When no accident really is an accident

This issue came up recently and I thought I would share it with you:

Claimant has a desk job in a large corporation, iIn the office, during normal working hours, walking between a conference room and her desk, her ankle suddenly gives out and she falls to the carpeted floor.  Her injuries are serious as she fractured the ankle and suffered a possible torn shoulder labrum when her arm braced the fall. 

The question left to me was: is this an accident?  Your answer after the jump.

 

Claimants must prove entitlement to mileage

This is a quick post but an important one.  It is necessary to understand that despite Claimant completing the standard mileage form she is not automatically entitled to reimbursement.  A Claimant must still prove to the JCC that entitlement is warranted.

 

Do Claimants need IME’s anymore?

Last week I wrote about the Parodi decision which reinforces the self help section of chapter 440.  [see s. 440.13(2)(c)]   The main thrust of my post was that the stakes are now considerably raised with such a decision.

In that case the First DCA found that should Claimant receive unauthorized treatment on his own, and prove that the treatment was compensable and medically necessary, then the doctors providing said treatment could testify in Claimant’s case in chief. 

After talking with a mediator about the Parodi case, he declared that Claimant’s no longer need to use their IME anymore.  They can just go and find a doctor to provide treatment under a letter of protection (LOP).  While I see his point, I don’t think the situation is as dire as that for Employers and Carriers.

 

Ethics in resolving attorney fees, Part II

A few months ago, I wrote about the ethics involved in settling attorney’s fees with Claimant attorneys.  There is a lot of pressure to close cases, and sometimes a Claimant attorney will want to carve up a settlement to include a large side fee for benefits that were not obtained. 

In Lanza v. Damien Carpentry, I noted the First DCA is going to give the Judges of Compensation Claims latitude to determine whether Carrier paid fees are warranted.  In Lanza, the E/C refused to divide up the settlement so that Claimant attorney would receive a fee above the statutory guidelines for unobtained benefits.  Claimant attorney tried to back out of the settlement, but the JCC and the First DCA enforced the agreement.  At the time, I wrote:

 

For a PEO, notice is everything

I don’t have an update on First DCA cases today, but I did have a recent research project on Professional Employment Organizations (PEO’s) that I thought I would share with you.

For many of us in the industry, PEO’s are an evolutionary step towards spreading risk of Workers’ Compensation claims.  Besides handling payroll for employers, PEO’s provide W/C insurance for many small businesses, offering them lower premiums than they would find individually.   But its important for PEO’s and employers who contract with PEO’s that any change in coverage, even termination of coverage, requires proper notice to employees.

 

Stakes are raised even higher when denying claims

I’ve written about the 3-day rule and the 5-day rule located in section 440.13, but there is also the self help provision that Employer/Carriers must worry about.  Now the First DCA just reinforced  s. 440.13(2)(c), otherwise known as the self help provision, which allows Claimant to seek medical treatment on her own, if said treatment is later found to be compensable and medically necessary.

What this means is to deny a claim or deny medical benefits carries higher risks.

 

New website reports Employers who do not have W/C coverage

The Sun Sentinel published an interesting article last week on a new whistle blower website, set up by the Chief Financial Officer (and Senate candidate) Alex Sink.  The Department of Financial Services is cracking down on Employers who fail to secure coverage.  Employees can  also check if their Employer has coverage on the DFS site.

Considering the state of the economy and that most Employers are enduring layoffs, the reporting of non-compliance by former employees is probably a motivating factor behind whistle blowers.  If you are an Employer who does not have coverage and has four or more employees, now is a time to get that coverage.  Because hiding it will just make the penalties that much worse than the premiums and now, more than ever, you are likely to get caught.

 

Wake up call to Employers and Carriers: vocational factors do matter in PTD claims

This rule isn’t new.  It was around before the 1994 changes to the PTD provision and the First DCA accepted it as the post 2003 standard.   Despite the language of the statute (not mentioning it), the JCC must consider vocational restrictions as well as physical restrictions. 

Simply waiving a 50 mile job search in front of the Judge is not going to cut it.   The First DCA held this rule before, but in Garcia v. Fence Masters, Inc., they really hammer it home.

 

First DCA limits “Objective Relevant Medical Evidence” Defense

I can understand the facts of Morrow v. Sam’s Club and why the First DCA ruled the way they did for that specific case.  But, I am worried that the decision can open up a can of worms for a host of issues outside of just a recommendation for a specialist.

 

Offering a Claimant a list of doctors is same as authorization of doctor

Many times I recieve files from adjusters who already provided a list of doctors for Claimant to choose from, be it for a specialist referral by the PCP or a one time change request.  Under the 2003 law, an Employer/Carrier does not have to provide such list to Claimants.  Even under the managed care statute, section 440.134, the only list you need to provide is for the PCP.  If you provide lists to Claimant, that is ok.  Just note you are not required to do so. 

But, a question arises if an adjuster provides a list, is that considered “authorization” even if the adjuster does not set the appointment?  The First DCA answered that question last week.