Workers' Compensation

October 11, 2018

Jeffrey P. Gale, P.A. // Florida Workers’ Compensation SOL Tolling, Impairment Rating & Guides

Our firm recently settled a hard fought workers’ compensation case arising from a 1995 industrial accident. We received the initial call from the Claimant in March of this year (2018). He explained that he had not received medical care for his injuries, tibia and fibula fractures, since three months post surgery in 1995, but had for the past ten years been experiencing progressively worsening pain for which he now wished to be examined by a doctor. He claimed to be unaware of the Florida workers’ compensation system’s two year statute of limitations (SOL).

We accepted the case and proceeded to undertake discovery on four critical issues, the answers to which would decide whether or not the carrier would be estopped from relying on the statute of limitations defense.

Did the workers’ compensation carrier send the claimant the section 440.185(4), Florida Statutes informational brochure which sets forth an explanation of his rights, benefits, and procedures for obtaining benefits and assistance under the Florida Workers’ Compensation Law?
If not, did the claimant otherwise gain knowledge of these rights, say, for example, from a lawyer or even a friend?
Did the carrier obtain a date of MMI or a permanent impairment rating from the medical provider it authorized and pay the impairment benefits?
If not, was the claimant otherwise aware of his entitlement to impairment benefits?

In 1995, as today, carriers were instructed by section 440.185(4) to inform claimants of their rights under the workers’ compensation law. While a failure to do this could toll the SOL — i.e., keep it from running — it is not an absolute. The workers’ compensation judge (JCC) is charged with determining “whether the claimant lacked actual knowledge of his rights under the workers’ compensation law, and, if so, whether the absence of such knowledge was the cause of the claimant’s failure to obtain the requested care within the limitation period.” Fontanills v. Hillsborough County School Board, 913 So.2d 28, 30 (Fla. 1st DCA 2005).

August 16, 2018

Jeffrey P. Gale, P.A. // Issues Related to Positive Alcohol and Drug Test Results in Florida Workers’ Compensation Cases

by Jeffrey P. Gale, P.A.

Employees testing positive for alcohol or drugs in their system at the time of injury face an uphill battle to recover workers’ compensation benefits. Under subsection 440.09(3), Florida Statutes (2018), compensation is not payable if the injury was occasioned primarily by the intoxication of the employee. If the employer has reason to suspect that the injury was occasioned primarily by the intoxication of the employee or by the use of any drug, urine and/or blood testing is authorized. A positive test result may create the presumption “that the injury was occasioned primarily by the intoxication of, or by the influence of the drug upon, the employee.” Section 440.09(7)(b), Florida Statutes (2018). Unless the employee can overcome the presumption, benefits will be denied. Section 440.09(3).

There are two standards for overcoming the presumption. Which one applies depends on whether or not the employer has instituted a drug-free workplace in accordance with Florida Statute 440.102.

“If the employer has implemented a drug-free workplace, this presumption may be rebutted only by evidence that there is no reasonable hypothesis that the intoxication or drug influence contributed to the injury.” Section 440.09(7)(b), Florida Statutes (2018).
“In the absence of a drug-free workplace program, this presumption may be rebutted by clear and convincing evidence that the intoxication or influence of the drug did not contribute to the injury.” Section 440.09(7)(b), Florida Statutes (2018).

Standard number 1 is more difficult for claimants to overcome than number 2. Sometimes, neither applies. In Wright v. DSK Group, 821 So.2d 455 (Fla. 1st DCA 2002), testimony was adduced from witnesses that claimant had ‘”smoked marijuana on the day of his injury.”‘ Relying on this testimony alone, the judge of compensation claims (JCC) applied the presumption and required the claimant to meet standard number 2. The JCC was reversed on appeal, with the court holding that the presumption did not apply and the employer failed to meet its burden that the work-related injury ‘”was occasioned primarily by the … influence of any drugs … not prescribed by a physician.”‘ Section 440.09(3), Fla. Stat. (1999). See generally Temporary Labor Source v. E.H., 765 So.2d 757 (Fla. 1st DCA 2000) (affirming a ruling that the presumption authorized by section 440.09(7)(b) does not arise when confirmation testing did not conform with applicable rules and that, as a result, the employer was required to establish that the injury was caused primarily by the influence of drugs), review denied, 786 So.2d 1189 (Fla.2001). “When the presumption in section 440.09(7)(b) does not apply, employer/carriers must `establish, by the greater weight of the evidence, that the work-related injury was occasioned primarily by the intoxication of the employee.'” See Thomas v. Bircheat, 16 So. 3d 198, 200 (Fla. 1st DCA 2009) (quoting Wright v. DSK Group, 821 So. 2d 455, 456 (Fla. 1st DCA 2002); see also Sterling v. Mike Brown, Inc., 580 So. 2d 832, 835 (Fla. 1st DCA 1991) (affirming JCC’s order finding employee’s injury was primarily caused by his intoxication even without presumption).

August 3, 2018

Jeffrey P. Gale, P.A. // Clarifying Meaning of “Authorized Treating Provider” Under Florida Statute 440.13(5)(e)

by Jeffrey P. Gale, P.A.

Florida statute section 440.13(5)(e) limits who may give medical opinions in workers’ compensation trials to “a medical advisor appointed by the judge of compensation claims or the department, an independent medical examiner, or an authorized treating provider.”

Our office recently accepted a 23 year old workers’ compensation case where the employee has not received any workers’ compensation benefits for 22 years. The workers’ compensation insurance carrier has raised two defenses to the claim: (1) Statute of Limitations and (2) causal relationship between the current complaints (back and leg pain) and the injury suffered in 1995 (a tibial fracture requiring medullary rodding) — see, 440.02(36).

To carry our burden of establishing the necessary causal connection (to defeat defense #2), medical testimony must be presented. The original surgeon, who was then authorized by the workers’ compensation carrier, is still practicing medicine in Miami-Dade County. Our plan is to have him evaluate the claimant to give his opinion on the issue.

The employer/carrier (E/C) claims that the doctor is no longer “an authorized treating provider,” precluding him from being qualified to give the key opinion testimony. We believe that E/C is wrong.

August 1, 2018

Jeffrey P. Gale, P.A. // ADA vis-a-vis Workers’ Compensation Martin v. Carpenter Defense

by Jeffrey P. Gale, P.A.

In 1961, the Florida Supreme Court denied benefits to a workers’ compensation claimant who claimed to hurt her back on the job, for misrepresenting a past medical condition in a job application. See, Martin v. Carpenter, 132 So.2d 400 (Fla. 1961).

For a number of years prior to completing her job application, the claimant had experienced pains in her back. She had on several occasions during those years sought medical treatment for her back condition. When claimant sought employment by the employer she was required to complete a document named “Physical Examination Record” as a condition precedent to employment. The first question on the form asked if the applicant had ever been subject to various diseases and infirmities including “Back injury or Backache.” To this question claimant answered “No.”

The employer/carrier advanced two defenses to the claim for benefits, the second contention being that claimant, because of falsification of the pre-employment questionnaire as to her physical condition, is not entitled to compensation.

July 4, 2018

Jeffrey P. Gale, P.A. // Neglecting Duty Prevents Application of Florida Workers’ Compensation Statute of Limitations

by Jeffrey P. Gale, P.A.

Every type of legal matter has a time bar to when legal proceedings can be maintained to address a dispute. The time bar is known as the statute of limitations. The Florida workers’ compensation statute of limitations is contained in section 440.19, Florida Statutes.

Especially in the area of workers’ compensation, the courts have formulated ways of overcoming the SOL defense. One avenue is by demonstrating — it is the claimant’s burden — that the employer/carrier (E/C) have neglected or shirked their responsibilities and obligations to notify claimant[s] of possible benefits under the Workers’ Compensation Act. Gauthier v. Florida International University, 38 So.3d 221 (Fla. 1st DCA 2010). The result of making the proper proof is that the E/C will be estopped from relying on a statute of limitations defense.

In Gauthier, the claimant sustained a serious eye injury. Despite its knowledge of claimant’s severe ocular injury, E/C never pursued a date of maximum medical improvement (MMI) — section 440.02(10), Florida Statutes — or a permanent impairment rating (PIR) — 440.02(22) — thus avoiding the payment of permanent impairment benefits — 440.15(3) — which, if paid, would have tolled the statute of limitations.

June 27, 2018

Jeffrey P. Gale, P.A. // Florida Workers’ Compensation Responsibility Without Compensability

by Jeffrey P. Gale, P.A.

For the most part, workers’ compensation insurance companies limit their payment of medical expenses to conditions caused by work-related accidents. In some instances, however, carriers may be required to cover expenses for unrelated conditions. The primary instances are when (1) diagnostic testing is required to determine the compensability of an injury, (2) an unrelated condition presents a hindrance to the recovery of a compensable medical condition, and (3) controlling an unrelated condition, like high blood pressure, is necessary to allow the claimant to undergo a related procedure, like surgery.

Both principles are grounded on section 440.13(1)(k), Florida Statutes, which provides:

“Medically necessary” or “medical necessity” means any medical service or medical supply which is used to identify or treat an illness or injury, is appropriate to the patient’s diagnosis and status of recovery, and is consistent with the location of service, the level of care provided, and applicable practice parameters. The service should be widely accepted among practicing health care providers, based on scientific criteria, and determined to be reasonably safe. The service must not be of an experimental, investigative, or research nature.

Treatment to determine whether an injury is compensable

Laxner v. Target Corporation, 41 So.3d 396 (Fla. 1st DCA 2010). To establish entitlement to medical treatment, care, and modalities that have an investigatory or diagnostic purpose, workers’ compensation law does not require claimant to prove the major contributing cause of the need for treatment or diagnostic testing is her workplace accident or injury; rather, the award of such medical care is dependent on a finding that the evaluation is reasonably required to determine the cause and extent of claimant’s injuries.

May 28, 2018

Jeffrey P. Gale, P.A. // “On-call” Attendant Care in Florida’s worker’s compensation system

by Jeffrey P. Gale, P.A.

The current definition of “attendant care,” which is not significantly different than in past versions of the statute, is as follows:

Florida Statute 440.13(1)(b). “Attendant care” means care rendered by trained professional attendants which is beyond the scope of household duties. Family members may provide nonprofessional attendant care, but may not be compensated under this chapter for care that falls within the scope of household duties and other services normally and gratuitously provided by family members.

At the outset, it should be noted that the Claimant has the burden of proving the quantity, quality, and duration of the attendant care. See Adams Bldg. Materials, Inc., v. Brooks, 892 So.2d 527, 530 (Fla. 1st DCA 2004) (citing Orange Cnty. Sheriff’s Dep’t v. Perez, 541 So.2d 652, 654 (Fla. 1st DCA 1989) (holding claimant has burden to prove “the quantity, quality and duration of attendant services claimed”)).

May 17, 2018

Jeffrey P. Gale, P.A. // Compensation Without an “Accident” (Florida Workers’ Compensation Law)

by Jeffrey P. Gale, P.A.

Florida Statute 440.02(1), which is contained in the definitions section of Florida’s workers’ compensation system, defines “Accident” as “an unexpected or unusual event or result that happens suddenly.” Can an injury resulting from an event that is not unexpected or unusual be compensable under Florida’s workers’ compensation system? Yes.

In Bryant v. David Lawrence Mental Health Center, 672 So.2d 629 (Fla. 1st DCA 1996), the Employee/Claimant, who was employed as a housekeeper at a mental health facility, squatted to lift a bag of laundry off the floor of the laundry room and felt immediate pain in her right knee. She sustained a tear of the lateral meniscus in that knee.

Because squatting is not an unexpected or unusual event, the Employer/Carrier denied the claim, and it was able to get the judge of workers’ compensation claims (JCC) to agree with its position that “her [the Claimant’s] injury was idiopathic and did not arise out of the claimant’s employment because her employment did not expose her to any greater risk than she experiences in her everyday life and to which the population as a whole is exposed.” (Miriam-Webster defines idiopathic as an injury “arising spontaneously or from an obscure or unknown case.”)

April 15, 2018

Jeffrey P. Gale, P.A. // “Reasonable Person” Standard in Florida Workers’ Compensation Notice Cases

by Jeffrey P. Gale, P.A.

Florida’s workers’ compensation system has two distinct time bars for filing petitions to seek benefits. Most people are at least vaguely aware of one of the concepts, known as the statute of limitations (SOL). Florida’s workers’ compensation SOL is enunciated in section 440.19, Florida Statutes.

The other time bar is laid out in Florida Statute 440.185(1), reproduced below:

(1) An employee who suffers an injury arising out of and in the course of employment shall advise his or her employer of the injury within 30 days after the date of or initial manifestation of the injury. Failure to so advise the employer shall bar a petition under this chapter unless:

(a) The employer or the employer’s agent had actual knowledge of the injury;

(b) The cause of the injury could not be identified without a medical opinion and the employee advised the employer within 30 days after obtaining a medical opinion indicating that the injury arose out of and in the course of employment;

(c) The employer did not put its employees on notice of the requirements of this section by posting notice pursuant to s. 440.055; or

(d) Exceptional circumstances, outside the scope of paragraph (a) or paragraph (b) justify such failure.

This blog addresses subsection (d).

The statute is often interpreted strictly to the detriment of the injured worker. Accordingly, while there is some room for challenge built into every subsection of the statute, it is nevertheless advisable to err on the side of caution by giving notice [to the employer] whenever practicable within 30 days of having even the slightest indication a work-related injury may have been sustained.

April 8, 2018

Jeffrey P. Gale, P.A. // Florida Workers’ Compensation Medicare Set-Aside Issues

by Jeffrey P. Gale, P.A.

Individuals receiving Florida workers’ compensation benefits for serious medical conditions must give deep thought and consideration to the role of Medicare in their future medical plans. This is especially so for those who are eligible or soon to be eligible for Medicare.

Because workers’ compensation has primary responsibility [for covering medical care associated with work-related injuries] versus Medicare’s secondary payor status, failing to adequately account for Medicare’s imperatives may keep the Centers for Medicare & Medicaid Services (CMS), a branch of the Department of Health and Human Services (HHS), the federal agency that runs the Medicare Program, from covering much needed future care and services.

Most Florida workers’ compensation cases end up settling. The settlement can take the form of a lump sum (all at once) payment or a structured settlement (which may also include a lump sum component). In consideration for this compensation, claimants must typically forego the right to receive future workers’ compensation medical benefits.

Given its status as a secondary payor, Medicare expects a portion of the lump sum and structured settlement money to be used by the claimant to cover the cost of medical care received in the future in connection with the work-related injuries. Until the amount, which should be pre-established by experts and approved by Medicare — in the absence of pre-approval, we try to get the workers’ compensation insurance carrier to agree to cover the difference between the informal earmarked amount and a later amount Medicare may claim is due — is exhausted and properly accounted for, Medicare will not undertake its role as a secondary payor, i.e., begin making payments for work-related injuries. For example, if $53,000 (a number we used in a recent settlement) were earmarked for this purpose, Medicare would not make any payments until the entire $53,000 (plus interest, if applicable) were exhausted on the claimant’s medical care (for Medicare covered services only — meaning that any money expended for non-covered services does not count against the set-aside amount that must be exhausted before Medicare pays penny one.) See, July 23, 2001 Medicare memo.