New Jersey Administrative Code
Title 12 - LABOR AND WORKFORCE DEVELOPMENT
Chapter 21 - FAMILY LEAVE INSURANCE BENEFITS
Subchapter 2 - PRIVATE PLANS
Section 12:21-2.6 - Appeals

Universal Citation: NJ Admin Code 12:21-2.6

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The appeal procedures for private plan family leave insurance cases are found at N.J.A.C. 1:12A and at the N.J.A.C. 12:18 Appendix.

(b) If a claimant covered under a private plan is denied benefits by the insurer for any period of family leave or he or she disagrees with a determination of benefits made by the insurer, he or she has the right to appeal the determination or denial.

(c) The appeal or complaint shall be filed with the Division within one year after the beginning of the period for which benefits are claimed. Such appeal or complaint shall be filed, either personally or by mail, by the claimant or his or her representative. A late appeal shall be considered on its merits if it is determined that the appeal was delayed for good cause. Good cause exists in circumstances where it is shown that:

1. The delay in filing the appeal was due to circumstances beyond the control of the appellant; or

2. The appellant delayed filing the appeal for circumstances that could not have been reasonably foreseen or prevented.

(d) Any appeal or complaint by a claimant claiming benefits under an approved private plan shall be filed on a form and in a manner prescribed by the Director. The claimant must include the reasons for the appeal or complaint and explain why he or she disagrees with the determination or denial of benefits on the form.

(e) Upon receipt of such appeal or complaint, the Division shall conduct an investigation and such informal conferences as it may deem necessary to determine the facts and settle the issues.

(f) Any appeal or complaint shall be deemed filed on the day it is delivered to the office of the Division of Temporary Disability Insurance, Labor and Workforce Development Building, PO Box 957, John Fitch Plaza, Trenton, New Jersey 08625-0957, or if mailed, the complaint shall be deemed filed on the postmarked date appearing on the envelope in which the complaint is mailed; provided, postage is prepaid and the envelope is properly addressed.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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