Injured employees and those with job-acquired illnesses typically qualify for two main types of benefits. They can request disability benefits if they become unable to work because of their medical challenges. They can also request medical benefits that can pay for the cost of their necessary treatment.
Medical benefits can be quite valuable for workers with job-acquired health challenges. They don’t have to pay a deductible or worry about coinsurance. Workers’ compensation covers the full cost of their care. However, there are some limits that do apply to medical coverage provided through workers’ compensation. The benefits may eventually end, leaving a worker without access to treatment or forcing them to cover their own care costs.
When do New Jersey workers’ compensation medical benefits typically end?
After a worker fully recovers
The best-case scenario for an injured worker is that they make a full recovery. If they no longer have any symptoms and can fully return to work, they are no longer eligible for ongoing medical benefits. However, they may be able to apply to resume certain medical benefits if their symptoms ever recur.
After achieving maximum medical improvement
Many workers have injuries that could have long-term career implications. Particularly if they work in a blue-collar profession, they may never regain the functional capabilities they lose because of an injury. Still, they may reach a point where they stop responding to treatment. The physician overseeing a New Jersey workers’ compensation claim can file paperwork asserting that the employee achieved maximum medical improvement (MMI).
At that point, the employee may not qualify for ongoing treatment benefits. Instead, workers’ compensation may only cover care costs related to symptom management. If a worker is unlikely to respond to treatment attempts, workers’ compensation does not pay for that care.
After medical non-compliance
Occasionally, a worker who has not fully recovered or achieved MMI could become ineligible for ongoing benefits. If a physician determines that a worker is medically non-compliant, they can report the issue and potentially terminate their benefits.
When workers refuse to undergo necessary treatment or attend physical therapy, their failure to follow medical instructions contributes to their ongoing symptoms. Their personal responsibility for their delayed recovery might make them ineligible for continued benefits. Sometimes, workers get accused of medical non-compliance or a doctor declares that they achieved MMI when that is not actually true. Those facing complex workers’ compensation claims or appeals may need assistance.
If they contest the determination by the doctor overseeing their care, they may sometimes be able to resume receiving benefits despite a prior declaration that they achieved MMI or became medically non-compliant.
Understanding the rules that govern New Jersey workers’ compensation can help employees get the support they require when they are dealing with a medical condition caused by their employment.