N.J. Admin. Code § 12:18-3.1

Current through Register Vol. 56, No. 24, December 18, 2024

Section 12:18-3.1 - Extent of coverage

(a) A claimant shall not be entitled to any benefits from the Fund with respect to any period of disability commencing while he or she is covered under a private plan.

(b) A claimant shall not be paid any benefits under N.J.S.A. 43:21-3 and N.J.S.A. 43:21-4 for any period of disability commencing while he or she is a "covered individual" as defined in N.J.S.A. 43:21-27(b).

(c) An individual who is covered by a private plan or is separated from his or her employment for a period of two weeks or more immediately prior to the disability shall not be entitled to any benefits under the State plan.

(d) If application for benefits is made under a private plan or for disability during unemployment (N.J.S.A. 43:21-4) and it is determined that the claim should have been made under the State plan, a claimant shall not be deprived of benefits under the State plan for failure to give timely notice and proof of disability provided that:

1. The application to the private plan or for disability during unemployment (N.J.S.A. 43:21-4) would have been timely noticed to the State plan if it had been then made; and

2. Proof of disability is made under the State plan not later than the time prescribed by the Act.

(e) If a claimant is paid benefits under the State plan, the amount of such benefits shall not be deducted from the amount of benefits to which he or she may be entitled for a subsequent period of disability under a private plan, or for disability during unemployment (N.J.S.A. 43:21-4). If a claimant is paid benefits under a private plan, the amount of such benefits shall not be deducted from the amount of benefits to which he or she may be entitled for a subsequent period of disability under the State plan, or for disability during unemployment (N.J.S.A. 43:21-4).

(f) Where a covered employee has utilized a licensed medical practitioner, and that licensed medical practitioner has examined the covered employee and has diagnosed him or her with a disabling condition, and where the licensed medical practitioner has certified that the employee's condition renders him or her unable to perform the duties of his or her employment for a given period of time, the claimant may only be denied benefits during that period so certified where:

1. The Division has contacted the covered employee's personal licensed medical practitioner and has reached a mutual agreement therewith as to a change in the period of the covered employee's disability;

2. A licensed medical practitioner designated by the Commissioner of Labor and Workforce Development or his or her designee 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 examination;

3. A covered employee refuses to submit to or fails to attend an examination conducted by a licensed medical practitioner designated by the Commissioner of Labor and Workforce Development or his or her designee, 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 Division 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.

(g) If a physical examination of a claimant is required, the Commissioner of Labor and Workforce Development or his or her designee shall authorize such examination to be made by a licensed medical practitioner. Upon submission of a written report of the examination to the Department of Labor and Workforce Development, a basic, normative fee customarily charged by a physician in a given specialty for each such examination, shall be paid to the examining medical practitioner, which fee shall be charged to the administration account. Upon recommendation of the Director and upon a finding that an increase or decrease in the customary or "fair market" fee is necessary or appropriate to be cost effective and supply a sufficient pool of examiners, the Commissioner may increase or decrease the customary fee pursuant to a schedule issued by the Commissioner on a Statewide or county basis for one or more of these groups of examiners. In cases requiring the services of a specialist, or in cases requiring clinical tests supporting the diagnosis, the Commissioner or his or her designee shall, in his or her discretion, authorize such services or tests, the fees to be fixed in advance, not to exceed the fees professionally established for such services or tests by the appropriate State or county organization, whichever is the lesser.

(h) The responsibility for coverage shall be established by the covered individual's last employer. The application for benefits shall be processed by the insurer, if the employer has an approved private plan and the individual is covered by that plan, or the State plan if the employer has State plan coverage. However, claims coming within the purview of N.J.A.C. 12:18-1.5, 2.10 or 3.5 shall be governed thereby.

N.J. Admin. Code § 12:18-3.1

As amended, R.1974 d.284, effective 10/17/1974.
See: 6 N.J.R. 68(e), 6 N.J.R. 437(b).
Amended by R.1994 d.241, effective 5/16/1994.
See: 26 N.J.R. 1326(a), 26 N.J.R. 2131(a).
Amended by R.1998 d.157, effective 4/6/1998.
See: 30 N.J.R. 12(a), 30 N.J.R. 1288(a).
In (d) and (e), deleted references to N.J.S.A. 43:21-3 throughout; and in (f) and (g), substituted references to medical practitioners for references to physicians, dentists, podiatrists, chiropractors, practicing psychologists, public health nurses, and optometrists throughout.
Amended by R.2000 d.327, effective 8/7/2000.
See: 32 N.J.R. 169(a), 32 N.J.R. 1700(a), 32 N.J.R. 2908(a).
Rewrote (f).
Amended by R.2003 d.214, effective 5/19/2003.
See: 35 N.J.R. 1039(a), 35 N.J.R. 2226(a).
Rewrote (g); added (h).
Amended by R.2008 d.310, effective 10/20/2008.
See: 40 N.J.R. 2655(a), 40 N.J.R. 6209(a).
In (f)2, (f)3, and (g), inserted "and Workforce Development" throughout; and in (g), substituted "State" for "state".