Workers' Compensation

March 5, 2011

Florida Workers’ Compensation Lien and PIP Benefits

It is common practice to seek PIP benefits for an insured who has paid money out-of-pocket to satisfy a workers’ compensation lien. Is the PIP carrier let off the hook for payments when the workers’ compensation lien is waived? According to the holding in Cannino v. Progressive Insurance Co., Fla: Dist. Court of Appeals, 2nd Dist. 2010, the answer is No.

When a person is injured in a motor vehicle accident while in the course of his employment, he may be entitled to medical and lost wage benefits from workers’ compensation and PIP (personal injury protection) insurance.

The Florida Motor Vehicle No-Fault Law, sections 627.730-.7405, Florida Statutes, requires motorists to maintain a minimum of $10,000 in insurance for PIP benefits to cover loss sustained as a result of bodily injury, sickness, or death related to motor vehicles. § 627.736(1). The insurance generally covers eighty percent of medical and related expenses and sixty percent of wage loss. Id. PIP benefits are primary, except that workers’ compensation benefits “shall be credited against” PIP benefits. § 627.736(4).

The injured person may also be able to recover money from the bodily injury coverage of the at-fault party’s insurance policy for damages such as pain and suffering.

When a workers’ compensation carrier provides benefits to an injured worker, it retains a lien (i.e., right to be reimbursed) up to the value of those benefits on any money received by the workers’ compensation claimant from the bodily injury coverage of the at-fault party’s insurance policy. (Typically, the reibursement rate is not dollar-for-dollar. See the Manfredo formula for how to calculate the rate of reimbursement.) The workers’ compensation carrier is allowed to waive the lien.

In 2004, Cannino was injured in an automobile accident while in the course of his employment by West Coast Fence of Tampa. He received workers’ compensation benefits from West Coast Fence’s carrier, Pinnacle Benefits, Inc. Cannino had a personal motor vehicle insurance policy issued by Progressive, but he did not seek immediate payment of his personal injury protection (PIP) benefits under that policy.
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February 21, 2011

Most Important Florida Workers’ Compensation Case – Aguilera v. Inservices, Inc.

by Jeffrey P. Gale, P.A.

In my opinion, the most important Florida workers’ compensation case of all time is Aguilera v. Inservices, Inc., 905 So.2d 84 (Fla., 2005). Aguilera made it clear that workers’ compensation insurance carriers and adjusters are not immune from being sued for the tort of intentional infliction of emotional distress where their conduct in handling a claim is more than simply bad faith or a breach of contract, but where the conduct is intentional and outrageous. What this means is that carriers and adjusters can be sued in circuit court for damages caused by outrageous conduct.

The Aguilera decision reinstated a lawsuit, which had been dismissed by a lower appellate court, the 3rd DCA, brought by an injured worker against the workers’ compensation carrier and claims adjuster. Although a confidential settlement was reached in the case, word on the street is that the case settled for in excess of one million dollars. Given the damage caused by their outrageous conduct, this was a small price to pay.

This Florida Supreme Court decision has gotten the attention of workers’ compensation insurance companies and their claims adjusters. No longer can claims be handled with complete indifference and a lack of regard for the health, safety, and welfare of injured workers without consequence. This is not to say that injured workers get everything they want. This is far from the case. There is still room for legitimate disputes. What the decision does mean is that there is no place in the workers’ compensation system for mean-spirited claims handling.

UNDERLYING FACTS:

On April 21, 1999, Aguilera was struck by a forklift and pushed against a pallet. He suffered immediate injuries and was rushed to the emergency room. Testing performed in the ER showed blood in Aguilera’s urine.
Subsequently, Aguilera began to complain of kidney and bladder pain.
On May 24, after two physicians examined him and concluded that he could not return to work, Aguilera’s attorney requested that he be examined by a board certified urologist.
The workers’ compensation insurance carrier denied authorization of the urologist, asserting that Aguilera’s injury was not work related.
On June 17, 1999, the insurance carrier was again notified that urological care was now needed on an emergency basis because Aguilera’s urine had begun to smell like feces.
On June 21, Aguilera was advised that his workers’ compensation benefits were being terminated as of July 9, 1999, notwithstanding the report of two doctors, including the opinion of the insurance carrier’s own doctor, that he should not return to work.
On June 25, 1999, the insurance company intervened and blocked Aguilera’s receipt of medication prescribed by the hospital emergency room doctor for his urinary condition.
On June 30, the carrier again denied authorization of emergency medical care for the urinary problems, claims it was not medically necessary.
On July 7, 1999, Aguilera’s treating doctor advised the carrier that his need for medical care was urgent and that his condition was deteriorating.
On July 9, 1999, the carrier’s own doctor issued prescriptions for various urinary tests.
On July 30, 2009, the adjuster intervened and simply unilaterally cancelled some of the medical testing.
Testing that was ultimately done revealed that Aguilera had a fistula, a hole in his bladder.
On August 6, 1999, Mippy Heath became the new insurance company case manager. She was specifically told by Aguilera’s attorney that she should have no direct contact with Aguilera. She also agreed that no intervention with Aguilera’s care would be attempted.
On August 19, Aguilera’s attorney alerted the insurance carrier that the injured employee was in need of emergency care for the fistula. Heath refused the authorization and insisted on a second opinion.
On August 25, Heath secretly appeared at the physician’s office for Aguilera’s appointment. She urged Aguilera to lie to his attorney that she has not appeared at his doctor’s appointment.
Subsequently, Heath insisted that Aguilera submit to the administration of invasive tests that were not only painful but also contraindicated by his then-present medical condition. The insurance company then proceeded to use Aguilera’s refusal to submit to the tests as a basis to justify a refusal and denial of his then needed critical, surgical treatment.
By November 4, 1999, Heath, the case manager, and a nurse practitioner also employed by the insurance carrier had changed positions and agreed that Aguilera needed immediate hospitalization for surgery. However, the insurance carrier’s adjuster again intervened and overruled the decision of medical personnel simply because he wanted a second opinion from a general surgeon. Notwithstanding this intervention, the insurance carrier did not follow its own position and authorize Aguilera to consult with a general surgeon, but instead again changed course and sent Aguilera to a gastroenterologist. At this point in time, Aguilera had allegedly been urinating feces and blood for over six months.
Aguilera’s ultimate surgery, the need for which had been diagnosed as an emergency as early as June of 1999, was not finally authorized or approved until March 22, 2000. By this time, according to the allegations, Aguilera had been urinating feces and blood for over ten months.

Florida’s workers’ compensation laws provide employees limited medical and wage loss benefits, without regard to fault, for losses resulting from accidental workplace injuries. The carrier’s failure to provide benefits in a timely manner or at all may result in the assessment of minor monetary penalites and interest. However, the workers’ compensation system does not have a mechanism for making carriers/adjusters accountable for serious injuries caused by outrageous claims handling.

In exchange for not having to prove fault for losses resulting from accidental injuries, employees have relinquished their right to seek common law recovery from the employer for those injuries. This concept is commonly known as “workers’ compensation immunity.” (See Florida Statute 440.11.)
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February 16, 2011

Florida Workers’ Compensation Attorney’s Fees – Round II (Emma Murray; Jennifer Kauffman)

by Jeffrey P. Gale, P.A.

At the urging of Governor Jeb Bush, Florida’s Republican-controlled legislature in 2002 passed a workers’ compensation bill designed to limit carrier-paid attorney’s fees to claimants’ attorneys. The measure was challenged in the courts by claimants (injured workers), who argued that it was unconstitutional (denied access to courts & equal protection) and that it should be interpreted to allow for “reasonable” attorney’s fees.

Five years after the bill’s effective date, the Florida Supreme Court, in Murray v. Mariner Health and Ace USA, 994 So.2d 1051 (Fla.2008), held that the statute provided for reasonable attorney’s fees. The court did not rule on the constitutional issues.

In a clear rebuke to the Florida Supreme Court, in it’s next legislative session, which began on March 1, 2009, less than seven months after the Murray decision, the still-again Republican-controlled legislature took another shot at limiting fees. What it did was remove the word “reasonable” from Florida Statute 440.34. The Legislature’s goal was to make it difficult for injured workers to obtain adequate legal representation by denying their attorneys reasonable attorney’s fees.

In the Murray case, Ms. Murray was successful at the trial level in convincing a judge of workers’ compensation claims (JCC) that her injuries were sustained in a work-related accident. (The employer/carrier (e/c) had denied her injuries.) In a subsequent attorney’s fee hearing, the JCC found that claimant’s counsel expended eighty hours of reasonable and necessary time on the case. However, the JCC, although concluding in his written order that $16,000 was a reasonable fee, felt constrained by the statute and awarded only $684.84, or an hourly rate of $8.11. According to the JCC, this amount was “manifestly unfair.” (Note: the e/c in this case paid their attorney $16,050 (135 hours at $125 an hour) in the unsuccessful effort to resist paying benefits.) It was this order that was appealed and eventually made its way to the Florida Supreme Court. As a result of the decision, Ms. Murray’s attorney was awared $16,000 for his efforts at the trial level.
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January 19, 2011

Florida Workers’ Compensation Statute of Limitation

by Jeffrey P. Gale, P.A.

A statute of limitation is a provision that ends a person’s or company’s right to sue with regard to a legal dispute. Every legal dispute in Florida is subject to a statute of limitation, with the time period in any particular matter depending on the nature of the dispute. Florida Statute 95.11 sets forth the statute of limitation periods for most legal disputes. The statute of limitation for workers’ compensation cases is set forth in Florida Statute 440.19.

The workers’ compensation statute of limitation is a provision that ends a person’s right to claim benefits or sue for compensation and damages unless the person meets certain conditions. For accident dates after January 1, 1994, a claim or petition for benefits is forever barred unless it is filed within (1) two years of the date of the injury; or (2) after the initial two years, within one year of the last payment of compensation or provision of remedial treatment, care or attendance.

The start of every statue of limitation period is triggered by an occurence or event. For example, in a breach of contract matter, the triggering event is the breach of the contract. For wrongful death, it is the date the cause of the wrongful death was confirmed or suspected, typically the date of the accident. In workers’ compensation cases, the work-related accident starts the limitation period running.

In cases involving clearly identifiable accidents and injuries, such as breaking an ankle after falling from a ladder, the date of accident as the triggering event is obvious. However, not all triggering events are so obvious. For example, a worker may feel a twinge in his back from lifting a heavy box, and for a time feel only minor discomfort, then one day, even a week or two later, experience full-blown symptoms indicative of a bad herniated disc injury. Under this scenario, the statute of limitation period may not begin to run until the full-blown symptoms manifested, which is when the injured worker, as a reasonable person, should recognize the “nature, seriousness, and probable compensable character of his injury or disease.” [see Herb’s Exxon v. Whatmough, 487 So. 2d 1169, 1172 (Fla. 1st DCA 1986)]. In other words, the triggering event may come after the actual date of accident.

Other examples of how the workers’ compensation statute of limitation is applied:

Occupational Disease: An occupational disease is one that arises from the hazard of a disease particular to a job that distinguishes it from the usual run of occupations, or the incidence of the disease is substantially higher in that occupation [see Florida Statute 440.151]. In cases involving occupational disease, the statute of limitation clock begins to run from the date of disability. Disability is defined in Section 440.02(13) as “incapacity because of the injury to earn in the same or any other employment the wages which the employee was receiving at the time of the injury.” This means that the date when the SOL clock begins to run may be different from the date the injured worker was first exposed or when he or she detected the disease, or even when symptoms first appeared.
Injuries from Repetitive Trauma: A repetitive trauma injury is one in which disability results from months or even years of minor, but repetitive trauma. (My first workers’ compensation trial involved a repetitive trauma injury. We alleged and, fortunately, were able to prove, that our client’s serious back condition developed from years of lifting heavy bed box mattress frames from ground level to overhead shelves.) In these cases, the SOL begins to run from the date of the disability or the date of last injurious exposure, whichever is later.

January 12, 2011

Determining the Settlement Value of Florida Workers’ Compensation Cases

by Jeffrey P. Gale, P.A.

Many factors go into determining the settlement value of a Florida workers’ compensation case. Although the opposing parties are seeking different outcomes – the Claimant wants to recover as much as possible, while the Employer/Carrier wishes to settle for as little as possible – each side benefits from performing a fair and honest evaluation; neither party gains an advantage from being deluded about a case’s true value.

This is not to say that the parties, after performing their assessments, will always arrive at similar conclusions. Law is more art than science. Judgment calls based on a countless number of variables often result in significantly different conclusions. The goal of successful negotiating is to narrow the differences to an acceptable agreement.

Before considering the factors that influence case value, it should be noted that no party to a workers’ compensation case can be forced to settle. Not even a judge of workers’ compensation claims can force a settlement on the parties. Moreover, there is no jury system in workers’ compensation where a verdict is reached awarding a lump sum of money. Most workers’ compensation cases are mediated, but the settlement can only come through an agreement of the parties.

It should also be noted that compensation for non-economic damages (sometimes referred to as, Pain & Suffering) is not awardable in workers’ compensation cases. (See these blogs: personal injury; wrongful death.)
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January 9, 2011

Differences Between Florida’s Workers’ Compensation System and the Wrongful Death Act for Loss of Life

by Jeffrey P. Gale, P.A.

Yesterday’s blog was about the primary legal differences between Florida’s workers’ compensation and personal injury systems with regard to accident-related bodily injuries. Today’s blog will address the differences, which are significant, between Florida’s workers’ compensation system and it’s Wrongful Death Act for the loss of life due to accidents.

For the most part, the laws in Florida regarding compensation for death caused by accidents are prescribed by statute. Workers’ compensation addresses the issue through Florida Statute 440.16, while Florida’s Wrongful Death Act (768.16-768.26), covers it in the context of third-party liability. (CAVEAT: There are exceptions to Florida’s workers’ compensation immunity laws that could make the employer liable for damages under the Wrongful Death Act. A lawyer should always be consulted to consider the issue.) The differences between the two bodies of law are significant.

THE MAIN DIFFERENCES:

Negligence. As a legal concept, negligence is generally defined as conduct that is culpable because it falls short of what a reasonable person would do to protect another individual from foreseeable risks of harm. It is often difficult to prove negligence. While negligence does not have to be established in a workers’ compensation case, it is a necessary and essential element of every wrongful death case other than those involving strict liability.
Damages. The monetary compensation for death in workers’ compensation may not exceed $150,000, up from $100,000 from just a couple of years ago. With the exception of death caused by medical malpractice (see this blog), the wrongful death statute does not contain a similar arbitrary cap. The wrongful death statute allows for what is known as non-economic damages (e.g., loss of companionship; mental pain and suffering). Florida’s workers’ compensation system does not. The primary reasoning for the difference has to do with the issue of negligence. The Florida Legislature has decided that not being allowed to recover non-economic damages is a fair price to pay for not having to prove negligence in workers’ compensation cases. In my view, $150,000 hardly makes for a fair trade-off. Workers’ compensation allows for the recovery of $7,500 in funeral expenses.
Who May Recover Damages. Both bodies of law contain statutory schemes for who may recover damages for death resulting from an accident. Each scheme is convoluted. The monetary benefits through workers’ compensation are paid on a periodic basis, while the compensation under the Wrongful Death Act are paid in a lump sum. I have prepared a flow chart for who may recover under the Wrongful Death Act – follow this link.
Statute of Limitations. Two (2) years for each. There are exceptions and variations on this black-letter statement, so a knowledgeable lawyer should be consulted before any conclusions are reached.
Trial by Jury. Not available in workers’ compensation cases. Available upon request in wrongful death cases.
Attorney Representation. Available in both types of cases.

The issues addressed in this blog are complex and complicated, not nearly as simple as they may appear here. It is for this reason that we encourage and highly recommend that these issues be addressed with a qualified attorney.
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January 8, 2011

The Differences Between Florida Workers’ Compensation and Personal Injury Cases

by Jeffrey P. Gale, P.A.

As our law firm has an expertise in workers’ compensation and personal injury cases, we are frequently asked to explain to our clients and other lawyers the differences between the two. Although both types of cases involve bodily injuries, they have little else in common.

With rare exception (see Florida Statute 440.11), the remedies available against employers for job related accidents are controlled by Chapter 440 of the Florida Statutes, which is the body of law devoted to workers’ compensation cases. Personal injury cases are controlled by different statutes and case law. The differences are significant.

THE MAIN DIFFERENCES:

Negligence. As a legal concept, negligence is generally defined as conduct that is culpable because it falls short of what a reasonable person would do to protect another individual from foreseeable risks of harm. It is often difficult to prove negligence. Whereas proving negligence is not required in workers’ compensation cases, it is an essential element of every personal injury case except those involving strict liability.
Compensation for Pain and Suffering. Because workers’ compensation claimants are relieved of the heavy burden of having to prove negligence, the Florida Legislature, as a trade-off, does not allow them to be compensated for pain and suffering. In contrast, personal injury claimants can be compensated for pain and suffering. This difference is easily the most difficult concept for our workers’ compensation clients to understand. It is counter-intuitive. We spend a significant amount of time discussing this concept with all of our workers’ compensation clients.
Medical Benefits. Medical benefits are furnished to injured workers pursuant to the workers’ compensation system. It is a lousy system for injured workers (see this blog), with the biggest negative being that employers and their insurance carriers control the selection of all medical providers. By contrast, personal injury claimants do not have automatic medical benefits; claimants must fend for themselves in obtaining medical care. PIP (motor vehicle accidents), health insurance, and Medicare/Medicaid are the main sources sometimes available to cover the expense. It is more difficult for the uninsured. Arrangements can sometimes be made through the lawyer for the provision of medical care. In theory, the personal injury claimant is supposed to be compensated at the end of the case for past and future medical expenses.
Lost Wages. Like medical benefits, eligibility for workers’ compensation lost wages starts with the report of a work related accident. The benefit amount ranges from 66-2/3% to 80% of 80% of lost wages. Except for permanent total disability (PTD – 440.15(1)), a difficult standard to prove, the limit for the number of weeks of temporary disability benefits (i.e., prior to reaching maximum medical improvement) a claimant may receive is 104. Only a small percentage of claimants receive the full 104 weeks of benefits. The personal injury system for the payment of lost wages is significantly different. There is no built-in equivalent, like in workers’ compensation, for self-executing benefits to be paid. In some instances, PIP and private disability insurance fill the role, but often those benefits are not available or applicable. For the most part, it is not until the case is resolved that the personal injury claimant is compensated for lost wages past and future. The standards that apply for the determination and entitlement to lost wages also are different between workers’ compensation and personal injury cases.
Trial by Jury. Not available in workers’ compensation cases. Available upon request in personal injury cases.
Statute of Limitations. 2 years for workers’ compensation, 4 years for personal injury. (Be careful not to confuse the personal injury statute of limitations with the statutes of limitations applicable to wrongful death cases (2 years) and medical malpractice (2 years). Also, in personal injury cases against a governmental entity, although the statute of limitations is 4 years, a particular written statutory notice of claim must be given within 3 years. Finally, and of great importance, sometimes there are ways of extending a statute of limitations beyond the black-letter numbers given above. Accordingly, it is important to discuss these issues with an attorney before concluding that it is too late to pursue any legal claim based on a statute of limitations.)
Attorney Representation. Available in both types of case. We handle both type of cases on a contingent basis (no fees and costs payable by the client until we win the case), but, by law, the fee formulas are significantly different.

There are numerous other differences between workers’ compensation and personal injury cases, but these are the main ones. Needless to say, an experienced legal professional should be consulted to discuss all of these issues.
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December 30, 2010

Wage/Income Loss Claims for “Illegal Immigrants”/Undocumented Workers in Florida Personal Injury and Workers’ Compensation Cases

by Jeffrey P. Gale, P.A.

The question often arises in Florida as to whether undocumented workers can be compensated for lost wages (past and future) in personal injury and workers’ compensation cases. With few exceptions, the answer appears to be No.

Although the damages available in workers’ compensation and personal injury cases may differ, both offer elements of awards for lost wages. Proving entitlement requires showing that the lost wages are related to the injuries. However, the employer (wc) and defendant (pi) may nullify the proof by establishing that the claimant is prohibited from working in the United States due to immigration issues. In other words, an immigrant who is not authorized to work in the United States, cannot be compensated under Florida law for lost income resulting from an accident.

The two primary exceptions in workers’ compensation cases are (1) the employee is totally, as opposed to partially, unable to work because of his injuries, and (2) the employer knew or should have known of the employee’s status as an unauthorized alien prior to the disabling accident. (The law of Florida does not impose on an employer the burden of verifying forged or borrowed green cards – Florida Statute 448.09 – nor is there any such federal requirement.)
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December 23, 2010

Florida Workers’ Compensation – Out Of State Accidents

by Jeffrey P. Gale, P.A.

Many scenarios arise that bring into question the applicability of Florida’s workers’ compensation system for accidents that occur in other states. The general rule is that a worker injured outside of the state is eligible for Florida’s workers’ compensation benefits if:

(1) The employer and the employee entered the contract of employment in Florida; or (2) If the principal location of the employment is in Florida.

(Only one of the two elements must be met, not both.)

The statutory language, located at 440.09(1)(d), reads as follows: “If an accident happens while the employee is employed elsewhere than in this state, which would entitle the employee or his or her dependents to compensation if it had happened in this state, the employee or his or her dependents are entitled to compensation if the contract of employment was made in this state, or the employment was principally localized in this state. However, if an employee receives compensation or damages under the laws of any other state, the total compensation for the injury may not be greater than is provided in this chapter.”
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December 11, 2010

Florida Workers’ Compensation Lost Wages Benefits

by Jeffrey P. Gale, P.A.

Florida’s workers’ compensation system contains many different types of wage loss benefits. Each is unique in scope and character. They are:

Temporary total disability (TTD; 440.15(2)): Unable to work prior to maximum medical improvement (MMI)
Temporary partial disability (TPD; 440.15(4)): Able to work with restrictions
Impairment benefits (IB): Based on medical impairment rating upon reaching MMI
Permanent Total Disability (PTD; 440.15(1)): Unable to perform substantial gainful employment after reaching MMI. (See blog.)
Retraining: While being retrained in a certified program. (440.491) (See blog.)

Other monetary benefits that may be available to injured workers include:

Unemployment Compensation: Terminated from employment without cause
Social Security Disability (SSD): Similar to workers’ compensation PTD
Supplemental Security Income (SSI): Need-based, depends on income and assets

If you have questions about any of these benefits, contact our office for a free, confidential consultation.
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