N.J. Admin. Code § 12:21-3.1

Current through Register Vol. 56, No. 23, December 2, 2024

Section 12:21-3.1 - Extent of coverage

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

(b) A claimant shall not be paid any benefits under 43:21-3 and 4 for any period of family leave commencing while he or she is a "covered individual" as defined in 43:21-27(b)(2).

(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 family leave shall not be entitled to any benefits under the State plan.

(d) If application for benefits is made under a private plan or for family leave insurance benefits during unemployment, 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 provided that:

1. The application to the private plan or for family leave insurance benefits during unemployment, 43:21-4, would have been timely noticed to the State plan if it had been then made; and

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

(e) If an employee is overpaid benefits under the State plan, the amount of such overpayment shall not be deducted from the amount of benefits to which he or she may be entitled under a private plan or under 43:21-3 and 4 as an unemployed claimant for a subsequent period of family leave. If an employee is overpaid benefits under a private plan, the amount of such overpayment shall not be deducted from the amount of benefits to which he or she may be entitled under the State plan, or under 43:21-3 and 4 as an unemployed claimant for a subsequent period of family leave.

(f) Where a care recipient has utilized a health care provider, and that health care provider has examined the care recipient and has diagnosed him or her with a serious health condition, the claimant may only be denied benefits during that period so certified where:

1. The Division has contacted the care recipient's personal health care provider and has reached a mutual agreement therewith as to a change in the period of the care recipient's serious health condition or care required by the care giver;

2. A licensed medical practitioner designated by the Commissioner of Labor and Workforce Development or his or her designee has examined the care recipient and has determined that the care recipient no longer has a serious health condition or requires care by the care giver. Where such a determination has been made, benefits shall not be paid beyond the date of examination;

3. A care recipient 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 claimant shall be disqualified from receiving all benefits for the period of family leave in question, except as to benefits already paid; or

4. The Division has obtained credible factual evidence showing that the care recipient is performing activities that demonstrate a serious health condition does not exist. In such instances, benefits shall not be paid beyond the date that such factual evidence is obtained.

(g) If a physical examination of a care recipient 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 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 Family Temporary Disability Leave Account as a cost for the administration of family leave insurance benefits payments. 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 by the Commissioner.

(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 by the State plan if the employer has State plan coverage. However, claims coming within the purview of 12:21-2.1 0 or 3.6 shall be governed thereby.

N.J. Admin. Code § 12:21-3.1