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 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 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

Longshore Employment Defined.

Coverage under the Longshore and Harbor Workers’ Compensation Act requires a master-servant relationship between employer and an employee. Crowell v. Bensen, 285 U.S. 22, 54 (1932). The Act defines employee as “any person engaged in maritime employment, including any longshoreman or other person engaged in longshoring operations, and any harbor-worker including a ship repairman, shipbuilder, and ship-breaker.” 33 U.S.C. § 902(3). The Act also sets out a long list of potential employees who do not fit the criteria: clerical and secretarial workers, marina workers, fishermen, etc.

The issue of employment is usually reached int he context of an alleged independent contractor seeking benefits. Just because an employer has not secured LHWCA coverage for an employee does not mean that that worker is not covered under the Act as an employee. Tanis v. Rainbow Skylights, 19 BRBS 153 (DOL Ben. Rev. Bd. 1986). Continue reading Longshore Employment Defined.

The Jones Act v. Longshore

​Which workers’ compensation act applies: the Longshore and Harbor Workers’ Compensation Act or the Jones Act? The Jones Act and the LHWCA are mutually exclusive. Thus, when dealing with a “water-based” (as opposed to “land-based”) LHWCA claim, it must be determined if the claim falls within the criteria of LHWCA coverage, or belongs more properly under the Jones Act. Of course, the claim might not belong under either jurisdiction and should be decided under a state workers’ compensation act.

The Jones Act (The Merchant Marine Act, 1920, 46 U.S.C. § 688), in pertinent part, reads as follows:
Any seaman who shall suffer personal injury in the course of his employment may, at his election, maintain an action for damages at law, with the right of trial by jury, ... and in case of the death of any seaman as a result of any such personal injury the personal representative of such seaman may maintain an action for damages at law with the right of trial by jury. ... Jurisdiction in such actions shall be under the court of the district in which the defendant employer resides or in which his principal office is located.

Admiralty jurisdiction and the coverage of the Jones Act depends only on a finding that the injured was “an employee of the vessel, engaged in the course of his employment” at the time of his injury. The fact that a Jones Act petitioner’s injury occurred on land is not material. 46 U.S.C. § 740; Senko v. La Crosse Dredging Corp., 352 U.S. 370, 373 (1957). Continue reading The Jones Act v. Longshore