PETITION FOR APPEAL OF DENIAL / TERMINATION OF STATE TEMPORARY DISABILITY INSURANCE BENEFITS
(New Jersey Administrative Proceeding)
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
- Exhibit Index
1. DOCUMENT HEADER
1.1 Title & Parties
PETITIONER: [CLAIMANT LEGAL NAME],
v.
RESPONDENT: New Jersey Department of Labor & Workforce Development, Division of Temporary Disability Insurance, and, if applicable, [PRIVATE DISABILITY INSURANCE CARRIER LEGAL NAME].
1.2 Effective Date
This Petition is deemed filed on [MM/DD/YYYY] (the “Effective Date”) upon receipt by the Division of Temporary Disability Insurance (“Division”) and docketing by the Office of Administrative Law (“OAL”).
1.3 Jurisdiction & Governing Law
This administrative appeal is governed by New Jersey state disability law and the procedural rules of the OAL. Venue is proper in the OAL pursuant to applicable state regulations.
1.4 Recitals
A. Petitioner was employed by [EMPLOYER NAME] and became unable to perform the material and substantial duties of his/her regular occupation on [DATE OF DISABILITY].
B. Petitioner timely filed a claim for temporary disability benefits, Claim No. [CLAIM NUMBER], which was denied / terminated on [DATE OF AGENCY DETERMINATION] (the “Determination”).
C. Petitioner now timely seeks administrative review of the Determination.
2. DEFINITIONS
For ease of reference, the following capitalized terms are used throughout this Petition:
“Administrative Record” – The complete file maintained by the Division concerning Petitioner’s claim, including all submissions and determinations.
“Benefit Amount” – The weekly disability benefit calculated under New Jersey law for the applicable Benefit Period, capped at the statutory maximum for the relevant calendar year.
“Benefit Period” – The span of consecutive weeks for which Petitioner seeks benefits, beginning [MM/DD/YYYY] and projected to end [MM/DD/YYYY] or upon medical clearance to return to work, whichever occurs first.
“Impairment” – The medical condition(s) substantiated by objective clinical findings that prevent Petitioner from performing work activities as defined by New Jersey temporary disability regulations.
“Medical Certification” – A properly executed medical report on Division-approved forms, signed by a licensed physician, advanced practice nurse, or other statutorily authorized provider.
“Vocational Evidence” – Information demonstrating the impact of Petitioner’s Impairment on his/her ability to engage in past relevant work or any suitable gainful employment, including functional capacity evaluations, labor-market surveys, and expert opinions.
3. OPERATIVE PROVISIONS
3.1 Statement of Issues on Appeal
a. Whether the Division erred in finding that Petitioner is not disabled under applicable statutory criteria.
b. Whether the Division failed to give proper weight to Petitioner’s Medical Certification(s) and supporting Vocational Evidence.
c. Whether the Determination violated due-process safeguards by omitting a clear statement of reasons or by disregarding material evidence.
3.2 Relief Requested
Petitioner respectfully requests that the OAL:
1. Reverse the Determination;
2. Award temporary disability benefits for the full Benefit Period, together with statutory interest; and
3. Grant such other relief as is equitable and just under New Jersey law.
3.3 Performance Standards & Deadlines
- Respondent shall file the Administrative Record within [__] days of service of this Petition.
- Petitioner shall submit supplemental evidence, including updated Medical Certification(s) and Vocational Evidence, no later than [__] days before the scheduled hearing date.
- A de novo evidentiary hearing shall be held within the timeframe prescribed by OAL rules.
[// GUIDANCE: Confirm current OAL scheduling requirements; deadlines vary and may be accelerated for benefit-payment cases.]
4. REPRESENTATIONS & WARRANTIES
4.1 Petitioner represents and warrants that:
a. All facts set forth herein and in supporting Exhibits are true and correct to the best of Petitioner’s knowledge, information, and belief;
b. Petitioner has fully cooperated with all reasonable requests from the Division and provided complete Medical Certification(s); and
c. No material fact has been intentionally withheld that would adversely affect eligibility for benefits.
4.2 Survival. The representations in this Section 4 survive the conclusion of the administrative proceeding.
5. COVENANTS & RESTRICTIONS
5.1 Ongoing Disclosure. Petitioner covenants to promptly supplement the record with any material change in medical condition or employment status.
5.2 Cooperation. Petitioner agrees to attend any independent medical examination (“IME”) reasonably requested by Respondent, provided that Respondent bears all related costs.
5.3 Notice Obligations. Respondent shall promptly notify Petitioner and counsel of any additional documentation required for adjudication, allowing no less than [__] days for compliance.
6. DEFAULT & REMEDIES
6.1 Events of Default
a. Respondent’s failure to transmit the Administrative Record by the deadline in Section 3.3.1;
b. Respondent’s failure to pay benefits within [__] days of a final favorable decision;
c. Petitioner’s failure to appear at a scheduled hearing without good cause.
6.2 Cure Periods
The non-defaulting party shall provide written notice specifying the default. The defaulting party has [10] days to cure, unless a shorter period is mandated by regulation.
6.3 Remedies
a. Upon Respondent default, Petitioner may seek default judgment and immediate payment of all due benefits plus statutory interest.
b. Upon Petitioner default, the OAL may dismiss this Petition without prejudice, subject to reinstatement for good cause.
c. The prevailing party may move for an award of reasonable attorney fees and costs where authorized by statute or rule.
7. RISK ALLOCATION
7.1 Indemnification
Not applicable. No party seeks indemnification in this administrative benefits proceeding.
7.2 Limitation of Liability
Any monetary liability of Respondent to Petitioner is limited to the Benefit Amounts lawfully payable under New Jersey temporary disability law, plus any statutory interest and authorized fees.
7.3 Force Majeure
Neither party shall be deemed in default for delays caused by events beyond its reasonable control, provided that prompt written notice is given and diligent efforts to resume performance are undertaken.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Petition is governed by the substantive and procedural laws of the State of New Jersey.
8.2 Forum Selection
Exclusive jurisdiction lies in the Office of Administrative Law for initial adjudication, with subsequent appellate review as permitted by New Jersey court rules.
8.3 Arbitration
Not available. This matter is statutorily committed to administrative adjudication.
8.4 Jury Waiver
Not applicable—administrative proceeding.
8.5 Injunctive Relief
Petitioner reserves the right to seek interim benefit payments or other equitable relief if undue delay threatens irreparable harm.
9. GENERAL PROVISIONS
9.1 Amendments. This Petition may be amended only by written filing conforming to OAL rules.
9.2 Assignment. Neither party may assign rights or obligations arising out of this Petition without written consent of the other party and the OAL, except as required by law.
9.3 Severability. If any provision is found invalid, the remainder shall be enforced to the fullest extent permitted.
9.4 Integration. This Petition, together with all Exhibits, constitutes the entire submission for administrative review.
9.5 Electronic Signatures. Electronic signatures that comply with N.J. court-approved technology standards shall be deemed originals.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, Petitioner executes this Petition as of the Effective Date.
[CLAIMANT NAME], Petitioner
Address: [ADDRESS]
Phone: [PHONE]
Email: [EMAIL]
[Optional Attorney Block]
[ATTORNEY NAME], Esq.
Attorney for Petitioner
Firm: [FIRM NAME]
Bar ID: [BAR NUMBER]
Address: [ADDRESS]
Phone: [PHONE]
Email: [EMAIL]
[// GUIDANCE: Attach notarization or verification statement if required by OAL rules.]
11. EXHIBIT INDEX
Exhibit A – Medical Certification(s) and Objective Clinical Evidence
Exhibit B – Vocational Evidence (Functional Capacity Evaluation, Labor-Market Survey, Expert Report)
Exhibit C – Chronological Benefit Calculation Worksheet
Exhibit D – Prior Agency Correspondence and Determination Notice
Exhibit E – Any Additional Supporting Documentation
[// GUIDANCE:
1. Filing Deadline: Confirm the current statutory deadline (commonly 7 calendar days from receipt or 10 calendar days from mailing of the Determination).
2. Service: Serve a copy on the Division, the private carrier (if applicable), and the Attorney General if required.
3. Hearing Preparation: Organize exhibits in the same order as referenced above and provide copies to the OAL and Respondent at least 5 days before hearing.
4. Medical & Vocational Evidence: Ensure all expert reports strictly address functional limitations, prognosis, and expected duration, tying findings to statutory eligibility factors.
5. Privacy: Redact or code Social Security numbers and protected health information per state confidentiality rules.]