All posts by Greg Lois

Greg Lois is the managing partner of LOIS LLC and dedicates his practice to defending employers and carriers in New York and New Jersey workers' compensation claims. Greg is the author of a popular series of "Handbooks" on workers' compensation, and is the co-author of the 2016 & 2017 Lexis-Nexis New Jersey Workers' Compensation Practice Guide. Greg can be reached at 201-880-7213 or glois@loisllc.com

New Jersey Supreme Court Awards Lost Wages to Volunteer with No Paying Job

Attorney Gregory loisIn a decision that will cause significant hardship to many municipalities in New Jersey, the state’s highest court ruled that a municipal volunteer who had no paying job is entitled to wage replacement benefits at the highest statutory rate when injured, despite the fact that there is no actual lost time from any paying employment. This decision will have a big impact on New Jersey, where most of the 565 small towns and municipalities have various volunteer organizations providing ambulance and firefighter service. While the decision falls in line with the wage-replacement benefit for volunteer first responders in neighboring New York and Pennsylvania the ruling will have a big impact on the highly-taxed small towns in New Jersey where this is a reversal of more than 100 years of precedent. Continue reading New Jersey Supreme Court Awards Lost Wages to Volunteer with No Paying Job

New Jersey Appeals Court Limits Payments to Ambulatory Surgery Centers

In a decision issued January 29, 2019 a New Jersey Appellate Court has ruled that even though Medicare includes a CPT code and pays for specific treatment rendered in a ambulatory surgery center this does not obligate a New Jersey auto insurer to make payment for medical treatment billed under such code. At issue were bills submitted to an auto insurance carrier for treatment allegedly rendered in an out-patient facility to the claimant’s low back. The medical fees in dispute involved invoices from the facility not the doctor.

In this case, the facility, Specialty Surgery Center of North Brunswick, sough $32,500 in reimbursement from an automobile insurer for CPT code 63030, which refers to “lower back disc surgery.” The New Jersey Appeals Court ruled that the CPT code provided for reimbursement of physicians only, and not to ambulatory surgery centers. The court further found that despite Medicare’s position on reimbursement for that code, the surgery center was not entitled to payment under New Jersey’s personal injury protection (“PIP”) fee schedule promulgated by the New Jersey Department of Banking and Insurance for automobile claims.

While not mentioning the implications for medical provider claims in New Jersey workers’ compensation cases, this case stands for the proposition that where an ambulatory surgery center is seeking payment for fees that greatly exceed the normal reimbursement and justify those claims by referring to Medicare or other jurisdictional rules, the workers’ compensation carrier can argue that New Jersey’s PIP fee schedule should be relied upon by the workers’ compensation judge as a reasonable estimate of costs (where the surgery center accepts PIP payments). Case discussed: New Jersey Manufacturers Ins. Co. v. Specialty Surgical Center of North Brunswick, A-0319-17T1, A -0388-17T1 (N.J. App. Div. Jan. 29, 2019).

New Jersey Medical Provider Claims Have a Six-Year Statute of Limitations

Attorney Greg LoisOn January 17, 2019 the New Jersey Appellate Division ruled that medical providers filing a “Medical Provider Application for Payment or Reimbursement of Medical Payment” seeking additional money from workers’ compensation insurance carriers have six years to file their claims. This is longer than the two year Statute of Limitations which applies to the underlying workers’ compensation claim. This decision will increase the number of Medical Provider Claims filed in New Jersey.

Reasoning of the Appellate Court.

In The Plastic Surgery Center, PA. v. Malouf Chevrolet-Cadillac, Inc, the New Jersey Appellate Division decided that a medical provider has to file a claim in the Division of Workers’ Compensation within six years of the service provided. The case has been reported.

The Court noted that suits on contracts in New Jersey have a six-year statute of limitations under N.J.S.A. 2A:14-1. When the New Jersey Legislature amended the New Jersey statute in 2012 granting exclusive jurisdiction over disputed medical charges to the Division of Workers’ Compensation, the Legislature never addressed which statute of limitations would apply. The Court found that the rationale for a two year statute of limitations does not fit N.J.S.A. 34:15-51, which is the statute of limitations provision in New Jersey. The Court ruled that

“[w]e are most persuaded that the Legislature intended to leave unaltered the time within which medical-provider claims must be commenced because the Act’s two-year-bar simply doesn’t fit.”

The Court found that a two-year rule could mean that the statute would run on the rights of the medical provider to file before the medical service is even provided because the medical provider might not render its service until after two years from the date of accident.

Impact of this Decision.

According to the statistics provided by the Division of Workers’ Compensation, one of every five claim petitions in New Jersey is a Medical Provider Claim. This decision will likely embolden medical providers, working outside of New Jersey but closely watching the medical provider claim action in this State because they are covetous of the “usual and customary” (extremely high) payment scheme, to accelerate the trend of opening satellite offices in New Jersey and with he plan of continuing to persuade their patients to “cross a river” and seek ambulatory surgery, procedures, and treatment in New Jersey at a much higher cost to the carrier.

This decision does not address the payment to be reimbursed where the claimant’s only contact with the state of New Jersey is the place of treatment rendered. Right now there are conflicting decision issued by trial-level judges (Judge of Compensation) in the many workers’ compensation courts (vicinages).

New Case Decision: New Jersey Workers’ Compensation Carriers Can Subrogate Minor Injuries Even Where Petitioner Could Not

In a decision released December 4, 2018, a New Jersey appeals court ruled that a workers’ compensation carrier can sue the tortfeasor in an auto accident case even though petitioner, who wasn’t permanently injured, could not. This decision will be of interest to all workers’ compensation carriers in New Jersey. Continue reading New Case Decision: New Jersey Workers’ Compensation Carriers Can Subrogate Minor Injuries Even Where Petitioner Could Not

New Case on the “Going and Coming” Rule in New York Good for Employers and Carriers

In Matter of Rodriguez v New York City Tr. Auth., decided May 31, 2018, the Appellate Division found that the injuries sustained by a subway conductor were not compensable even though the employee was on the employer’s property at the time of loss, was wearing the uniform provided by the employer, and was using a “free pass” provided by the employer to travel to the final work location. The Appellate Panel found that the claimant’s injuries were the result of a normal commute and therefore were not compensable, even though she was attacked after refusing to allow a turnstile jumper access to the station she was traveling through.

We will be presenting a live webinar today, June 18th at 12PM EST and 3PM EST discussing the facts of this case and the impact of the decision on the defense of your off-premises cases in New York as well as answering questions LIVE about specific fact scenarios like this one. Please feel free to join me for one of the sessions or to invite a member of your team at {{company_name}} to jump in. Here’s the link to register for either session: http://loisllc.com/webinars/register-for-webinars/

What is the “Going and Coming Rule”?

Employees are not deemed to be in the course of their employment when they are traveling to- and from-work. This rule of thumb is referred to as the “going-and-coming rule” or the “portal-to-portal” rule. Basically, there is no door-to-door coverage: the risk of travel to and from work is not distinctly related to any specific employment, and so is generally considered not arising out of and in the course of any particular employment.

​Exceptions to the Going-and-Coming Rule

Of course, there are exceptions. For example:

  • Outside workers – like traveling salesmen – who do not work at a fixed location and are required to travel between work locations. (See Bennett v. Marine Works, 273 N.Y. 429 [1937]).
  • Special errands – being sent by the employer to do something specific (and work-related). (See Neacosia v. New York Power Auth., 85 N.Y.2d 471 [1995]).
  • Paid travel expenses – where an employee is paid to use their own car for work-related travel, an injury occurring during that travel may be found to be compensable.
  • Some home office situations – the WCB recognizes that it is not unusual for management and professional workers to have home office with links to the employer’s office, making injuries in those locations compensable.
  • Entering or leaving the employer’s premises – in particular, injuries sustained while the employee is entering the worksite have been held compensable where the entrance to the worksite posed a special hazard. (See Bigley v. J & R Music Elec., 702 N.Y.S.2d 474 [3d Dep’t 2000].)

Continue reading New Case on the “Going and Coming” Rule in New York Good for Employers and Carriers

The Statute of Limitations in New Jersey Medical Provider Claims

The Division Of Workers’ Compensation’s jurisdiction includes medical fee disputes arising from New Jersey workers’ compensation claims.N.J.S.A. 34:15-15 states:
“Exclusive jurisdiction for any disputed medical charge arising from any claim for compensation for a work-related injury or illness shall be vested in the division.”
As evidenced by its situation inside of the New Jersey Workers’ Compensation section of the New Jersey Labor Statute, this provision is meant to apply to all New Jersey Workers’ Compensation claims.

Prior to the November 19, 2012 amendment to the New Jersey Workers Compensation Act (N.J.S.A. 34:15-15), the statue of limitations for fee disputes was set by N.J.S.A. 2A:14-1 as per Medical Diagnostic Assocs. v. Hawryluk, 317 N.J. Super. 338, 349 (App. Div. 1998), cert. denied, 160 N.J. 89 (1999). Under N.J.S.A. 2A:14-1, recovery upon a contractual claim or liability, express or implied, not under seal, or upon an account other than one which concerns the trade or merchandise between merchant and merchant, their factors, agents and servants, shall be commenced within 6 years next after the cause of any such action shall have accrued.” Continue reading The Statute of Limitations in New Jersey Medical Provider Claims