temporary Disability Benefits –
https://myleavebenefits.nj.gov/labor/myleavebenefits/about/laws
Employer Handbook – New Jersey’s Unemployment and Disability Insurance
Programs –
https://www.nj.gov/labor/handbook/content/contents.html
Current Minimum Gross Earnings Requirement –
https://nj.gov/labor/myleavebenefits/employer/
Current Weekly Benefit Rate and Contribution Rate –
https://www.nj.gov/labor/ea/employer-services/rate-info/
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CHAPTER 1 - NEW JERSEY TEMPORARY DISABILITY PROGRAM
In New Jersey, benefits are provided under the New Jersey Temporary Disability Benefits
Law. The purpose of the program is to provide some protection against wage loss caused
by short-term non-work-related disabilities. Coverage is provided under either the State
Plan, or an approved Private Plan, or under Disability During Unemployment. A claimant
must work within the State of New Jersey, or determined to be a New Jersey employee, to
be covered by one of the above programs, since the coverage available to an individual
claimant is determined by where the claimant works not by where the claimant resides
and not by the location of the employer’s corporate headquarters.
Although State Plan disability coverage is provided automatically to all covered employers,
the employer may, as an option, establish an approved Private Plan to replace the State
Plan. The Plan may be insured by the employer, by an insurance company, or by a union
welfare fund. It must be at least as liberal in benefit amounts, eligibility requirements, and
duration of payments as the State Plan. Employers wishing to apply for an approved
Private Plan may contact the Division of Temporary Disability Insurance, Plan Approval
Unit, PO Box 957, Trenton, NJ 08625-0957, or email: ppclaim@dol.nj.gov.
A third temporary disability program, Disability During Unemployment, is administered by
the State of New Jersey under the provisions of the Unemployment Compensation Law as
well as the Temporary Disability Benefits Law. This program covers claimants whose
disabilities begin more than 14 calendar days after the last day in covered employment.
Individuals who claim benefits under this program must meet all the eligibility requirements
of the Unemployment Compensation Law, except for their ability to work.
Additional information on these temporary disability programs may be found on the New
Jersey Division of Temporary Disability Insurance website, located at:
https://myleavebenefits.nj.gov
Please remember that under the Law, your Private Plan has been approved to replace the
New Jersey State Plan. Therefore, to ensure that the employees you cover receive proper
benefits, your interpretation of the Law and your claims procedures should be no more
restrictive than those of the State Plan.
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CHAPTER 2 - COVERAGE AND LIABILITY
Private Plan Coverage May Vary
When processing a temporary disability benefits claim, a Private Plan insurer, employer or
welfare fund must be aware of the employees covered by the Private Plan, since coverage
may vary from employee to employee. If the claimant is in the group covered by the Private
Plan, the Private Plan insurer, employer, or union welfare fund is responsible for handling
the claim instead of the State Plan.
The files of the Private Plan Compliance Section show the exact coverage for each
approved Private Plan. For example, a Private Plan that covers “all employees” means all
employees working in New Jersey for that employer are covered by that Private Plan
whether they are full-time, part-time, temporary, salaried, hourly, at various locations, etc.
A Private Plan that only covers a certain group, such as “all salaried employees”, means
that only New Jersey salaried employees are covered by that Private Plan and all other
employees are covered under either the State Plan or under another approved Private
Plan.
Last Employer Is Liable
Under Section 12:18-3.1(h) of the New Jersey Administrative Code, the last New Jersey
covered employer for whom the claimant worked, in terms of calendar dates, is liable for
the claim for temporary disability benefits. Therefore, the last employer for whom the
claimant worked prior to the disability must always be determined when processing a
temporary disability claim. The liable employer may be either a full-time or part-time
employer, since liability is not based on the claimant's work schedules.
Concurrent Employment
The last employer is responsible for the payment of temporary disability benefits, as
explained in the preceding paragraph. However additional provisions of the New Jersey
Administrative Code are applied when the claimant is in concurrent employment. The
claimant is determined to be in concurrent employment when:
• The claimant worked for two employers on the same last calendar day (the time of
day the claimant worked with each employer makes no difference),
OR
• One of the employers has paid continued pay to the claimant prior to the start of the
disability, up to and including the same last day worked at the other employer.
The following provisions, based on the New Jersey Administrative Code, are used to
determine the employer who will be liable for the claim when the claimant is in concurrent
employment:
One Private Plan Employer and One State Plan Employer - When the claimant was in
concurrent employment with one approved Private Plan employer and one State Plan
employer on the same last calendar day, the claim is the sole responsibility of the carrier
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for the Private Plan employer. Nothing can be paid by the State Plan.
Two Private Plan Employers - When the claimant was in concurrent employment with two
approved Private Plan employers on the same last calendar day, each Private Plan carrier
is responsible for paying a portion of the claimant’s weekly benefit rate (see “Calculating
Benefits When Claimant is in Concurrent Employment with Two Private Plan Employers”,
page 16).
Fourteen Days of Extended Coverage
The New Jersey Temporary Disability Benefits Law provides an extension of coverage
following cessation of employment. Individuals in covered employment (employment
subject to the New Jersey Temporary Disability Benefits Law) who stop work and
subsequently become disabled within 14 calendar days of the last day of work OR last day
in paid covered employment are covered under the Private Plan (or State Plan) of their last
employer. The Private Plan carrier (or the State Plan) is liable for the claim, as long as the
claimant has not begun work with another employer.
A claim for a disability that begins more than 14 calendar days after the last day in covered
employment may be denied by the Private Plan carrier. Upon receipt of the copies of the
denial and claim from the carrier, the Private Plan Compliance Section, Claims Review
Unit, will refer the claim to the Disability During Unemployment Section, who will determine
if the claim is payable by the State of New Jersey under the Unemployment Compensation
Law and the Temporary Disability Benefits Law.
Liability Determined by Date the Disability Began
The Superior Court of New Jersey, Appellate Division, ruled in the 1977 precedent decision
of Metropolitan Life Insurance Company vs. Early Montgomery, A-1791-74, that liability for
a claim is based on when the disability commenced, not on when the claimant was first
treated by a physician. Therefore, when the disability commenced within 14 days of the
claimant’s last day in employment, but the claimant did not see a physician until more than
14 days after the last day in employment, the Private Plan insurer (or the State Plan) is
responsible for the claim.
Vacation Pay Extends Employment
An employee who is not disabled and is on a paid vacation is in employment. That
individual’s employment is extended throughout the paid vacation. Therefore, a disability
that occurs during a paid vacation, or within 14 calendar days of the end of a paid vacation,
is the responsibility of the last employer. Please note that an unpaid vacation or other type
of unpaid absence does not extend an individual’s employment.
Governmental Employers
Under the New Jersey Temporary Disability Benefits Law, employment with governmental
employers is treated in various ways. The term “New Jersey covered employment”
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mentioned below means employment located in New Jersey with an employer who is
subject to the New Jersey Temporary Disability Benefits Law.
United States Government - Employment with the United States government is not New
Jersey covered employment. As a result, a claimant whose only employer in the base year
was the United States government is not eligible for temporary disability benefits under the
New Jersey State Plan nor under a Private Plan.
If a claimant has filed a temporary disability claim based on employment with both a
covered New Jersey employer and with the United States government, any wages earned
because of the employment with the United States government cannot be used for
determining the claimant’s eligibility for New Jersey temporary disability benefits.
New Jersey State Government - Employment with the State of New Jersey is covered
employment, and wages earned in that employment must be used for determining a
claimant’s eligibility. Employees of the State of New Jersey are covered by the New Jersey
State Plan for temporary disability benefits (not a Private Plan).
New Jersey County and Municipal Government - Counties and municipalities are exempt
from participating in the New Jersey Temporary Disability Benefits Law unless they
voluntarily choose to participate. If the county or municipality has voluntarily chosen to
participate under the Law, employment with them is New Jersey covered employment, and
wages earned with them must be used for determining a claimant’s eligibility. A county or
municipality may cover their employees under either the State Plan or an approved Private
Plan.
If the county or municipality has not chosen to participate under the Law, employment with
them is not New Jersey covered employment, and wages earned with that county or
municipality cannot be used for determining a claimant’s eligibility for temporary disability
benefits. Their employees are not covered under the State Plan nor under an approved
Private Plan.
Determining Liability for Relapses
The New Jersey Temporary Disability Benefits Law defines a relapse as “two periods of
disability due to the same or related cause or condition and separated by a period of not
more than 14 days shall be considered as one continuous period of disability; provided the
individual has earned wages during such 14-day period with the employer who was
his(/her) last employer immediately preceding the first period of disability.”
Based on the above definition, claims for individuals who suffer a second period of
disability, after recovering or returning to work from a prior disability, should be handled as
follows. (Please note: For purposes of clarity, the following examples express maximum
benefits only as “26 weeks”. The actual maximum duration of benefits is 26 weeks or an
amount equal to 1/3 the claimant’s base year wages, whichever is less. See page 17,
“Maximum Duration of Benefits”.)
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(1)
Relapse within 14 days or less - When a claimant who has been disabled recovers or
returns to work with the same employer, and again becomes disabled with the same
medical condition (suffers a medical relapse) within 14 days of their recovery or return to
work, the relapse must be treated as the same period of disability. Benefits resume as of
the first day of the relapse. Benefits paid both before and after the start of the relapse are
counted when calculating the 26-week maximum.
(2)
Relapse on 15
th
day or later - If the individual recovers or returns to work and
becomes disabled again on the 15
th
calendar day or later after the recovery or return to
work, a new period of disability is established. Whether or not the medical condition was
the same does not matter. Benefits begin anew, with a potential of another 26-week
maximum beginning at the start of the second disability.
(3)
New medical condition - When a claimant recovers or returns to work for any part of
at least one day and then becomes disabled again from a new medical condition (not a
relapse of the prior medical condition), a new period of disability is established. Benefits
begin anew, with a potential of another 26-week maximum beginning at the start of the
second disability.
(4)
New employer - A new period of disability is established when a claimant who has
been disabled returns to work for a new employer and becomes disabled again at any time
after the return to work with that employer. Benefits begin anew, with a potential of another
26-week maximum. Benefits must be paid by the new employer's temporary disability
carrier. The carrier for the old employer has no further liability.
(5)
Did not return to work - When a claimant who has been disabled for more than 14
calendar days subsequently recovers but does not return to work anywhere, and then
becomes disabled again due to any illness or condition, a new claim for Disability During
Unemployment is created. This is so because the new disability began beyond the 14-day
extended coverage period following the claimant's last day in employment with their last
employer, and they have not returned to work. The insurer who was responsible for the
first period of disability has no further liability and may deny the claim. Upon receipt of the
denial, the Claims Review Unit will forward the claim to the Disability During Unemployment
Section for processing.
Overlapping Disabilities
Claims from individuals who have not returned to work or recovered from a non-work-
related disability and then suffer a second non-work-related illness or injury that overlaps
the first, must be handled as one period of disability. The insurer must continue payments.
Total liability is 26 weeks beginning at the start of the first disability.
Late Filing of a Claim
A claim must be filed, or notice given to the employer or to the State Plan within 30 days of
the beginning of the disability. Unless the claimant has a good reason for filing the claim
late, the claimant may be penalized.
The penalty for late filing consists of starting benefit payments 30 calendar days prior to the
date of receipt of the claim or notice. Please note that this is a penalty, not an outright
denial of the entire claim, except when the claimant has recovered from the disability more
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than 30 days prior to the receipt of the claim.
Return to Work on Part-Time Basis
Occasionally a disabled claimant may return to work or continue to work on a part-time
basis after a disability. Under Section 12:18-3.11 of the New Jersey Administrative
Code, the only situation where the claimant may continue collecting temporary disability
benefits when returning or continuing to work part-time is where the claimant had both a
full-time and a part-time employer prior to the disability, is unable to perform the duties
of their regular full-time employment but is able to perform totally different duties with
their part-time employer.
Changing any element of the above situation (one employer prior to the disability, two part-
time employers, returning to the full-time employer, etc.) results in a termination of
temporary disability benefits when the claimant returns to work.
When benefits are payable in this situation, they are calculated in the following manner:
• If the claimant returns or continues to work at the part-time employer only, one-
seventh of the weekly benefit rate must be subtracted from the claimant’s benefits
for each day worked, and the remainder paid to the claimant.
• If the claimant returns to work at the full-time employer at any time, benefits are
terminated upon that return to work.
• For days during the disability where the claimant has not worked at either the part-
time or the full-time employer, the full amount of temporary disability benefits must
be paid.
Partial Return to Work
Section 43:21-40(d) of the New Jersey Temporary Disability Benefits Law provides that for
any week beginning on or after June 17, 2020 with respect to a period of disability of an
individual who is otherwise eligible for benefits but only able to return to work on a reduced
basis while recovering from the disability, the individual, if permitted by the employer to
return to work on the reduced basis, shall be paid an amount of benefits with respect to
that week such that the sum of the wages and those benefits paid to the individual,
rounded to the next lower multiple of $1.00, will equal the weekly benefit amount the
individual would have been paid if totally unable to perform the duties of employment due
to disability provided that:
1)
The individual must have been totally unable to perform the duties of employment
due to the disability and receiving full benefits for at least seven consecutive days prior to
claiming partial benefits under this subsection;
2)
The maximum duration of partial benefits paid pursuant to this subsection is eight
weeks, unless the division, after review of medical documentation from a qualified
healthcare provider, approves in writing an extension beyond eight weeks, but in no case
shall the duration be extended to more than 12 weeks;
3)
And if the individual is able to return to work on a reduced basis, but the employer
is unable or otherwise chooses not to permit the individual to do so, the individual will
continue to be eligible for benefits until the individual is fully recovered from the disability
and able to perform the duties of employment, but nothing in this subsection shall be
construed as increasing the total number of weeks of disability benefits for which the
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individual is eligible.
Labor Disputes
Disability Beginning Before a Labor Dispute - If a claimant’s disability begins before the
start of a labor dispute, temporary disability benefits must continue to be paid to the
claimant throughout the labor dispute. There is no reduction or cessation of temporary
disability benefits.
Disability Beginning During a Labor Dispute - If a claimant’s disability begins during a labor
dispute, and the claimant is in the affected group, no temporary disability benefits are
payable for the duration of the labor dispute. If the labor dispute ends and the claimant is
still disabled, temporary disability benefits are payable from the end of the labor dispute
forward. There is no retroactive payment to that claimant for the period that they were
involved in the dispute.
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CHAPTER 3 - MEDICAL ISSUES
Disability Date
The disability date (the date the disability started) is the first full calendar day of disability
after the last date of work. The disability date should be verified by the claimant's
physician. The disability date may be any day of the week including Saturday and Sunday.
It does not have to be a day the claimant was scheduled to work. Also, the disability date
is not movable as a result of vacation pay, sick pay, etc.
First Date of Treatment
It is sometimes difficult for a claimant to obtain an immediate appointment with a physician.
Therefore, under the New Jersey Administrative Code, if the claimant is first treated within
ten days of the beginning of the disability and if the claimant has been disabled for 22
calendar days or more, benefits are paid from the date the disability started.
If the first treatment occurred more than ten days after the start of the disability, benefits
begin as of the date of that first treatment.
Licensed Medical Practitioners
For temporary disability benefits to be paid, a claimant must be under the continuous care
of a licensed physician, dentist, optometrist, podiatrist, practicing psychologist, advanced
practice nurse, chiropractor, or certified nurse midwife. Other types of specialties, nurses,
and midwives, may not certify disabilities unless they are under the supervision of a
licensed physician. Physical therapists and social workers may not certify a disability.
Under the New Jersey Administrative Code, a licensed medical practitioner may not charge
a fee for completing medical forms required by the Division of Temporary Disability
Insurance or by a Private Plan insurer.
Independent Medical Examinations
When the claims processor feels that a physician's prognosis date is too long in relation to
the nature of the disability or the disability becomes medically questionable for some other
reason, the insurer may exercise the option under the Law of scheduling an independent
medical examination of the claimant by a licensed physician. In accordance with the Law,
an independent exam can be scheduled no more frequently than once per week. The cost
of the independent medical exam is the responsibility of the insurer.
If the claimant is found able to work by the independent physician, benefits must be
authorized up to the date of the exam, and may then be terminated. When the claimant
fails to appear for an exam, all further benefits may be denied, except for benefits already
paid.
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Pregnancy Claims
In accordance with the New Jersey Attorney General's Opinion No. 2-1979, pregnancy
disability claims must be processed in accordance with the treating physician’s certification,
as in all other disability claims. Normal pregnancy is considered a disability when the
treating physician certifies that the claimant is unable to work. The claimant does not need
to have complications of pregnancy for the claim to be payable.
When certified by the claimant’s treating physician, a normal pregnancy may be disabling
and therefore payable up to four to six weeks before the expected date of birth, and up to
six to eight weeks after the date of birth. This is the usual disability period for a normal
pregnancy, as shown by treating physicians on claims submitted to the New Jersey State
Plan.
Various complications can result in longer periods of disability. A Caesarean section may
extend the period of disability after the date of birth to a period of 8 to 10 weeks. Length of
payment also could depend, like other disabilities, on the individual's occupation and age.
As in other disabilities, a claimant must be unable to perform the duties of her regular job.
The physical factors involved with a pregnancy sometimes prevent a woman from doing a
job which entails heavy lifting. This type of disability is compensable if a claimant exhibits
symptoms preventing her from working. However, it is not compensable if the claimant
stops work for precautionary reasons only.
Some women are exposed during pregnancy to toxic chemicals, radiation, or other
environmental risks on the job. This type of claim is not payable when the claimant stops
work due to a possible risk of chemical or X-ray exposure to the fetus, because the
claimant herself is not disabled. Her absence is precautionary, and therefore not due to a
medically disabling condition.
In the above situations where the claimant has stopped work due to precautionary reasons
and the temporary disability claim is not yet compensable, the claimant should be advised
to apply for unemployment benefits.
Acceptable Medical Basis for Denial
As part of the claim process, a claimant is required to submit medical documentation to the
insurer from their treating licensed physician certifying that the claimant is disabled, giving
the diagnosis, and giving the beginning and ending dates of the claimant’s disability. Under
Section 12:18-2.4(b) of the New Jersey Administrative Code (quoted below), if the
above medical certification is submitted, the claimant may only be denied
temporary disability benefits on a medical basis when one or more of the following
four factors are present:
“1. The employer, insurer or organization paying benefits has contacted the covered
employee’s personal licensed medical practitioner and has reached a mutual agreement
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therewith as to a change in the period of the covered employee’s disability;
“2. A licensed medical practitioner designated by the employer, insurer or organization
paying benefits has examined the covered employee and has determined that the covered
employee is no longer disabled. Where such a determination has been made, benefits
shall not be paid beyond the date of the examination;
“3. A covered employee refuses to submit to or fails to attend an examination conducted
by a licensed medical practitioner designated by the employer, insurer or organization
paying benefits, in which case the covered employee shall be disqualified from receiving all
benefits for the period of disability in question, except as to benefits already paid; or
“4. The employer, insurer or organization paying benefits has obtained credible factual
evidence showing that the covered employee is performing activities that demonstrate that
he or she is able to perform the duties of his or her regular employment. In such instances,
benefits shall not be paid beyond the date that such factual evidence is obtained.”
Please note that the above Administrative Code does not provide for the denial of
benefits on the basis of other medical factors. Factors which may not be used as a
medical basis for denial include, but are not limited to, the following:
• The insurer’s opinion that the medical documentation in the file does not support the
claimant’s disability;
• A review of the medical documentation in the claim file by the insurer’s staff
physician, nurse, or claims processor;
• A review of the claimant’s job description;
• The lack of a list of job restrictions or limitations;
• The insurer’s disagreement with the course of treatment;
• The content or lack of the treating physician’s office notes;
• The results of laboratory tests;
• Information in references such as maternity guidelines, morbidity tables, etc.
Therefore, if valid medical certification has been submitted from the treating physician, and
none of the above four conditions listed in the New Jersey Administrative Code are
present, and the claimant is eligible in every other way, then the claimant has satisfied the
requirements of the New Jersey Temporary Disability Benefits Law. When the
requirements of the Law have been satisfied, the claimant must be paid temporary
disability benefits covering the dates stated by the treating physician.
Morbidity Table
A morbidity table showing the estimated lengths of disabilities may be helpful when
authorizing initial benefits on a claim. It may also be used to establish a date on which to
request additional medical information from the claimant. However please note that
benefits cannot be denied based solely on the contents of a morbidity table. For a copy of
the table used by the New Jersey State Plan, contact the Claims Review Unit.
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Requesting Updated Medical Information
Medical information can be requested as frequently as weekly, but no more often, in
accordance with the Law. This information should be requested from the claimant or their
physician. Please note that under the Law, there is no time limit within which a claimant
must submit an updated medical certification for continued benefits.
Light Duty
The definition of a period of disability, found in Section 43:21-27(g) of the New Jersey
Temporary Disability Benefits Law, is the entire time during which the claimant is unable to
perform the duties of his or her employment as it existed prior to the start of the disability.
Thus, the claimant who is unable to do his or her regular job is considered disabled. It
should be noted that benefits cannot be denied based on the claimant's refusal to accept
light duty work, since the claimant cannot perform the duties of their regular job (light duty
work is not the claimant’s regular job).
Illegal Drugs and Alcohol
A disability due to the use of illegal drugs is not payable if the use of the drugs constitutes
a crime of the first, second or third degree. However, as a result of the "Americans with
Disabilities Act," individuals whose disabilities are caused by illegal substance abuse may
be eligible for temporary disability benefits if they are no longer using illegal drugs, and if
they are being treated for their disability. They must also meet all other requirements of the
Law to be eligible.
Alcoholism is a compensable disability provided the individual is under medical care, since
it is a disease. It is not considered to be a willfully and intentionally self-inflicted injury.
Self-Inflicted Injury
Although the New Jersey Temporary Disability Benefits Law prohibits payment to a
claimant for any period of disability due to willfully and intentionally self-inflicted injury, a
decision of the New Jersey Superior Court established a precedent for the handling of
disabilities such as attempted suicide. The Court ruled that benefits must be paid if an
attempted suicide was not willful nor intentional, based on the claimant’s incapacity to
govern his conduct in accordance with reason.
Therefore, claims for self-inflicted injury should be handled as follows:
• If the treating physician indicates an underlying medical cause for the claimant’s
actions, benefits should be paid.
• If the treating physician initially does not indicate an underlying medical cause, the
treating physician should be contacted to obtain information on whether there was
an underlying cause.
• If contact with the treating physician does not reveal any underlying medical cause,
the claim may be denied on the basis that the disability is the result of a self-inflicted
injury.
14
Cosmetic Surgery
If surgery was performed for cosmetic reasons only, rather than as a remedy of a sickness
or injury, temporary disability benefits may be denied. However temporary disability
benefits are payable if cosmetic surgery is reconstructive in nature or necessary to correct
a disabling condition.
Elective Surgery
There is no exclusion in the New Jersey Temporary Disability Benefits Law for elective
surgery. Therefore, temporary disability benefits must be paid in these cases if the
claimant’s physician certifies to the claimant’s disability. Disabilities due to organ and bone
marrow donations are payable to both donors and recipients.
Deceased Claimants
The policy of the New Jersey Division of Temporary Disability Insurance is to pay
temporary disability benefits up to and including the date of death. Since an approved
Private Plan cannot be more restrictive than the State Plan, Private Plan insurers and
employers must handle these benefits in the same manner.
15
CHAPTER 4 - HOW TO CALCULATE STATUTORY BENEFITS
Current Rates and Earnings Requirements can be found here:
https://www.nj.gov/labor/ea/employer-services/rate-info/
Base Week
A base week is one of the earnings factors used to determine a claimant’s eligibility and to
calculate a claimant’s benefits. A base week is defined as earnings in a calendar week of
not less than 20 times the State minimum wage in effect on October 1 of the previous
calendar year, raised to the next higher multiple of a dollar if not already a multiple thereof
OR any week (up to 13 weeks) in which the claimant is separated from employment due to
a declared state of emergency during the base year.
Base Year
The base year is the period within which the required wages must be earned by the claimant
to establish a valid claim. The base year, with respect to the benefit year, is the period
consisting of the first four completed quarters of the last five completed quarters of the
calendar year preceding the period of disability.
EXAMPLE: A disability began Wednesday, January 25, 2023. The base year is
October 1, 2021 through September 30, 2022
Earnings Requirements
A claimant may satisfy the earnings requirements in one of two ways. Only one of the
following earnings tests need to be met to establish a valid claim. The earnings do not need
to be entirely with the last employer but may be with all New Jersey covered employers
in the base year.
The claimant must have earned:
EITHER ....... 20 base weeks of earnings in the base year (they do not have to be
consecutive weeks) OR being a week (up to 13 weeks) in which the claimant is
separated from employment due to a declared state of emergency during the base
year.
OR .............. in the alternative, earnings in the base year of at least 1,000 times the
State minimum wage in effect on October 1 of the previous calendar year, raised to the
next higher multiple of $100.00 if not already a multiple thereof.
16
Wage Information from Prior Employers
Wages from all New Jersey covered employers in the base year must be used to calculate
eligibility for temporary disability benefits. Wage information should be obtained by the
insurer directly from prior employers. If necessary, the Claims Review Unit may obtain
prior wage information from the State's Wage Record computer system, and mail or fax a
print-out of the wages to the insurer. Please contact the Claims Review Unit if such wage
information is needed to process a claim.
Calculating the Weekly Benefit Rate
The formula for the New Jersey statutory temporary disability weekly benefit rate is 85% of
the claimant’s average weekly wage, to a maximum of 70% of the statewide average
weekly remuneration paid to workers two years prior to the current year. Thus, the
maximum weekly benefit rate changes on January 1 of each year.
THE WEEKLY BENEFIT RATE IS CALCULATED AS FOLLOWS:
• Calculate the claimant's average weekly wage by dividing the total base year
earnings (in dollars) by the actual number of base weeks in the base year. Then
multiply the result by 85% to obtain the weekly benefit rate to be paid to the
claimant.
• If the claimant has enough gross wages to qualify for a claim, but there are no base
weeks in the entire base year, the claim is invalid. The claimant must have at least
one base week in the base year to be monetarily eligible.
Alternative Base Year I
If the individual does not have sufficient base weeks or base wages in the base year to
qualify for benefits, the examiner will use Alternative Base Year I. Alternative Base Year I,
with respect to the Benefit Year, means the last four completed quarters of the calendar
year immediately preceding the period of disability.
17
Alternative Base Year II
If the individual does not have sufficient base weeks or base wages in the alternative base
year I, the examiner will use Alternative Base Year II. Alternative Base Year II, with respect
to the Benefit Year, means the three most recent completed quarters of the calendar year
plus the balance of the unfinished quarter immediately preceding the period of disability.
Calculating Benefits When Claimant is in Concurrent Employment with Two Private
Plan Employers
Under the New Jersey Administrative Code, when the claimant is in concurrent
employment with two Private Plan employers (see “Concurrent Employment”, page 4) the
two Private Plan carriers must share the payment of the weekly temporary disability benefit.
(see Worksheet 1 provided in the Appendix)
First, the claimant’s average weekly wage and weekly benefit amount are calculated using
wages from all employers in the base year (see “Calculating the Weekly Benefit Rate,”
page 15).
Then, the portion of the weekly benefit to be paid by each Private Plan carrier is calculated
as follows:
Step One: The claimant's income from each Private Plan employer in the base year prior
to the disability is added together to obtain the total income for that period.
Step Two: The percentage of income earned with each Private Plan employer in the base
year is calculated.
Step Three: Each carrier then pays their percentage of the weekly benefit rate. The total
weekly benefit cannot be less than that provided by the most favorable Private Plan.
Calculating Benefits When Claimant in Concurrent Employment with One Private
Plan Employer and One State Plan Employer
Under the New Jersey Administrative Code, when the claimant was in concurrent
employment with one approved Private Plan employer and one State Plan employer on the
same last calendar day (see “Concurrent Employment”, page 4), the claim is the sole
responsibility of the carrier for the Private Plan employer. Nothing can be paid by the State
Plan. (see Worksheet 2 provided in the Appendix)
The weekly benefit to be paid by the Private Plan carrier is calculated as follows:
Step One: The claimant's income from the Private Plan employer in the base year prior to
the disability is added together with the claimant's income from the State Plan employer in
the base year to obtain the total income for that period.
Step Two: Divide the total earnings in the base year by the number of base weeks (based
on the total earnings for each week). This yields the average weekly wage.
Step Three: Multiply the average weekly wage by 85% and round it down to the next lower
dollar. This yields the weekly benefit rate payable by the Private Plan carrier.
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Maximum Duration of Benefits
The maximum duration of benefits that must be paid by the Private Plan insurer for each
period of disability is either 26 times the weekly benefit rate or an amount equal to one-third
the claimant's total base year earnings, whichever is the lesser, unless the approved
Private Plan provides for a longer duration.
EXAMPLE A: A claimant is receiving benefits of $450 per week and had total base
year earnings of $45,000.
26 weeks x $450 per week = $11,700
OR
1/3 x $45,000 base year earnings = $15,000
In the above example, the claimant's benefits are exhausted after they have
received $11,700 (26 weeks), the lesser of the above two-dollar amounts.
EXAMPLE B: A claimant is receiving benefits of $450 per week, and had total base
year earnings of $21,000:
26 weeks x $450 per week = $11,700
OR
1/3 x $21,000 base year earnings = $7,000
In the above example, the claimant's benefits are exhausted after they have
received $7,000 (approximately 15 weeks), the lesser of the above two-dollar
amounts.
Some Private Plans are more liberal than the State Plan in that they provide a maximum of
26 weeks for all claims. Therefore, the one-third provision cannot be used under those
plans.
Money from Another Source Is Not Part of 26 Week Maximum
Please note that neither the New Jersey Temporary Disability Benefits Law nor any
approved Private Plan provides for 26 weeks of Private Plan benefits from all sources. The
only source of approved Private Plan benefits is the Private Plan carrier. Money from other
sources such as employer sick pay, workers’ compensation, etc. is not part of the 26
weeks of Private Plan benefits. Therefore, the 26 weeks of benefits under an approved
Private Plan begin only when the insurer begins making their Private Plan payments.
Waiting Week
The waiting period for a claim (the waiting week) is the first seven calendar days of a
disability, beginning with the date the disability began, unless the Private Plan provides for
a shorter waiting period. To serve a waiting week, the claimant must be disabled for seven
consecutive calendar days. Periods of disability of six calendar days or less do not satisfy
the waiting week requirement unless the Private Plan provides for a shorter waiting week.
19
Retroactive payment of the waiting week must be made when the claimant has been
disabled for 22 calendar days or more, as defined in the 1976 New Jersey Superior Court
decision of Continental Casualty Company vs. Samuel Knuckles, and the claimant is
otherwise eligible. This decision stated that benefits for the waiting week cannot be paid
unless benefits are payable for any part of each of the three weeks after the waiting week.
Thus, the point at which the waiting week must be paid occurs three weeks and one day
(22 calendar days) after the start of a disability. A claimant does not need to be disabled
for 28 days to be paid for the waiting week.
Also, the waiting week is not movable. The dates of the waiting week cannot be changed
due to sick pay, vacation pay, workers' compensation benefits, etc.
20
CHAPTER 5 - BENEFIT CHECKS AND WITHHOLDINGS FROM BENEFITS
Checks Must Be Payable to the Claimant
Under the Law temporary disability checks must be made payable to the claimant. They
cannot be made payable to the employer.
Some employers wish to advance monies to the claimant in an amount that either equals
or exceeds the benefit amount payable under the Private Plan. In this arrangement, if the
Private Plan contains Limitation (h) (see “Limitation (h)”, page 27), the employer may
arrange to advance such monies to the claimant and have the claimant sign the temporary
disability check over to the employer when the check is issued by the Private Plan carrier.
The Private Plan carrier may only mail the benefit check to the employer provided that the
claimant has knowingly and voluntarily signed a written agreement authorizing the delivery
of his or her temporary disability benefit check to the employer.
Please note that the above procedure cannot be used (a) when the claimant is receiving
less than the amount he or she is entitled to under the Private Plan, since the claimant is
entitled to keep some or all of the Private Plan benefits, and (b) when the Private Plan
does not contain Limitation (h) since the claimant is entitled to keep all temporary disability
benefits issued by the Private Plan carrier regardless of the amount of money paid by the
employer.
Tax and Other Withholdings from Benefits
Federal Income Tax (Allowable) - Temporary disability insurance benefits are considered to
be "third party sick pay" and as such, are subject to Federal Income Tax. If a claimant
wishes to have Federal Income Tax withheld from the gross benefit amount at the time the
benefit is paid, they may authorize the insurer to do so. Otherwise, the claimant pays
Federal Income Tax on the benefits when filing their Federal Income Tax return at the
end of the year. For more information, contact the Internal Revenue Service’s recorded
information at (800) 829-4477, or a representative at (800) 829-1040. See also the Internal
Revenue Service website at www.irs.ustreas.gov.
Social Security and Medicare Tax (FICA) (Mandatory) - Benefits under the New Jersey
Temporary Disability Benefits Law are, by Federal Law, subject to Social Security and
Medicare taxes (FICA). This mandatory withholding is made at the time the check is
issued to the claimant. The employer is also liable for the employer's share of FICA.
Contact the Internal Revenue Service (see above) for further information.
New Jersey State Income Tax (Not Allowable) - Under the New Jersey State Income Tax
Law, Private Plan or State Plan temporary disability benefits received by the claimant are
not taxable. Therefore, New Jersey State Income Tax cannot be withheld from Private
Plan benefits. For further information, call the New Jersey Division of Taxation at (609)
292-6400, or see their website at www.state.nj.us/treasury/taxation.
21
Other Withholdings (Not Allowable) - Except for Federal Income Tax and Social Security
and Medicare Tax (FICA), benefits under the New Jersey Temporary Disability Benefits
Law are not subject to other health, medical, or any other employer withholding.
Garnishments (Mandatory by Court Order Only) - Garnishments, such as those for child
support, are mandatory only when granted by a court order. Otherwise, the New Jersey
Temporary Disability Benefits Law does not allow for the withholding of temporary disability
benefits to satisfy other debts.
22
CHAPTER 6 - DENIALS AND OVERPAYMENTS
Reasons for Denial
The reasons used for denial of a claim are limited to those provided by the New Jersey
Temporary Disability Benefits Law, the New Jersey Administrative Code, and the
employer's approved Private Plan. (For a list of allowed medical reasons for denial, see
“Acceptable Medical Basis for Denial”, page 10). If an employer has chosen to establish a
Private Plan that is more liberal than the State Plan, claims must be processed under the
more liberal provisions. For example, if the Private Plan does not contain the 20 base
week earnings requirement, benefits cannot be denied on the basis of lack of earnings.
Termination from Job
Benefits may not be denied under any Private Plan based on the termination of the
claimant’s job since there is no such disqualification in the Law. This includes but is not
limited to voluntarily quitting the job, being laid off, fired, suspended, etc.
There is only one exception to this. If the claimant was terminated for gross misconduct
and would be disqualified for unemployment compensation benefits under subsection (b) of
R. S. 43:21-5, then disability benefits may be denied if the private plan invokes this
limitation.
Denial Procedure
Whenever Private Plan temporary disability benefits are denied or terminated, a
denial letter or form must be sent to the claimant by the insurer, self-insured
employer, or union welfare fund. The letter or form may be in any format. However, it
must always: (a) advise the claimant of the reason for the denial, and (b) notify the
claimant of their right of appeal to the following address:
New Jersey Department of Labor and Workforce Development
Division of Temporary Disability and Family Leave Insurance
Claims Review Unit
PO Box 957, Trenton, NJ 08625-0957
Email: [email protected]
A copy of the denial letter or form, together with a copy of the disability claim file, must be
sent to the Claims Review Unit at the above address. All reasons for denial should be
listed. Please be sure that the claimant's Social Security number is shown on the
denial letter or form.
The Claims Review Unit reviews all denials to ensure that the decisions have been made in
accordance with the Law, the Code, and the provisions of the approved Private Plan. If
necessary, we will contact the insurer, employer, or union welfare fund, explain the error or
omission, and advise them of the action needed to correct the claim. We also request that
we be advised of the final resolution of the matter.
23
Appeals
The claimant has a right to appeal to the New Jersey Department of Labor and Workforce
Development if they disagree with the decision of a Private Plan insurer, employer or union
welfare fund regarding some aspect of the temporary disability claim. The claimant’s appeal
must be submitted within one year of the date of the beginning of the disability. The appeal
should be sent to the Claims Review Unit at the above address, who will forward it to the
Private Plan Hearing Officer. The Private Plan Hearing Officer will notify all parties of the
date and time of the hearing. Hearings are held by telephone. A party to the hearing may
be represented by an attorney, but it is not required.
Following the hearing, the Private Plan Hearing Officer will issue a written order addressing
the issues heard. This order must be complied with unless one of the parties disagrees
and wishes to appeal the order. Any legally interested party may then file an appeal with
the Superior Court of New Jersey, Appellate Division, PO Box 006, Trenton, New Jersey
08625-0006 or call (609) 292-4822 to obtain the appropriate forms to initiate an appeal.
The appeal to the Appellate Division must be filed within 45 days of the date of mailing of
the Private Plan Hearing Officer’s order.
Overpayments
The New Jersey Temporary Disability Benefits Law provides that a claimant who has been
overpaid temporary disability benefits is liable to repay those benefits regardless of the
reason for the overpayment. The individual is liable to repay the overpaid amount in full, or
have it withheld from future benefits.
However, if the individual received the overpayment because of Division, insurer, employer
or physician error and they did not misrepresent or withhold a material fact to obtain
benefits, the following limits apply: (a) the amount withheld from future benefits cannot be
greater than 50% of the amount of each future check; and (b) repayment may be waived if
the individual is permanently disabled or deceased.
Except in situations involving misrepresentation or the withholding of a material fact, the
Law provides that the individual shall not be liable for repayment unless they are notified
of the overpayment within four years from the time the benefits in question were paid. The
demand for repayment must include an explanation of the provisions of the Law. All
demands for refunds of overpaid benefits may be appealed by the claimant. Appeals
should be directed to the Division of Temporary Disability and Family Leave Insurance,
Claims Review Unit, PO Box 957, Trenton, NJ 08625-0957, phone: (609) 292-2720,
email: ppclaim@dol.nj.gov.
24
CHAPTER 7 - WORK-RELATED DISABILITIES
The New Jersey Temporary Disability Benefits Law provides benefits for non-work-related
disabilities, while accidents or illness caused by the work are covered under the New
Jersey Workers' Compensation Law. Therefore, a Private Plan carrier may deny a claim
when the disability was caused by the claimant’s work except as explained below. A
permanent partial or permanent total work-related disability previously incurred does not
bar the payment of a current Private Plan or State Plan temporary disability claim.
Contested Workers’ Compensation Claims
Situations arise where a claimant becomes disabled at work, applies for workers'
compensation benefits, and is denied. Also, workers' compensation carriers may pay
benefits for a period of time and then stop, for various reasons. In the above situations the
Private Plan carrier must pay temporary disability benefits, but only if the claimant is
contesting(appealing) the denial or stoppage of the workers' compensation claim and has
met all other eligibility requirements. The Private Plan carrier may be reimbursed out of the
workers' compensation award, if the decision is overturned by the court.
Contested Claims Procedure - In order to receive benefits from the Private Plan carrier
when the workers’ compensation claim is contested, the claimant and the carrier must
proceed as follows:
1. The claimant should obtain an attorney to represent them in the Workers'
Compensation Court. If the claimant does not have an attorney, a referral service is
available from each County Bar Association in New Jersey. An attorney is prohibited from
charging a fee for this service until the case has been concluded in court.
2. The claimant's attorney or the claimant must file a Claim Petition with the Division of
Workers' Compensation indicating that workers' compensation benefits are not being paid.
3. The claimant must then complete and sign an agreement to reimburse the Private Plan
carrier. A form for this purpose may be supplied by the Private Plan carrier, or a
Certification of Contested Workers' Compensation Claim (Form DP-221) can be obtained
from the Division of Temporary Disability and Family Leave Insurance, Claims Review
Unit, PO Box 957, Trenton, NJ 08625-0957, (609) 292-2720, email: ppclai[email protected].gov.
4. The completed insurer's form or Form DP-221 should be sent to the Claims Review Unit
who will verify that the case is contested by contacting the workers' compensation carrier
and by consulting the Division of Workers' Compensation computer system.
5. Upon verification, the Claims Review Unit will notify the Private Plan carrier in writing that
the case is contested. They will give the Claim Petition Number to the carrier and will
advise them that Private Plan benefits must now be paid.
6. The Private Plan carrier must then pay benefits to the claimant. The claimant must be
otherwise eligible in every respect under the Temporary Disability Benefits Law as well as
25
under the employer's approved Private Plan.
7. When Private Plan benefits begin, the Private Plan carrier should file a temporary lien
with the Division of Workers' Compensation. A final lien should be filed at the end of the
claim. The insurer may use their own lien form, or they may obtain a form for this purpose
(Form DP-74) from the Claims Review Unit. The completed liens may be sent to the
Claims Review Unit, or directly to the Division of Workers' Compensation for inclusion in
the judge's case file.
8. If workers' compensation benefits are subsequently awarded by the Workers’
Compensation Court, the Private Plan carrier will be reimbursed out of the award, as
specified by the Judge in their Order. Reimbursement to the Private Plan carrier should
also be made in cases where the claimant agrees to a settlement with the workers'
compensation carrier.
Occurrence of Second Disability
A claimant may suffer a second, non-work-related disability while they are receiving
workers' compensation benefits. If the work-related disability ends, but the claimant
continues to be disabled due to the second, non-work-related disability, the claim is
handled as follows.
If the non-work-related disability began more than 14 calendar days after the claimant's last
day in employment (employment means the last day worked prior to the occurrence of the
workers' compensation injury), the claim may be denied by the Private Plan carrier. The
Claims Review Unit will refer this claim to the Disability During Unemployment Section for
consideration.
If the non-work-related disability began within 14 calendar days of the claimant's last day in
employment, the Private Plan carrier is liable for the claim. Private Plan benefits would
begin the day after the workers' compensation benefits ended, and beginning at that point,
may be paid for up to 26 weeks.
Private Plan Liable for Up to 26 Weeks in Addition to Workers’ Compensation
The definition of a "contested" workers' compensation case includes those cases where
the workers' compensation carrier paid some benefits and then stopped. The length of
time paid by the workers’ compensation carrier does not change the maximum duration of
benefits payable by the temporary disability carrier.
Please note that neither the New Jersey Temporary Disability Benefits Law nor any
approved Private Plan provides for 26 weeks of Private Plan benefits from all sources. The
only source of approved Private Plan benefits is the Private Plan carrier. Money from other
sources such as workers’ compensation benefits is not part of the 26 weeks of Private Plan
benefits. Therefore, in contested workers’ compensation cases, the Private Plan
carrier is potentially liable for payment of temporary disability benefits for up to 26
weeks in addition to the period of time paid by the workers’ compensation carrier,
26
even if the workers’ compensation carrier paid 26 weeks or more.
This policy was defined by the New Jersey Superior Court, Appellate Division, in the
decisions issued in the cases of Armando DelRio vs. Board of Review, No. A-2107-81T1,
and Elizabeth Brinkerhoff vs. CNA Insurance Co., No. A-1498-91T2. Copies of these
decisions are available from the Claims Review Unit upon request.
Claim Not Compensable Under Workers’ Compensation Law
If the Workers' Compensation Court finds that a claim is not compensable under the
Workers' Compensation Law, the claimant is entitled to keep the Private Plan benefits
previously paid to them, and no reimbursement is due the Private Plan carrier. This
procedure is contained in Section 43:21-29 of the New Jersey Temporary Disability
Benefits Law which states:
"Disability shall be compensable subject to the limitations of this act, where a
covered individual suffers any accident or sickness not arising out of and in
the course of the individual's employment or if so arising not compensable
under the workers' compensation law (Title 34 of the Revised Statutes), and
resulting in the individual's total inability to perform the duties of
employment." (Emphasis added.)
Private Plan Benefits Payable for Work-Related Disability When Employed by Two
Employers
A decision issued on March 1, 2000 by the New Jersey Supreme Court in the case of
Charles D. Scott (A-6-99) changed the handling of cases for claimants who have two
employers and who are receiving workers’ compensation benefits from one of them.
Formerly, no Private Plan nor State Plan temporary disability benefits were payable in such
cases. In the above decision the Supreme Court ruled that an individual who was injured
at one job and collecting workers’ compensation benefits for that injury, may also be
eligible for temporary disability benefits through their other employer. This ruling has been
incorporated into the New Jersey Administrative Code, Section 12:18-1.5. It should be
noted that these are not contested workers’ compensation cases.
As a result of the above Supreme Court decision, claims of the above type that began
March 1, 2000 or later must be handled as follows:
• The claimant must have had two employers, be receiving temporary workers’
compensation benefits from one employer, and have applied for temporary
disability benefits regarding the other employer.
• The most recent covered employer who is not a party to the workers’ compensation
claim is the last employer for purposes of the temporary disability claim.
• The claimant must otherwise meet all eligibility criteria for the payment of Private
Plan temporary disability benefits.
27
• Wages from all covered employers, including the employer from whom the claimant
is collecting workers’ compensation benefits, must be used to calculate the
claimant’s weekly temporary disability benefit rate and maximum benefit amount.
• The weekly Private Plan temporary disability benefit rate is reduced by the weekly
temporary workers’ compensation benefit rate, dollar for dollar, and the claimant is
paid temporary disability benefits at the adjusted rate.
• Any reduction in the weekly temporary disability benefit will also reduce the
maximum total benefits payable during the period of disability.
Please note that to process a claim for the type of case described above, the Private Plan
temporary disability carrier must obtain information concerning the amount of weekly
workers’ compensation benefits being paid, and the amount of wages earned by the
claimant with the other employer in the base year prior to the disability.
Also, the Private Plan temporary disability carrier should ensure that the weekly amount of
workers’ compensation benefits is subtracted from the weekly amount of Private Plan
temporary disability benefits, and that the claimant is paid at the adjusted rate. If the
weekly workers’ compensation benefit rate is greater than the weekly temporary disability
benefit rate, no benefits are payable by the temporary disability carrier.
Further Information on Workers’ Compensation Program
For further questions on workers' compensation matters such as filing workers’
compensation claims, workers’ compensation benefit amounts, informal and formal
workers’ compensation hearings, etc. contact the New Jersey Division of Workers'
Compensation, PO Box 381, Trenton, NJ 08625, or telephone (609) 292-2414. See also
the New Jersey Division of Workers’ Compensation website at
http://www.nj.gov/labor/wc/wc_index.html
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CHAPTER 8 - REDUCTION OF BENEFITS
A claimant may receive money during the period of a disability that may completely bar
benefits, that may reduce them, or that may have no effect on benefits. The following is a
discussion of several types of money that could be received and their effect on temporary
disability benefits.
Sick Pay or Regular Weekly Wage from the Employer
Continued pay from the employer during the disability in the form of sick pay or regular
weekly wage is regarded as payment for services rendered (or remuneration), and may
have an impact on the weekly disability benefit amount paid by the Private Plan carrier.
The impact depends upon the amount of money paid by the employer, and whether the
employer’s Private Plan contains Limitation (h) of the Law (see “Limitation (h)” below and
“Calculating the Reduction of Benefits Due to Sick Pay and Vacation Pay”, page 29).
Please note that, except for New Jersey state, county and municipal employers, the New
Jersey Temporary Disability Benefits Law does not require that a claimant must use their
sick leave before temporary disability benefits can be paid (see page 31 for sick leave
payable by governmental employers).
Vacation Pay
Vacation pay designated for a specific period of time which falls within the period of
disability is considered allocated vacation pay, and is continued pay. It may affect the
disability benefit amount as explained below in “Calculating the Reduction of Benefits Due
to Sick Pay and Vacation Pay”, page 29.
If the vacation pay is not designated for any specific period, it is considered unallocated,
and thus cannot be considered to have been received during the period of disability. This
vacation pay will not affect the disability benefit amount.
Limitation (h)
Section 43:21-39(h) of the New Jersey Temporary Disability Benefits Law (Limitation (h))
provides that the weekly dollar amount of money paid by the employer during the disability,
plus the weekly dollar amount of temporary disability benefits, must not exceed the
claimant’s regular weekly wage prior to the disability. If the amount paid by the employer
plus the amount payable by the Private Plan carrier exceeds the claimant’s regular weekly
wage prior to the disability, temporary disability benefits from the carrier must be reduced
(see “C. Employer Paying More Than the Difference”, page 29).
In cases where the Private Plan does not invoke Limitation (h), the claimant must be paid
the full, unreduced amount of temporary disability benefits, regardless of the amount of
money paid by the employer.
29
Calculating the Reduction of Benefits Due to Sick Pay and Vacation Pay
By determining the type of money received from an employer and using the provisions of
Limitation (h) shown above, it is possible to determine whether sick or vacation pay from an
employer has an effect on temporary disability benefits.
A.
Employer Paying Full Salary - When the continued pay from the employer is equal to
the claimant’s full salary, and the Private Plan contains Limitation (h), no temporary
disability benefits are payable during the period the employer is paying the full salary.
EXAMPLE: The employer, whose Private Plan contains Limitation (h), is continuing
to pay the claimant’s full salary of $600 per week.
The weekly disability rate is
$510.
Step One: $510 weekly disability benefit + $600 continued pay = $1,110
total. (The total of $1,110 exceeds the claimant’s average weekly wage by
$510.) Step Two: $510 weekly disability benefit - $510 excess amount = 0.
In the above example, since a reduction of the entire $510 is required, no temporary
disability benefits are payable.
Please note that if at some point the employer ceases paying full salary and begins paying
partial salary or nothing at all, and the claimant is still disabled, Private Plan benefits must
begin to be paid at that point.
B.
Employer Paying the Difference - Under the Law, the last employer can pay the
difference between the claimant’s average weekly wage and the weekly temporary disability
benefit amount, with no impact on the claim. In this situation it does not matter whether the
Private Plan contains Limitation (h) because the total received by the claimant never
exceeds their average weekly wage.
EXAMPLE: A claimant’s regular weekly wage is $600 per week and the weekly
disability benefit amount is $510 per week. The employer is paying continued pay
of $90 per week.
$510 weekly disability benefit + $90 weekly continued pay = $600 total
In the above example, the total received ($600) does not exceed the claimant’s
average weekly wage ($600). Therefore, there is no reduction in the weekly disability
benefits.
C.
Employer Paying More Than the Difference - If the total of the weekly temporary
disability benefit amount from the insurer and the weekly continued pay from the employer
exceeds the claimant’s average weekly wage prior to the disability, and if the Private Plan
contains Limitation (h), the weekly benefit amount payable by the temporary disability
insurer can be reduced.
EXAMPLE: A claimant’s average weekly wage is $600 per week, and the weekly
30
disability benefit rate is $510. The employer is paying continued pay of $300 per
week, and the Private Plan contains Limitation (h).
Step One: $510 weekly disability benefit + $300 continued pay = $810 total.
(The total of $810 exceeds the claimant’s average weekly wage by $210.)
Step Two: $510 weekly disability benefit - $210 excess amount = $300 reduced
temporary disability benefit.
In the above example, a reduction of the weekly temporary disability benefit amount
by $210 is required, yielding a reduced benefit of $300 per week.
D.
Two Employers - When a claimant has two employers, and one of the employers
issues continued pay to the claimant during the disability, the continued pay is handled as
follows. (For an explanation of concurrent employment, see page 4.)
When the claimant was not in concurrent employment:
• If the continued pay was from the last employer, benefits may be reduced.
EXAMPLE: The claimant last worked for Employer A on January 25, 2023, and last
worked for Employer B on January 26, 2023. Employer B issued continued pay
during the disability. Benefits may be reduced as explained in “Calculating the
Reduction of Benefits Due to Sick Pay and Vacation Pay”, page 29, since the
continued pay was from the last employer.
• If the continued pay was not from the last employer, benefits may not be reduced.
EXAMPLE: The claimant last worked for Employer A on January 25, 2023, and last
worked for Employer B on January 26, 2023. Employer A issued continued pay
during the disability. Benefits may not be reduced since the continued pay was not
from the last employer.
When the claimant was in concurrent employment, continued pay from either employer
may reduce the claimant’s benefits since both employers are considered the “last
employer”. Also, if the employer who is liable for the payment of temporary disability
benefits has a Private Plan, the Private Plan must contain Limitation (h) (see “Limitation
(h)”, page 28). The reduction of benefits in this situation is calculated in the following
manner for each week of the claimant’s disability:
Step One: Add together the claimant’s average weekly wage with both employers.
Step Two: Subtract the amount of continued pay from the total obtained in Step One.
Step Three: Pay the amount remaining after Step Two above, up to the current weekly
maximum benefit amount, for each week covered by the continued pay.
EXAMPLE: A claimant is in concurrent employment with a Private Plan and a State
Plan employer and becomes disabled. The claimant’s combined average weekly
wage with both employers prior to the disability was $1200, and the liable
employer’s Private Plan contains Limitation (h). The claimant is receiving continued
pay during the disability in the amount of $800 per week from his State Plan
31
employer.
Step One: Total average weekly wages with both employers prior to the disability =
$1200
Step Two: $1200 total wages - $800 continued pay = $400 difference
Step Three: Reduced weekly benefit = $400
Note: If the difference reached in Step Two above is more than the current weekly
maximum temporary disability benefit amount, only the current weekly maximum
benefit amount is paid, unless the Private Plan pays higher benefits.
OTHER TYPES OF MONIES RECEIVED (in alphabetical order):
Federal Disability Benefits
Disability benefits received resulting from employment with the United States Government,
such as employment with the United States Post Office, is a complete bar to New Jersey
temporary disability benefits (not just a reduction) beginning on the date the Federal
disability benefits began.
Maintenance and Cure Benefits
New Jersey Temporary Disability Benefits must be reduced by the amount of Maintenance
and Cure benefits required under Federal law and paid by a maritime employer to
employees on sea-going vessels beginning on the date the Maintenance and Cure benefits
began.
Military Veteran’s Pension
Military veteran’s pension benefits paid to a claimant by the United States government for a
prior military service-connected disability that is unrelated to the current disability are not a
bar to the receipt of New Jersey temporary disability benefits. This is because (a) the
current New Jersey employer did not contribute to the military pension, (b) the current
disability is unrelated to the military disability, and (c) the military disability was previously
incurred.
New Jersey State, County or Municipality Sick Leave
A claimant employed by the State of New Jersey, or employed by a county or municipality
that has elected to become a covered employer under the New Jersey Temporary
Disability Benefits Law, may be eligible to receive State Plan or approved Private Plan
temporary disability benefits. However, that claimant may be required by their employer to
use up to two weeks of accumulated sick leave before temporary disability benefits can be
paid. Under no circumstance shall the claimant be required to use their last weeks’ worth of
accumulated sick time before receiving benefits.
32
No-Fault Auto Insurance Benefits
There is no provision in the New Jersey Temporary Disability Benefits Law for a reduction
of temporary disability benefits when a claimant is receiving no-fault auto insurance
benefits resulting from an auto accident. Therefore, a Private Plan carrier must pay the full
amount of temporary disability benefits regardless of the amount paid by an automobile
insurance carrier. Also, a Private Plan carrier cannot subrogate against benefits the
claimant receives from an auto insurance carrier since this type of subrogation is not
provided for in the New Jersey Temporary Disability Benefits Law.
It should be noted that an auto insurance carrier may reduce the amount of their benefits
by the amount of Private Plan or State Plan temporary disability benefits the claimant has
received.
Payment in Lieu of Notice
A claimant whose employment has been terminated and who receives payment in lieu of
notice continues to be in employment until the end of the period covered by that payment.
No temporary disability benefits are payable for the period covered by the payment in lieu
of notice. This is a complete bar to benefits for that period, not just a reduction.
Pensions
Section 12:18-3.4 of the New Jersey Administrative Code mandates that temporary
disability benefits shall be reduced by the amount paid concurrently under any
governmental or private retirement pension program to which a worker's most recent
employer contributed on their behalf. A pension from other than the last employer does not
affect the disability benefit amount. For example, if an employee had worked for 30 years
for a prior employer (Employer A) before being hired by another employer (Employer B), any
pension they continue to receive from Employer A would have no effect on the disability
benefit amount paid through Employer B's Private Plan.
However, pension from the last employer (Employer B) will affect the disability benefit
amount if Employer B contributed to the pension program. Temporary disability benefits
should then be reduced or denied entirely depending upon the amount of the pension
payments a claimant receives, as shown below. Under the New Jersey Administrative
Code, Section 12:18-3.4(b), the reduction of benefits must start on the date the first
pension check is issued.
The following steps are used to calculate the pension deduction when such a deduction
must be made.
Step One: Divide the monthly pension rate by 30 to obtain the daily pension rate.
Step Two: Multiply the daily pension rate by 7 to obtain the weekly pension rate.
Step Three: Subtract the weekly pension rate from the weekly temporary disability rate to
obtain the reduced weekly temporary disability rate paid to the claimant.
33
EXAMPLE: A claimant is receiving temporary disability benefits of $350 per week,
and then begins receiving a pension of $900 per month from his last employer.
Step One: $900 monthly pension ÷ 30 = $30 daily pension rate
Step Two: $30 daily pension rate x 7 = $210 weekly pension rate
Step Three: $350 weekly disability rate - $210 weekly pension rate = $140
In this example, the claimant's reduced weekly temporary disability rate is $140.
Lump Sum Pension Payment - The temporary disability benefit amount is not reduced by
any pension that is not an on-going periodic payment to the employee. A lump sum
pension payment is not an on-going periodic payment if it is not allocated to any specific
week or weeks within the period of disability. Therefore, the disability benefit amount will
be reduced for the week the lump sum pension is paid, but not for the remainder of the
disability.
However, if the last employer states that a lump sum pension has been distributed in
full but indicates a specific beginning and ending date covered by the payment, the lump
sum is regarded as allocated pension. The disability benefit amount will be reduced during
the entire period covered by the pension.
Severance Pay
Severance pay is not remuneration since it is not compensation for personal services.
Therefore, severance pay has no impact on the amount of temporary disability benefits
paid. The full amount of Private Plan benefits must be paid regardless of the amount of
severance pay received by the claimant.
Social Security Disability Benefits
Under the New Jersey Temporary Disability Benefits Law when a claimant begins receiving
Social Security disability benefits, Private Plan benefits stop as of the date the Social
Security disability benefits began. Thus, Social Security disability benefits are a complete
bar to temporary disability benefits (not just a reduction), beginning on the effective date of
the Social Security award as shown in the award letter sent to the claimant by the Social
Security Administration.
Social Security Retirement Benefits
As a result of the 1955 New Jersey Supreme Court decision in the case of Charles L.
Deaney vs. Linen Thread Company Inc., Social Security retirement benefits do not reduce
the temporary disability benefit amount. Therefore, the full amount of temporary disability
benefits must be paid regardless of the amount of Social Security retirement benefits being
received by the claimant.
Supplemental Benefits or Gifts
There is a distinction between continued pay as a gift and continued pay as remuneration.
34
Any payment given to the employee outside the contract of hire is regarded as a gift.
Continued pay as a gift is considered a supplemental benefit and has no impact on the
disability benefit amount.
Temporary Disability Benefits from Another State
New Jersey Temporary Disability Benefits must be reduced by the amount of temporary
disability benefits paid under the law of another state (see list of other states with
temporary disability statutes, page 1) beginning on the date the benefits from the other
state began. Since there is no coordination of benefits among the states that have
temporary disability benefit programs, the claimant must submit documentation showing
the dates and amounts paid under the program of the other state paying benefits.
1. If a claimant is in New Jersey covered employment and is also in covered
employment in another state with a temporary disability benefits program,
(New York, Rhode Island, California, Hawaii, Washington, or Massachusetts)
Washington D.C. or Puerto Rico, the claimant is required to file for benefits
with the other state before New Jersey benefits can be paid. If the
employment is in New York this procedure must be followed if the New York
employment is within six (6) months of the first day of disability.
2. If the disability is the result of a work-related sickness or injury occurring in
another state, New Jersey benefits will not be paid. New Jersey does not
have subrogation rights in any other state or with the federal government.
3. If the claim is denied under that other state’s law for a reason that would
not make them ineligible under New Jersey State law, the claim must be
paid at the full weekly benefit rate.
4. If the claimant is paid on their other state claim they must submit
documentation showing the period of eligibility and the amount paid.
The New Jersey temporary disability benefits will be reduced by the
amount paid under the other state’s law.
Unemployment Benefits
A claimant’s receipt of unemployment compensation benefits is a complete bar to
temporary disability benefits (not just a reduction) beginning on the date the unemployment
benefits began. The receipt of unemployment benefits indicates that the claimant is not
disabled, since a claimant must be physically able to work in order to receive these
benefits.
35
CHAPTER 9 - SEMI-ANNUAL AND ANNUAL REPORTS
The New Jersey Administrative Code, Sections 12:18-2.29, 2.30, and 2.31 requires that
insurance companies, self-insured employers, and union welfare funds file semi-annual
and annual reports showing the temporary disability claims activity under their approved
Private Plan(s). The semi-annual and annual report forms, together with instructions, are
mailed to Private Plan carriers by the Approvals Unit at the appropriate time. The reports
must then be completed and emailed to: [email protected]v.
The two semi-annual reports must be completed showing the number of new claims filed
during the six-month periods ending June 30 and December 31, the number of claims
accepted during those periods, and the gross amount of Private Plan benefits paid during
those periods.
The annual report must be completed showing claims activity for the entire calendar year.
The information requested includes gross premiums earned, total administrative costs of
operating the Private Plans, and total amount of temporary disability benefits paid under
the approved Private Plan(s).
Information obtained from these reports is used by our office for statistical and planning
purposes only. No bills or tax payments are based on these reports.
36
CHAPTER 10 – FAMILY LEAVE INSURANCE PROGRAM
Beginning July 1, 2020, Family Leave Insurance can be claimed for up to twelve (12)
weeks of continuous leave or up to 56 days of intermittent leave during a 12- month period
beginning with the first date of the claim. Benefits are payable from the first day of leave.
There is no waiting period. Benefits are payable to covered employees from either the
New Jersey State Plan or an approved employer-provided private plan to:
• Bond with a child during the first 12 months after the child’s birth, if the covered
individual, or the domestic partner or civil union partner of the covered individual, is
a biological parent of the child, or is a parent of the child pursuant to a valid
gestational carrier agreement, or the first 12 months after the placement of the child
for adoption or as a foster child with the individual.
• Care for a family member with a serious health condition supported by a
certification provided by a health care provider.
“Family member” means a sibling, grandparent, grandchild, child, spouse, domestic
partner, civil union partner, parent-in-law or parent of a covered individual, or any
other individual related by blood to the employee, and any other individual that the
employee shows to have a close association with the employee which is the
equivalent of a family relationship.
“Child” means a biological, adopted, or foster child, stepchild or legal ward of a
covered individual, child of a domestic partner of the covered individual, or child of a
civil union partner of the covered individual, including a child who becomes the child
of a parent pursuant to a valid written agreement between the parent and the
gestational carrier.
New Jersey State Plan
Employees covered under the New Jersey State Plan can obtain information pertaining to
the program and an application for Family Leave Insurance benefits by visiting the Division’s
website at https://myleavebenefits.nj.gov.
If an employee is receiving State Plan temporary disability benefits for pregnancy, after the
child is born, the Division will mail the employee information on how to file a claim for
Family Leave Insurance benefits to bond with the newborn child. If a claim is filed to have
Family Leave Insurance benefits begin immediately after the employee recovers from their
pregnancy related disability, they will be paid at the same weekly benefit amount as they
were paid for their pregnancy related disability claim. If an employee is receiving
pregnancy disability benefits through their employer or their employer’s private insurance
carrier however their employer participates in the state Family Leave Insurance plan, they
should obtain an application for Family Leave Insurance benefits by visiting the Division’s
website at: https://myleavebenefits.nj.gov.
Private Plan
An employer can elect to provide workers with Family Leave Insurance benefits coverage
37
under a private plan approved by the Division of Temporary Disability Insurance.
Employers will provide information regarding the private plan and the proper forms to
claim benefits to employees covered under the private plan.
38
APPENDIX
39
Review of Signature Requirement
For Processing of Claims
The State, like any legally recognized entity, does require the Claimant to certify that his
statements are true, via a signature. This is the tacit agreement by the Claimant that they
are entering into a contractual agreement with the State for the processing and possible
payment of a Temporary Disability Claim. This allows for the prosecuting of fraud cases or
overpayments.
We also require the same of the Treating Medical Provider and the Employer.
Obviously, signing the original claim document is acceptable. We also accept faxed copies
as if they were the original document. We accept photocopies of the claim paperwork as
originals. And we except the electronic acknowledgement for a Web Claim as the
signature.
We will accept a printed signature, or an X-signature for the illiterate.
We also have a review process for agent signatures. Both because of Non-compos-mentis
or for the inability to physically sign any document (injury).
40
Severance Pay vs. Payment in Lieu of Notice
Severance Pay with Notice
If an employer gives an employee a notice of termination, with a specific last day of
work some days or weeks later, then the severance pay that is given at the end of the
period worked is a gift. (The claimant continued to work up to the date of termination.)
In this situation, the severance pay is usually a lump sum payment and is not
considered as salary. It is often contractual and based on years of service. This type of
pay does not extend employment or have any impact on the claim. It is a supplemental
benefit.
Pay in Lieu of Notice
If an employer gives an employee a notice of termination, but wants a worker to leave
immediately, and in lieu of notice pays the claimant for the days/weeks until the official
termination date, this is continuation pay and does extend employment. The individual
is still an employee, but is no longer physically working on the employer’s premises.
OR
If an employee gives notice to the employer of his intent to quit and the employer wants
the worker to leave immediately, but still pays the claimant for the days/weeks (until the
employee’s stated intended date of voluntary leaving), this is continuation pay and does
extend employment. The individual is still employed, but is no longer physically working
on the employer’s premises.
OR
WARN Act*
If an employer gives an employee a notice of termination due to a plant closing or mass
layoff and the Federal Worker Adjustment and Retraining Notification (WARN) Act
applies, the worker must be given 60 days’ notice. Should the employer want a worker
to leave immediately, and in lieu of notice pays the claimant 60 days (8 weeks) of
wages, the employment extends to the date of termination. This date may be in the
future.
*Applies to an employer who has greater than 100 employees and the plant closing will
result in an employment loss for 50 or more employees during any 30-day period or the
mass layoff will result in an employment loss during any 30-day period for 500 or more
employees, or for 50-499 employees if they make up at least 33% of the employer’s
active workforce.
41
Medical Practitioners
Acceptable Medical Practitioners
Medical Doctor MD
Osteopath DO
Podiatrist OPM
Dentist DDS
Optometrist OD
Chiropractor DC
Advanced Practice Nurse APN
Advanced Practice Registered Nurse APRN
Certified Nurse Practitioners CNP
Clinical Nurse Specialists CNS
Certified Nurse Midwife CNM
Psychologist
Acceptable Medical Practitioners
when under the supervision of
a licensed Physician
Physician Assistant PA
Certified Practicing Midwife CPM
Unacceptable Medical Practitioners
Licensed Clinical Social Workers LCSW
Professional Counselors
Faith Healers
Clergy
42
A Quick Guide to Dealing with LLC’s
LLC’s file three types of Federal Income Tax Forms:
Sole Proprietorship:
1040C
Membership/Partnership:
1065
Incorporation:
1120/1120s
Special issues:
Sole Proprietorship:
owner, spouse, parent, minor children
none of above
: Disability During-
Unemployment
: Eligible
Membership/Partnership:
member/partner
none of above
: Disability During-
Unemployment
: Eligible
Incorporation:
all
: Eligible
Sample Questions for Employer to Establish Coverage:
1) What type of LLC are you?
(Check off the correct option)
a) Sole Proprietorship: filing form 1040C with Federal IRS
b) Membership/Partnership: filing form 1065 with Federal IRS
c) Incorporation: filing form 1120 with Federal IRS
2) Claimant relationship to LLC? (Check off the correct option)
a) Owner
b) Spouse of owner
c) Child of owner
d)
Parent of owner
e)
Member/Partner
43
A Quick Guide for the
Payment of Pregnancy Claims
Normal Pregnancy (Single Gestation)
The first day of disability (FDD) can be no more than 4 weeks before the expected
delivery date (EDC)
If no delivery information is provided:
o Pay the claim no more than 4 weeks after the EDC
If the delivery information is provided:
o (A) Abortion – pay 4 weeks after the confirmed delivery date
o (B) Birth/Normal – pay 6 weeks after the confirmed delivery date
o (M) Miscarriage – pay 6 weeks after the confirmed delivery date
o (C C-Section – pay 8 weeks after the confirmed delivery date
Normal Pregnancy (Multiple Gestation)
The FDD can be extended for multiple gestations. Add 4 weeks prior to the EDC for
each gestation.
o Example: Twins – the FDD can be no more than 8 weeks before the EDC
o Example: Triplets – the FDD can be no more than 12 weeks before the EDC
If no delivery information is provided:
o Pay the claim no more than 4 weeks after the EDC
If the delivery information is provided:
o (A) Abortion – pay 4 weeks after the confirmed delivery date
o (B) Birth/Normal – pay 6 weeks after the confirmed delivery date
o (M) Miscarriage – pay 6 weeks after the confirmed delivery date
o (C) C-Section – pay 8 weeks after the confirmed delivery date
Complicated Pregnancy
The FDD can be at any time during the pregnancy. However, the FDD must be
confirmed. No future dates can be accepted. Refer to the physician’s signature date to
verify if the FDD is confirmed.
If no delivery information is provided:
o Pay the claim 6 weeks from either the physician’s signature date or the
employer’s last day of work (LDW), whichever is later/more recent.
If the delivery information is provided:
o (A) Abortion – pay 4 weeks after the confirmed delivery date
o (B) Birth/Normal – pay 6 weeks after the confirmed delivery date
o (M) Miscarriage – pay 6 weeks after the confirmed delivery date
o (C C-Section – pay 8 weeks after the confirmed delivery date
44
Complicated Pregnancy – Light Duty Requested
If claim is “complicated” by a light duty request send the following set of questions to the
employer(s) to confirm if light duty is available:
Please provide a description of the above named claimant’s work duties:
If lifting, pushing or pulling are involved, comment on weight and frequency:
Were lighter job duties available to her as of the date shown above in Item 7?
Yes No
Has the claimant delivered? Yes No
Type: Birth Miscarriage C-Section
When the Questionnaire is returned, review the information provided by the employer
and if light duty is not available, the claimant is considered disabled.
If no delivery information is provided:
o
Pay the claim 6 weeks from either the physician’s signature date or the
employer’s last day of work (LDW), whichever is later/more recent.
If the delivery information is provided:
o
(A) Abortion – pay 4 weeks after the confirmed delivery date
o
(B) Birth/Normal – pay 6 weeks after the confirmed delivery date
o
(M) Miscarriage – pay 6 weeks after the confirmed delivery date
o
(C) C-Section – pay 8 weeks after the confirmed delivery date
45
Calculating Benefits
1)
Regular Base Year, with respect to the Benefit Year, means the first
four quarters of the last five completed quarters of the calendar year
immediately preceding the period of disability.
2)
Alternative Base Year I, with respect to the Benefit Year, means the
last four completed quarters of the calendar year immediately
preceding the period of disability.
3)
Alternative Base Year II, with respect to the Benefit Year, means
the last three completed quarters of the calendar year plus the
balance of the unfinished quarter immediately preceding the period of
disability.
4)
If the individual does not have sufficient Base Weeks or Base
Wages in the Regular Base Year to qualify for benefits, the individual
shall have the option of designating that the individual’s Base Year
shall be the Alternative Base Year I.
5)
If the individual does not have sufficient Base Weeks or Base
Wages in the Alternative Base Year I to qualify for benefits, the
individual shall have the option of designating that the individual’s
Base Year shall be the Alternative Base Year II
46
Continued Pay and Other Benefits Impact List
Continued Pay
Impact
No Impact
Sick Pay – allocated to period of time
during the disability
Vacation Pay – allocated to a period of
time during the disability
Severance Pay in lieu of notice
Regular Salary paid during the
disability
Holiday Pay - paid during the disability
Maintenance and Cure – Merchant Seaman
Unallocated Sick Pay
Unallocated Vacation Pay
Severance Pay with notice
Employer pays the difference (EPD)
Bonus
Commission earned on sales made prior
to disability
Pensions
Impact
No Impact
Company Pension*
Union Pension*
Lump Sum Distributions*
401(k) Distributions*
*only if the chargeable employer contributed
Military Pensions
Federal Government Pensions
Railroad Retirement Pensions
Postal Employee Pensions
Pension from a non-chargeable prior
employer
Benefits
Impact
No Impact
Social Security Disability Benefits (SSD)
Workers’ Compensation Benefits (WC)
Unemployment Insurance Benefits (UI)
Social Security Retirement Benefits
Supplemental Security Income Benefits
Welfare Benefits
Supplemental Union Benefits
Supplemental Disability Insurance
Benefits
No-fault Auto Insurance Benefits
47
NOTICE OF TEMPORARY DISABILITY CLAIM DECISION
Private Plan Carrier:
Claimant Name and Address:
Date of this notice:
Social Security #:
Last Date Worked:
First Date Disabled:
Employer
Address:
Benefits paid on this claim prior to the date of this notice:
NONE
GROSS WEEKLY BENEFIT RATE PAID: $
FROM TO
YOU ARE HEREBY NOTIFIED THAT YOUR CLAIM FOR DISABILITY BENEFITS IS REJECTED FOR THE
REASON(S) CHECKED BELOW:
[
]
1. Returned to work after disability.
[ ] 2. Disability ended during waiting period.
[ ] 3. Maximum benefits exhausted.
[ ] 4. Employment not covered under Law.
[ ] 5. No medical documentation received.
[ ] 6. Disabled due to self-inflicted injury.
[ ] 7. Disability occurred during commission of crime of first, second or third degree.
[ ] 8. Working during disability.
[ ] 9. Receiving continued pay from employer during disability.
[ ] 10. Disability occurred during labor dispute.
[ ] 11. Disability began more than 14 days after last day worked.
[ ] 12. Disability is work related.
[ ] 13. Received U.I., S.S. Disability Benefits or Maintenance and Cure during disability.
[ ] 14. Did not meet minimum base week/salary requirement.
[
] 15. Late filing of claim without good cause.
[ ] 16. Failure to appear for impartial medical examination.
[ ] 17. Impartial medical examination found claimant able to work.
[ ] 18. Not too disabled to perform duties of regular employment.
[ ] 19. Failed to provide other required information.
[ ] 20. Not in class covered by employer’s Private Plan.
[ ] 21. Disability began before effective date of Private Plan.
[ ] 22. Disability began after termination date of Private Plan.
[ ] 23. Private Plan not insured by this insurer.
[
] OTHER
Explanation:
APPEALS
IF YOU DISAGREE WITH THIS DECISION, YOU HAVE THE RIGHT TO APPEAL OUR DECISION BY
CONTACTING PRIVATE PLAN COMPLIANCE, PO BOX 957, TRENTON, NJ 08625-0957.
Signature: Title: Phone:
48
CONCLUSION
This manual is intended to help you reach prompt, accurate decisions on New Jersey
temporary disability and family leave insurance claims. The Claims Review Unit is here
to assist you when questions or unique claim problems arise. You may also request a visit
to our office. Our representative will meet with you to discuss claims procedures, review
your Private Plan(s) and the Law. Call (609) 292-2720 or email ppclai[email protected]ov.
