40 Fla. L.
Weekly D2274dTop of Form
Weekly D2274dTop of Form
Workers’
compensation — Medical benefits — One-time change in authorized treating
physician — Judge of compensation claims erred in denying properly made
request for one-time change in authorized treating physician on ground that
there was no compensable injury where it was undisputed that sprain for which
claimant was treated met requirements of compensability — Finding that
workplace injury combined with claimant’s preexisting degenerative disk disease
to produce need for treatment did not preclude finding of compensability —
Because claimant suffered a compensable injury and received treatment for that
injury, he was entitled to one-time change in treating physician as an absolute
right where claimant made written request for change during course of treatment
compensation — Medical benefits — One-time change in authorized treating
physician — Judge of compensation claims erred in denying properly made
request for one-time change in authorized treating physician on ground that
there was no compensable injury where it was undisputed that sprain for which
claimant was treated met requirements of compensability — Finding that
workplace injury combined with claimant’s preexisting degenerative disk disease
to produce need for treatment did not preclude finding of compensability —
Because claimant suffered a compensable injury and received treatment for that
injury, he was entitled to one-time change in treating physician as an absolute
right where claimant made written request for change during course of treatment
ESAD BABAHMETOVIC, Appellant,
v. SCAN DESIGN FLORIDA INC/ ZENITH INSURANCE COMPANY, Appellees. 1st District.
Case No. 1D14-2986. Opinion filed October 8, 2015. An appeal from an order of
the Judge of Compensation Claims. Ellen H. Lorenzen, Judge. Date of Accident:
October 9, 2013. Counsel: Michael J. Winer of the Law Office of Michael J.
Winer, P.A., Tampa, for Appellant. William H. Rogner of Hurley, Rogner, Miller,
Cox, Waranch & Westcott, P.A., Winter Park, for Appellees.
v. SCAN DESIGN FLORIDA INC/ ZENITH INSURANCE COMPANY, Appellees. 1st District.
Case No. 1D14-2986. Opinion filed October 8, 2015. An appeal from an order of
the Judge of Compensation Claims. Ellen H. Lorenzen, Judge. Date of Accident:
October 9, 2013. Counsel: Michael J. Winer of the Law Office of Michael J.
Winer, P.A., Tampa, for Appellant. William H. Rogner of Hurley, Rogner, Miller,
Cox, Waranch & Westcott, P.A., Winter Park, for Appellees.
ON MOTION FOR
REHEARING
REHEARING
(PER CURIAM.) This cause is before us on Appellees’ motion for rehearing
and rehearing en banc. We grant the motion for rehearing, withdraw our prior
opinion issued May 1, 2015, and substitute this opinion in its place. We deny
the motion for rehearing en banc.
and rehearing en banc. We grant the motion for rehearing, withdraw our prior
opinion issued May 1, 2015, and substitute this opinion in its place. We deny
the motion for rehearing en banc.
In this workers’ compensation case, Claimant appeals an order of the Judge
of Compensation Claims (JCC) denying him a one-time change in authorized
treating physician, as permitted by section 440.13(2)(f), Florida Statutes
(2013). For the reasons set forth herein, we reverse the ruling.
of Compensation Claims (JCC) denying him a one-time change in authorized
treating physician, as permitted by section 440.13(2)(f), Florida Statutes
(2013). For the reasons set forth herein, we reverse the ruling.
Background
Claimant lifted a heavy box at work on October 9, 2013. His low back hurt,
so the Employer/Carrier (E/C) sent him to Fast Track Urgent Care and authorized
Fast Track to treat him. The provider at Fast Track diagnosed radiculitis and
checked the boxes on a Uniform Medical Treatment Status Reporting Form (Form
DWC-25) that indicated the “injury/illness for which treatment is sought” was
“work-related.” Fast Track also referred Claimant to Dr. Delgado, who first saw
Claimant on November 15, 2013. Dr. Delgado concluded Claimant had both a
resolving lumbar muscle sprain and, as a condition preexisting the date of the
work accident, degenerative disk disease. Dr. Delgado checked the same
“work-related” boxes on his DWC-25, but the same day he sent a letter to the
E/C indicating the cause “regarding the lumbar spine” was 60% the preexisting
condition and only 40% the “workplace injury.”
so the Employer/Carrier (E/C) sent him to Fast Track Urgent Care and authorized
Fast Track to treat him. The provider at Fast Track diagnosed radiculitis and
checked the boxes on a Uniform Medical Treatment Status Reporting Form (Form
DWC-25) that indicated the “injury/illness for which treatment is sought” was
“work-related.” Fast Track also referred Claimant to Dr. Delgado, who first saw
Claimant on November 15, 2013. Dr. Delgado concluded Claimant had both a
resolving lumbar muscle sprain and, as a condition preexisting the date of the
work accident, degenerative disk disease. Dr. Delgado checked the same
“work-related” boxes on his DWC-25, but the same day he sent a letter to the
E/C indicating the cause “regarding the lumbar spine” was 60% the preexisting
condition and only 40% the “workplace injury.”
On November 27, 2013, the E/C issued a Notice of Denial (Form DWC-12)
stating, under the heading “denied benefits,” “total claim denied,” and, under
the heading “reason for denial of benefits,” that the “industrial accident” is
not the major contributing cause (MCC) of the need for treatment. Both parties
agree that this form was intended to be a denial of compensability — that is,
a statement that there was never a compensable injury here.
stating, under the heading “denied benefits,” “total claim denied,” and, under
the heading “reason for denial of benefits,” that the “industrial accident” is
not the major contributing cause (MCC) of the need for treatment. Both parties
agree that this form was intended to be a denial of compensability — that is,
a statement that there was never a compensable injury here.
The instant
claim
claim
Despite the Notice of Denial, Claimant asked for a one-time change in
authorized treating physician. The E/C denied the one-time change, giving the
same reasoning given in the Notice of Denial: that the industrial accident was
not the MCC of the need for treatment. When the matter came before the JCC, the
parties asked the JCC to consider whether the work accident was the MCC of not
only the need for treatment, but also the “injury” — in other words, to
determine compensability. They also asked the JCC to consider whether Claimant
was entitled to the one-time change despite the E/C’s denial of compensability
— in other words, whether a claimant can receive a one-time change where there
was never a compensable injury.
authorized treating physician. The E/C denied the one-time change, giving the
same reasoning given in the Notice of Denial: that the industrial accident was
not the MCC of the need for treatment. When the matter came before the JCC, the
parties asked the JCC to consider whether the work accident was the MCC of not
only the need for treatment, but also the “injury” — in other words, to
determine compensability. They also asked the JCC to consider whether Claimant
was entitled to the one-time change despite the E/C’s denial of compensability
— in other words, whether a claimant can receive a one-time change where there
was never a compensable injury.
The JCC drew several conclusions. The JCC stated, “[t]here must first be a
compensable accident and injury before an employee is entitled to any benefit
allowed in Chapter 440” — thus rejecting Claimant’s argument that he is
entitled to a one-time change without first having to prove he had suffered a
compensable injury of any sort. The JCC found that “Dr. Delgado identified an
injury from the accident (a sprain) as well as a pre-existing condition
(degenerative disc disease) which combined to produce the potential need
for medical care,” and that Dr. Delgado opined the sprain was less than half of
the cause of the “injury and need for care.” (Emphasis added). The JCC then
found both that “the accident was not the [MCC] of the injury” and that “the
accident was not the [MCC] of claimant’s need for medical care.” Based on all
of this, the JCC denied the one-time change.
compensable accident and injury before an employee is entitled to any benefit
allowed in Chapter 440” — thus rejecting Claimant’s argument that he is
entitled to a one-time change without first having to prove he had suffered a
compensable injury of any sort. The JCC found that “Dr. Delgado identified an
injury from the accident (a sprain) as well as a pre-existing condition
(degenerative disc disease) which combined to produce the potential need
for medical care,” and that Dr. Delgado opined the sprain was less than half of
the cause of the “injury and need for care.” (Emphasis added). The JCC then
found both that “the accident was not the [MCC] of the injury” and that “the
accident was not the [MCC] of claimant’s need for medical care.” Based on all
of this, the JCC denied the one-time change.
Analysis
The JCC is correct that “[t]here must first be a compensable accident and
injury before an employee is entitled to any benefit allowed in Chapter 440” —
with one single exception: an advance payment under section 440.20(12), Florida
Statutes. See Lopez v. Allied Aerofoam/Specialty Risk Servs., 48
So. 3d 888, 889 (Fla. 1st DCA 2010). But the JCC erred in not recognizing the
existence of a compensable injury in this case. This error came about by the
JCC’s conflating the existence and cause of the injury — compensability
— with the existence and cause of the need for treatment.
Compensability is a concept used to convey the idea that the Florida Workers’
Compensation Law applies; it requires the presence of certain elements
described throughout chapter 440 by terms of art such as accident, injury,
arising out of work performed in the course and the scope of employment.
See generally Checkers Rest. v. Wiethoff, 925 So. 2d 348, 350
(Fla. 1st DCA 2006) (en banc) (explaining concept of compensability as “the
occurrence of an industrial accident resulting in injury”).
injury before an employee is entitled to any benefit allowed in Chapter 440” —
with one single exception: an advance payment under section 440.20(12), Florida
Statutes. See Lopez v. Allied Aerofoam/Specialty Risk Servs., 48
So. 3d 888, 889 (Fla. 1st DCA 2010). But the JCC erred in not recognizing the
existence of a compensable injury in this case. This error came about by the
JCC’s conflating the existence and cause of the injury — compensability
— with the existence and cause of the need for treatment.
Compensability is a concept used to convey the idea that the Florida Workers’
Compensation Law applies; it requires the presence of certain elements
described throughout chapter 440 by terms of art such as accident, injury,
arising out of work performed in the course and the scope of employment.
See generally Checkers Rest. v. Wiethoff, 925 So. 2d 348, 350
(Fla. 1st DCA 2006) (en banc) (explaining concept of compensability as “the
occurrence of an industrial accident resulting in injury”).
Causation, in workers’ compensation, is established by MCC, and MCC is a
concept that can potentially apply at two different stages of a determination
of entitlement to benefits: work must be the MCC of a compensable injury, and
also — where (as here) there is a preexisting condition — the compensable
injury must be the MCC of the need for treatment.1 Compare § 440.09(1), Fla. Stat. (2013)
(requiring employer to pay compensation or furnish benefits if employee suffers
accidental compensable injury “arising out of work performed in the course and
the scope of employment”), and § 440.02(36), Fla. Stat. (2013) (defining
“arising out of” by stating that injury “arises out of employment if work
performed in the course and scope of employment is the major contributing cause
of the injury”), with § 440.09(1)(b), Fla. Stat. (2013) (providing that
if compensable work injury “combines with a preexisting disease or condition to
cause or prolong disability or need for treatment,” employer need provide
compensation or benefits only to extent injury “is and remains more than 50
percent responsible for the injury as compared to all other causes combined and
thereafter remains the major contributing cause of the disability or need for
treatment”). Only the first of these MCC analyses factors into a determination
of compensability of the original injury.
concept that can potentially apply at two different stages of a determination
of entitlement to benefits: work must be the MCC of a compensable injury, and
also — where (as here) there is a preexisting condition — the compensable
injury must be the MCC of the need for treatment.1 Compare § 440.09(1), Fla. Stat. (2013)
(requiring employer to pay compensation or furnish benefits if employee suffers
accidental compensable injury “arising out of work performed in the course and
the scope of employment”), and § 440.02(36), Fla. Stat. (2013) (defining
“arising out of” by stating that injury “arises out of employment if work
performed in the course and scope of employment is the major contributing cause
of the injury”), with § 440.09(1)(b), Fla. Stat. (2013) (providing that
if compensable work injury “combines with a preexisting disease or condition to
cause or prolong disability or need for treatment,” employer need provide
compensation or benefits only to extent injury “is and remains more than 50
percent responsible for the injury as compared to all other causes combined and
thereafter remains the major contributing cause of the disability or need for
treatment”). Only the first of these MCC analyses factors into a determination
of compensability of the original injury.
Here, the JCC found the sprain (the workplace injury) and the degenerative
disk disease combined to produce the need for treatment. But such facts do not
preclude compensability — they merely implicate the possible availability of
particular medical and indemnity benefits. See § 440.15(5)(b), Fla.
Stat. (2013) (“If a compensable injury, disability, or need for medical care,
or any portion thereof, is a result of aggravation or acceleration of a preexisting
condition, or is the result of merger with a preexisting condition, only the
disabilities and medical treatment associated with such compensable injury
shall be payable under this chapter . . . .”). On the facts present in this
case, it was not disputed that the sprain otherwise met the requirements of
compensability (e.g., an injury by accident arising out of and in the course of
employment). Given these facts, the JCC should not have applied an MCC analysis
to determine the existence of a compensable injury, because there is no
evidence (nor allegation) that the sprain was caused by
degenerative disk disease or anything other than work.
disk disease combined to produce the need for treatment. But such facts do not
preclude compensability — they merely implicate the possible availability of
particular medical and indemnity benefits. See § 440.15(5)(b), Fla.
Stat. (2013) (“If a compensable injury, disability, or need for medical care,
or any portion thereof, is a result of aggravation or acceleration of a preexisting
condition, or is the result of merger with a preexisting condition, only the
disabilities and medical treatment associated with such compensable injury
shall be payable under this chapter . . . .”). On the facts present in this
case, it was not disputed that the sprain otherwise met the requirements of
compensability (e.g., an injury by accident arising out of and in the course of
employment). Given these facts, the JCC should not have applied an MCC analysis
to determine the existence of a compensable injury, because there is no
evidence (nor allegation) that the sprain was caused by
degenerative disk disease or anything other than work.
Because Claimant suffered a compensable injury and received treatment
therefor, he is entitled to a one-time change in treating physician as “an
absolute right” if he made a written request for such during the course of
treatment. Providence Prop. & Cas. v. Wilson, 990 So. 2d 1224, 1225
(Fla. 1st DCA 2008). The E/C concedes that Claimant properly requested a
one-time change; thus, he is entitled to the one-time change he requested. We
distinguish Falcon Farms v. Espinoza, 79 So. 3d 945 (Fla. 1st DCA 2012),
where this court reversed the award of a one-time change, because in Falcon
Farms there was no work-related injury at all, only a finding that the
claimant “presented no ‘persuasive medical evidence’ that an injury arose out
of employment,” which was not challenged on appeal. 79 So. 3d at 946.
therefor, he is entitled to a one-time change in treating physician as “an
absolute right” if he made a written request for such during the course of
treatment. Providence Prop. & Cas. v. Wilson, 990 So. 2d 1224, 1225
(Fla. 1st DCA 2008). The E/C concedes that Claimant properly requested a
one-time change; thus, he is entitled to the one-time change he requested. We
distinguish Falcon Farms v. Espinoza, 79 So. 3d 945 (Fla. 1st DCA 2012),
where this court reversed the award of a one-time change, because in Falcon
Farms there was no work-related injury at all, only a finding that the
claimant “presented no ‘persuasive medical evidence’ that an injury arose out
of employment,” which was not challenged on appeal. 79 So. 3d at 946.
For the foregoing reasons, we reverse the order on appeal and remand to
the JCC for the award of a one-time change under section 440.13(2)(f).
the JCC for the award of a one-time change under section 440.13(2)(f).
REVERSED and REMANDED with instructions. (WOLF and RAY, JJ., CONCUR;
BENTON, J., CONCURS WITH OPINION.)
BENTON, J., CONCURS WITH OPINION.)
__________________
1This is the rationale underlying case law holding that “[o]nce compensability
is established, an E/C can no longer contest that the accident is the MCC of
the injuries at issue. It can only contest the connection between a claimant’s
need for specific treatment or benefits, and the industrial accident.” Engler
v. Am. Friends of Hebrew Univ., 18 So. 3d 613, 614 (Fla. 1st DCA 2009); see
also City of Pembroke Pines v. Ortagus, 50 So. 3d 31, 32 (Fla. 1st
DCA 2010) (holding E/C must pay for treatment as long as compensable condition
remains MCC of need for treatment).
is established, an E/C can no longer contest that the accident is the MCC of
the injuries at issue. It can only contest the connection between a claimant’s
need for specific treatment or benefits, and the industrial accident.” Engler
v. Am. Friends of Hebrew Univ., 18 So. 3d 613, 614 (Fla. 1st DCA 2009); see
also City of Pembroke Pines v. Ortagus, 50 So. 3d 31, 32 (Fla. 1st
DCA 2010) (holding E/C must pay for treatment as long as compensable condition
remains MCC of need for treatment).
__________________
(BENTON, J., concurring in the judgment.) “When an E/C becomes aware that
a claimant has medical needs [of which a compensable injury is the purported
major contributing cause], it should either pay for them, pay and investigate
under section 440.20(4), or deny compensability.” Bynum Transp., Inc. v.
Snyder, 765 So. 2d 752, 754 (Fla. 1st DCA 2000). In the present case, the
employer or its insurance carrier accepted the injury as compensable, without
reservation. This election was binding. The statutory “pay and investigate
rule” requires:
a claimant has medical needs [of which a compensable injury is the purported
major contributing cause], it should either pay for them, pay and investigate
under section 440.20(4), or deny compensability.” Bynum Transp., Inc. v.
Snyder, 765 So. 2d 752, 754 (Fla. 1st DCA 2000). In the present case, the
employer or its insurance carrier accepted the injury as compensable, without
reservation. This election was binding. The statutory “pay and investigate
rule” requires:
Upon
commencement of payment as required under subsection (2) or s. 440.192(8), the
carrier shall provide written notice to the employee that it has elected
to pay the claim pending further investigation, and that it will advise the
employee of claim acceptance or denial within 120 days.
commencement of payment as required under subsection (2) or s. 440.192(8), the
carrier shall provide written notice to the employee that it has elected
to pay the claim pending further investigation, and that it will advise the
employee of claim acceptance or denial within 120 days.
§ 440.20(4), Fla. Stat. (2013) (emphasis added). In order to invoke the
benefits of the pay and investigate rule, an employer or its carrier must give
notice it is relying on the pay and investigate provision at or before
“commencement of payment.” Id. “A carrier that does not deny
compensability in accordance with s. 440.20(4) is deemed to have
accepted the employee’s injuries as compensable . . . .” § 440.192(8), Fla.
Stat. (2013) (emphasis added).
benefits of the pay and investigate rule, an employer or its carrier must give
notice it is relying on the pay and investigate provision at or before
“commencement of payment.” Id. “A carrier that does not deny
compensability in accordance with s. 440.20(4) is deemed to have
accepted the employee’s injuries as compensable . . . .” § 440.192(8), Fla.
Stat. (2013) (emphasis added).
In short, I join the judgment of the court on grounds the notice of denial
contesting the injury’s compensability came too late.
contesting the injury’s compensability came too late.
* * *