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.
Morrow v. Sam’s Club, 17 So.3d 763 (Fla. 1st DCA 2009). Workers’ compensation claimant was entitled to orthopedic evaluation recommended by his authorized treating physician; employer and carrier never contested medical necessity of referral, and uncontradicted evidence was that claimant’s authorized medical care provider made repeated recommendations for orthopedic evaluation, claimant’s doctor testified that compensable accident was major contributing cause of need for evaluation, and that purpose of evaluation was to determine whether claimant’s ongoing symptoms were related to his injury, or at least to determine whether there was objective basis for claimant’s symptoms. West’s F.S.A. § 440.13(2)(a).
Chance v. Polk County School Board, 4 So.3d 71 (Fla. 1st DCA 2009). Whenever the purpose of the diagnostic test is to determine the cause of a workers’ compensation claimant’s symptoms, which symptoms may be related to a line compensable accident, the cost of the diagnostic test is compensable, and this is true even though it should later be determined that the claimant suffered from both compensable and non-compensable conditions.
Roberts v. Spartan Premier Staffing, Inc., 909 So.2d 529 (Fla. 1st DCA 2005). It is the purpose for which the tests are undertaken, rather than the results, which determines the compensability of same under workers’ compensation law.
Somoza v. Sears Service Center Specialty Risk Services, Inc., 868 So.2d 591 (Fla. 1st DCA 2004 ). Cost of MRI (magnetic resonance imaging) ordered by workers’ compensation claimant’s authorized physician was compensable, where MRI was ordered to determine the cause of claimant’s symptoms and determine their causal relationship to workplace accidents.
Martinez v. Association of Poinciana, 642 So.2d 118 (Fla. 1st DCA 1994). Employer and its insurance carrier were required to pay for diagnostic testing and evaluation received by workers’ compensation claimant, even though testing did not confirm causal relationship between claimant’s complaints of chest and neck pain and weakness and pain in leg and hand and industrial accident in which he injured his wrist; testing and evaluation were undertaken on theory that claimant might be developing posttraumatic reflex sympathetic dystrophy as result of accident, which physician described as “most probable cause” of complaints.
Hindrance to recovery
Unlike the treatment-to-determine-compensability cases, compensability is not a consideration with this legal principle. In Roth Brothers of Florida v. Spodris, 642 So.2d 118 (Fla. 1st DCA 1994), the Claimant sustained a compensable back injury. Thereafter, he developed a non-compensable condition in his hip known as avascular necrosis. Two doctors recommended hip surgery, with one explaining that without the hip surgery “the back problem would deteriorate,” and that “it would be extremely difficult to achieve any improvement in the back condition … as long as the hip disease was present and not treated.” The Judge of Compensation Claims ordered the Employer/Carrier to pay for the hip surgery and his ruling was upheld on appeal.
The principle is limited to situations where “one of the primary purposes of the treatment is also removal of a hindrance to recover from the compensable accident…,” Decks, Inc. of Florida v. Wright, 389 So.2d 1074, 1076 (Fla. 1st DCA 1980), in contrast to when the removal of the hindrance to recovery from the compensable injury is merely an incidental effect of such treatment. Glades County Sugar Growers v. Gonzales, 388 So.2d 333, at 336 (Fla. 1st DCA 1980). (Italics added for emphasis.)
From more than 20 years of Republican legislation, the rights of workers injured on the job in Florida to receive medical care have been deeply eroded. To maximize the recovery of benefits, not just of medical benefits, it is advisable to seek the advice of legal counsel as soon as practicable. Most workers’ compensation attorneys handle such cases on a contingency fee basis, so there will be no charge for such legal services until the case is resolved favorably.
Controlling an unrelated condition.
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Jeffrey P. Gale, P.A. is a South Florida based law firm committed to the judicial system and to representing and obtaining justice for individuals – the poor, the injured, the forgotten, the voiceless, the defenseless and the damned, and to protecting the rights of such people from corporate and government oppression. We do not represent government, corporations or large business interests.
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