Being injured at work can be frustrating, scary, and confusing. The law is clear, however – if you’re injured at work, you should be compensated for lost work time and medical care. However, the employer and the worker’s compensation carrier must follow the regulations set out by law to properly deny coverage for your claim.
Click below to review the court’s decision reversing the trial outcome. At the trial level, Benn Haro & Isaacs represented the injured employee. The appellate court reversed a decision made by the Judge of Compensation Claims, which denied the injured employee coverage for a hospital stay following an injury.
The appellate court decided that the employer should have formally denied the claim for hospitalization earlier if they were going to deny the claim under the Pay-and-Investigate statute. In other words, the employer was required to pay all benefits due “as if the claim had been accepted as compensable” until they denied the claim outright. Thus, the fact that the employer waited until after the hospital stay to deny the claim means the employer should pay the hospital claim (but not any subsequent costs incurred).
In addition, the appellate court sent the proceedings back to the lower court to investigate other defenses that the employer had that were not addressed by the lower court originally. The appellate court found that the employer was entitled to a 10-day approval period when the injured employee was referred to the hospital for specialist care and surgery. In other words, the employer and insurance carrier have 10 days to deny coverage of referral to a hospital (which the carrier did), and therefore not be liable for payment of the hospital bill, UNLESS the care provided was emergency care. The question remaining for the lower court to determine is – was the care provided constituted “emergency care.”
This appellate decision was a case that Benn, Haro, & Isaacs argued at the trial level. If you are interested in a complimentary consultation to discuss your case we would be pleased to meet with you. Recall, there are no fees or costs unless we win your case for you. 954-324-COMP (2667). [email protected]
Under the Florida Workers’ Compensation Act, to be eligible to receive benefits, an injured workers must establish that his or her accidental compensable injury is the “Major Contributing Cause” of the need for medical care and/or disability. “Major Contributing Cause” is defined as the cause which is more than 50% responsible for the injury as compared to all other causes combined for which treatment or benefits are sought. In cases involving occupational disease or repetitive exposure, the injured worker must establish causation by the more stringent “clear and convincing” standard.
What if you re-injure or aggravate a pre-existing injury? In Florida, if you re-injure a body part that was previously injured, the Employer/Carrier is only obligated to furnish benefits to the extent the work-related injury is and remains more than 50% responsible for the injury as compared to all other causes combined and remains the reason you need medical treatment. The Courts in Florida have not interpreted pre-existing conditions to include injuries sustained as a result of a prior work-related accident. Therefore, if your prior injury was attributable to work-related accident, whether for the same Employer or a completely different Employer, the Insurance Carrier cannot use this as a means to deny you medical care.
Can the Insurance Carrier deny continued medical benefits after they have accepted my claim as compensable? The Employer/Carrier has a 120 day pay and investigate period from the initial provision of benefits to assert a denial of your claim. After that point, the Employer/Carrier can no longer contest that the accident is the “major contributing cause” of the injuries at issue. They can only contest the connection between a Claimant’s need for specific treatment or benefits, and the work-related accident. Once compensability of the injury is established, the burden shifts to the Employer/Carrier to demonstrate a break in the causation chain, such as the occurrence of a new accident or that the requested treatment was due to a condition unrelated to the injury which it had accepted as compensable.
What if your authorized doctor says your condition or injury is attributable to the normal aging process or arthritis? Case law supports that it is inappropriate to consider an injured workers’ normal-aged condition as a contributing, legal cause of the need for treatment in applying the major contributing cause analysis.
Disclaimer – This Blog Does Not Constitute Legal Advice – No Attorney-Client Relationship Formed by These Posts or By Any Comments, or By Comments Replying to Comments, on This Blog. The information and materials on this blog are provided for general informational purposes only and are not intended to be legal advice. The law changes frequently and varies from jurisdiction to jurisdiction. Being general in nature, the information and materials provided may not apply to any specific factual and/or legal set of circumstances. No attorney-client relationship is formed nor should any such relationship be implied. Nothing on this blog is intended to substitute for the advice of an attorney, especially an attorney licensed in your jurisdiction. If you require legal advice, please consult with a competent attorney licensed to practice in your jurisdiction. Past results are no guarantee of future results