Statewide Insurance Fund responds to first responders group

Staff report
Sussex County — In an article published today in the Township Journal and the Sparta Independent, titled 'Group calls on Trenton to fix 'broken system' of death benfit claims, (www.spartaindependent.com/apps/pbcs.dll/article?AID=/20170803/NEWS01/170809980/Group-calls-on-Trenton-to-fix-'broken-system'-of-death-benefit-claims) it was said that requests for comment from insurance carriers received no response by midday Wednesday. Shortly after the article was published, one of the insurance companies respnded to the request with a lengthy letter, reprinted in full below:
Thank you for giving Statewide Insurance Fund (“Statewide”) the opportunity to respond to the position taken by the Committee for Justice for Bill and Scott (“Committee”) and the families of Bill Martin and Scott Danielson both of whom tragically lost a family member to a heart attack. While the Statewide Insurance Fund is extremely sympathetic to any family that loses a member, it believes that the Committee and the families are not fully aware of the many facts relating to workers’ compensation claims and therefore improperly blaming “insurance carriers” and others for their frustration with the system. To help you and the public better understand how workers’ compensation claims for emergency service providers who suffer heart attacks are handled, we submit the following.
First, Statewide is not an insurance carrier. Insurance Companies are corporations founded to make a profit and have stockholders who want a return of their investments. Statewide, on the other hand, is a joint insurance fund. Joint Insurance Funds were created by the State of New Jersey at a time when insurance companies did not want to provide insurance coverage to municipalities and other public entities at affordable prices. The statutes which created them permitted municipalities, school boards and other public entities to join together to self-insure or to purchase commercial insurance at competitive rates.
Joint insurance funds do not make a profit; they have no stockholders and no investors. They are created to provide efficient and cost effective insurance to municipal and other local governments. The goal was to make available to local governments insurance coverage at affordable rates thereby serving as a safeguard against runaway tax increases resulting from dramatic increases in rates for property and liability coverage; in fact over three quarters of the public entities in New Jersey are members of joint insurance funds.
Unlike private insurance carriers there is no incentive to deny meritorious claims; in fact, since the funds are run by an executive committee comprises of municipal officials, there is a strong incentive to treat claims in a fair and efficient manner. Unlike private insurance companies, joint insurance fund meetings are open to the public as are their minutes. Since there is no profit motive the goal is to fairly handle and quickly resolve claims.
Accordingly, joint insurance funds have no incentive to delay or harass the employees or volunteers of their members; their goal is to pay claims that are due and not pay claims that are not meritorious. While joint insurance funds are interested in fair payments to meritorious claims, they are also careful to not pay claims that are not due. This is so because joint insurance fund have an obligation to each of their members to only pay meritorious claims and strenuously contest claims that should not be paid. In this regard the fund members believe that the taxpayers of their members deserve no less.
Statewide also believes that the Committee and the two families misunderstand how workers’ compensation claims are handled. The Workers’ Compensation Act dictates the benefits available to injured workers. If there is a dispute whether a claim is compensable or the benefits someone is entitled to, claimants have recourse to file a claim petition with the Workers’ Compensation Court which is staffed with highly experience, competent judges who know the workers’ compensation law and are not beholden to one side or the other. In fact, the workers compensation laws are set up for employees and many believe they generally favor employees over employers. Employees who bring claims are represented by experienced workers compensation lawyers who fight aggressively for their clients. Those who claim they are badgered or are being unreasonably delayed in pursuing their claims have recourse to the independent workers compensation judges for relief. Accordingly, the claims by the Committee and families who believe they are being unfairly treated by the workers’ compensation system made be clouded by the lack of understanding of the opportunities available to claimants through the court system. Joint insurance funds get no benefit out of delay; they want to resolve claims fairly so they can stop paying their lawyers and move on to the next matter. In particular they see no reason to mistreat emergency workers. Like everyone else they respect and appreciate the fine work done by the volunteers and want to see them protected in the way the law envisions.
Statewide also believes that the Committee and the families may not fully understand the law with respect to compensability of heart attacks and the “line of duty death” doctrine. In order for a heart attack to be compensable the claimant must prove that the injury or death was produced by a work effort or strain involving a substantial condition, event or happening in excess of the wear and tear of the claimant’s daily living. A first responder who suffers a heart attack while in the line of duty is entitled to a “presumption” that the heart attack was caused by the emergency services being provided. However this doctrine only applies when the injury or death occurs while the individual is responding, under orders from a competent authority, to a law enforcement, public safety or medical emergency. The doctrine does not apply when the heart attack occurs when the emergency service provider responds on his own.
This is an important distinction that was recognized by the Legislature when this doctrine was created. Heart attacks, as most people know, occur to older people for many different reasons. They may be caused by smoking, high cholesterol, congenital problems, family history or for other or unknown causes. The Legislature recognized that it was not fair to local taxpayers to pay possibly millions of dollars through the workers’ compensation system to a person who was an emergency services worker but who happens to have a heart attack, unrelated to his service. The decision as to whether a heart attack was caused by the emergency service or some independent cause is not always an easy one and requires evidence from medical records, family histories and the testimony of highly skilled medical experts. The workers’ compensation system is set up to address these issues fairly. However artificial deadlines, like those suggested by the Committee, are not realistic and would not lead to fair results. Those who suffer work caused heart attacks should receive workers’ compensation benefits; those who heart attacks are not related to their emergency service should not. It should be left to the workers’ compensation judges to decide which are meritorious and which are not.
While Statewide is sympathetic to the family members of emergency providers who lose a loved one, it believes it is unreasonable deadlines imposed on workers ‘compensation judges would be counterproductive and lead to unjust results either for the worker or the taxpayers who pay for the insurance. Such a deadline would not guarantee a more favorable outcome for the family for a heart attack victim when compensation was due, but might result in the decision that compensation is not due. An artificial deadline might deny the family of a heart attack victim the additional time needed to prove the case or might deprive a municipality and its taxpayers of the time needed to disprove a case. Experienced workers’ compensation judges are in the best position to judge the fairness of a particular case.
Finally, there is no evidence which suggests that first responders who belong to a union are treated differently or receive better treatment under the workers’ compensation laws than those who do not belong to a union. The law does not allow for union laborers to be treated differently than non-union laborers or volunteers. As far as Statewide is concerned, our claims representatives and panel counsel treat all claimants fairly, whether unionized or not.
Although Statewide disagrees with the criticisms made of the handling of heart attack claims in the workers’ compensation system, it offers some alternate proposals that would address the loss experienced by family members when emergency workers suffer fatal heart attacks. First, the Legislature should require, and pay for, a thorough yearly cardiac exam for fire fighters and EMS workers. This would identify any person who has an underlying and perhaps undiagnosed heart issue. Ensuring health volunteers is something that should be supported by the volunteers, their family and the municipalities for which they volunteer. It does not benefit volunteers’ with heart conditions to allow undiagnosed heart issues to go undetected.
Second, the most efficient way to assure families of emergency service workers who suffer fatal heart attacks in the line of duty to have available resources is for the Legislature to create a life insurance program for emergency workers. In times when it is difficult to secure enough volunteer fire and first aid volunteers, this would give an added incentive for new members to join and it would also provide assurance to volunteer’s families that they would not face the challenge of proving the heart attack was caused by their volunteer work. Moreover, it would provide a source of financial help to family members and a sense in the volunteers that should unforeseen fatality occur to them, their family will have financial resources.