Lambert v. Travelers
___ N.J. Super. ___ (App. Div. 2016)
Decided August 24, 2016
In consolidated appeals of work-related motor vehicle accident claims, petitioners argued for extinguishment of the medical portion of workers' compensation carriers’ liens as provided in N.J.S.A. 34:15-40 (Section 40). Petitioners argued that, since N.J.S.A. 39:6A-12 of the PIP statutes bars evidence in an action against a third-party tortfeasor of amounts “collectible or paid” under PIP coverage, the normal lien provisions of the Workers’ Compensation Act (i.e., Section 40) do not apply here. However, the Appellate Division disagreed and held that the right of the injured worker to pursue claims against the third-party tortfeasor, as well as the right of the workers' compensation insurer to be reimbursed, are governed by the Workers’ Compensation Act and not the PIP (AICRA) statutes in such cases. Accordingly, the injured worker may recover medical expenses from the third-party tortfeasor and N.J.S.A. 39:6A-12 does not apply. The workers' compensation insurer, in turn, has a right to be reimbursed for the appropriate portion of the medical expenses it has already paid under N.J.S.A. 34:15-40.
Talmadge v. Burns
446 N.J. Super. 413 (App. Div. 2016)
Decided June 22, 2016
In a work-related automobile accident case, petitioner appealed an order of the trial court denying her motion to declare the medical benefits portion of carrier’s N.J.S.A. 34:15-40 lien unenforceable. In her appeal she argued that, because those medical benefits that could have been paid through the PIP provisions of her automobile liability policy were not recoverable from the tortfeasor, the workers’ compensation carrier’s Section 40 lien for repayment of such medical costs should be denied. In opposition, the workers’ compensation carrier argued that it was entitled to a Section 40 reimbursement from any recovery paid to the petitioner from a third-party recovery against the tortfeasor. The Appellate Division agreed with the carrier and affirmed the decision below.
Rivelli v. MH&W Corp.
383 N.J. Super. 69 (App. Div. 2006)
Respondent/employer, which had entered into an earlier settlement which included its responsibility for a compensable cardiological condition, appealed the compensation judge’s order that it pay for petitioner’s Lipitor which was prescribed to lower petitioner’s high cholesterol. After taking notice of a recent release of the FDA announcing Lipitor as newly approved for treating cardiovascular conditions, the Appellate Division remanded the case for a determination on the: (1) relationship between petitioner’s high cholesterol condition and his work related compensable heart condition; and (2) use of Lipitor to treat the compensable heart condition.
Division Reserved Decisions
Bannon v. Ridgefield Board of Education
08-30924; 09-33181 decided January 13, 2016 by the Hon. Philip A. Tornetta, J.W.C.
Respondent filed a motion to terminate the medical treatment it was providing the petitioner. The petitioner opposed, and medical testimony was heard. After considering all the testimony and moving papers the judge found that, although the petitioner reached maximum medical improvement with reference to one type of treatment she was receiving, other forms of treatment still needed to be continued. Accordingly, the judge specified those necessary treatments in the Order entered.
Neglia v. Craft Carpentry & Drywall
12-1172 decided June 10, 2014 by the Honorable Philip A. Tornetta, J.W.C.
Petitioner filed motion for reconsideration of an earlier order that: (1) denied his motion for medical and temporary benefits; (2) dismissed his claim petition with prejudice; and (3) directed him to reimburse respondent for payments made for medical treatment. The Court entered this order pursuant to the Workers’ Compensation Fraud Act (N.J.S.A. 34:15-57.4). Here the Court denied the petitioner’s motion for reconsideration of its finding that the petitioner purposely or knowingly made false or misleading statements in claiming compensation benefits and failed to prove any causal relationship between the alleged work-related accident and his need for medical treatment.
Burn Surgeons of St. Barnabas v. Shoprite
09-16548 decided August 26, 2011 by the Honorable Virginia M. Dietrich, J.W.C
Dispute arose after petitioner treated a severely injured employee of the respondent and then submitted bills to the respondent's carrier listing two surgeons as "co-surgeons" rather than as "primary surgeon" and "assistant surgeon". The carrier alleged that such billing resulted in a higher rate than the usual, customary and reasonable rate it authorized. After careful review of the voluminous documentary and testimonial evidence about burn surgery procedures, medical coding and billing systems, and standard fee schedules, the judge decided in favor of the respondent by finding that its reimbursement to the petitioner was sufficient. Accordingly, the petitioner's claim for reimbursement at a higher rate was dismissed.
Sanchez v. The Gap
10-32557, decided November 23, 2011 by the Honorable Theresa L. Yang, J.W.C
Petitioner made a Motion for Medical Treatment and Temporary Disability Benefits requesting treatment for her neck and right shoulder. In denying the motion, the judge of compensation gave more weight to the findings of the respondent's medical expert in which he concluded that the petitioner had engaged in "symptom magnification".
Andaloro v. J R Cigar
06-10516 decided September 27, 2007 by the Honorable Philip A. Tornetta, J.W.C.
Petitioner’s motion for medical and temporary disability benefits alleged that she needed a chondral transplant or tibial osteotomy to treat her right knee, which was injured as a result of a work-related accident. However, the Judge of Compensation concluded that the petitioner failed to prove there was a causal relationship between the need for such treatment and the traumatic work injury. Accordingly, the motion was denied.
Hill v. Quick Chek Food Stores
00-40967 decided September 12, 2003 by the Honorable Peter F. Womack, J.W.C.
Petitioner fell on her hands and knees in a work-related accident. Initially, she complained about severe pain in her right knee and received surgery for that knee. But some time later, petitioner complained of severe pain in her left knee and in her hands. She alleged that these subsequent conditions also were caused by the accident in which she fell. The compensation judge found that there was sufficient evidence for finding a causal connection between the injury to petitioner’s left knee and her work accident, at least partly because the petitioner needed to shift weight off of her right knee and onto her left knee as a result of that accident. However, the judge did not find sufficient evidence for concluding that the painful condition of petitioner’s hands was causally linked to the same accident.
Baez v. South Jersey Health System
01-27910, decided April 12, 2002 by the Honorable Robert F. Butler, J.W.C.
The petitioner’s motion for medical and temporary benefits was returned, pursuant to N.J.A.C. 12:235-5.2(b)2, because it did not contain a medical report stating the specific type of treatment being sought as required by the cited rule.
Cable v. Woodbridge Sanitation
89-8958, decided May 30, 2001 by the Honorable Neale F. Hooley, J.W.C.
The respondent attempted to terminate trigger-point injections to a totally disabled petitioner. The judge allowed a continuation of the treatment with limitations.
Prudential Prop. & Cas., as nominee v. National Parts Supply
99-5187, decided May 9, 2001 by the Honorable Neale F. Hooley, J.W.C.
The workers’ compensation judge held that the resolution of petitioner’s claim pursuant to N.J.S.A. 34:15-20 does not terminate the rights of a subrogating PIP carrier who had paid the petitioner’s medical expenses related to the workers’ compensation injury. The judge also held that the recovery rights of the PIP carrier are not affected by the fact that the workers’ compensation carrier did not authorize the medical services.
Charman v. Trump Taj Majal
96-19976, decided February 3, 2001 by the Honorable Shelly B. Lashman, J.W.C.
The petitioner sought an order compelling respondent to provide for an electrical stimulus to his spinal cord. The workers’ compensation judge found that such palliative treatment is compensable since it tends to relieve petitioner of his symptoms.
Hartten v. Link Belt Construction Equipment
93-028693, decided December 7, 2000 by the Honorable Neale F. Hooley, J.W.C.
The insurance carrier sought a lien against the petitioner’s third-party settlement for the cost of rehabilitation services. The workers’ compensation judge held that the carrier was only entitled to a lien on services that were “necessary and reasonable”.
Freuler v. Macy’s
94-38805, decided July 18, 2000 by the Honorable Fred H. Kumpf, J.W.C.
Petitioner was injured when he was struck on his head and neck by a falling bar while on the job and by court order was to receive medical treatment. Respondent failed to comply with the court’s order for medical treatment. Petitioner subsequently returned to employment. At the trial for permanent disability the judge not only found permanent disability, but also ordered respondent to pay all attorney and expert fees as a consequence of not complying with the earlier court order.
Oddy v. Just Shirts
93-17977, decided July 9, 1999 by the Honorable Neale F. Hooley, J.W.C.
Petitioner requested additional surgery in the form of the installation of a spinal column stimulator. In denying the treatment, the judge of compensation considered that petitioner had been videotaped on surveillance performing activities contrary to her own testified abilities, and that medical experts accused petitioner of “symptom magnification”.
Romaine v. Cedar Grove Board of Education
93-34285, decided April 16, 1999 by the Honorable Anthony Minitti, J.W.C.
The petitioner suffered a work-related accident while she was receiving authorized treatment for a prior injury. The respondent claimed that it sent a letter to petitioner de-authorizing petitioners’ active treatment. Petitioner, however, interpreted the letter as denying authorization for new treatment but maintaining her current active treatment. The judge resolved the ambiguity in favor of petitioner and ordered respondent to pay for the disputed treatment.