JEFF REYNOLDS, APPELLANT,
v.
OAKLEY CONSTRUCTION AND HARTFORD INSURANCE COMPANY, APPELLEES
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This workers' compensation appeal addresses whether an employer/carrier must pay a hospital bill for a penile implant surgery when the claimant did not make an express request but the carrier had knowledge of the medical need and desire for the procedure. The court held that under Florida law, an express request is not required when the carrier has knowledge of the injury and fails to provide necessary treatment, and the carrier is estopped from denying authorization when it knew of the surgery, failed to object, and paid the related physician charges.
The court held that under Florida Statutes § 440.13(2)(a) and (b), an express request is not required when the carrier has knowledge of the injury and does not provide the medically necessary treatment. Additionally, the carrier is estopped from claiming the surgery was not authorized where it knew of the claimant's desire for the surgery, made no investigation or objection for approximately one year, and paid the physician's bill for the same surgery.
[1] A carrier may be estopped from denying authorization for a medical procedure when it has knowledge of the claimant's desire for the procedure, is aware that arrangements…
[2] A claimant may recover the expense of medically necessary treatment not provided by the employer/carrier if the employer/carrier had knowledge of the injury and failed to…
Previewing 2 of 5 headnotes on this case. FLexlaw’s editorially structured points of law — every proposition, pinpointed — are reserved for members.
Join FLexlaw to unlock all legal intelligence“the claimant is not entitled to recover such expense unless he has requested the employer to furnish same and the employer has failed, refused or neglected to do so, or if the nature of the injury requires such treatment and the employer has knowledge of the injury and does not provide the treatment”
Establishes the statutory framework allowing recovery for medically necessary treatment even without express request when employer has knowledge of injury.
Previewing 1 of 3 key quotes on this case — the court’s exact language, pinpointed for members.
Join FLexlaw to unlock all legal intelligenceJeff Reynolds, a paraplegic injured in an industrial accident, sought a second penile implant surgery after an unsuccessful first procedure. He commun…
The full statement of facts, procedural history, and disposition for this case are member content.
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SMITH, Judge.
This is an appeal and cross-appeal from an order denying payment of a hospital bill and awarding claimant a van. We affirm the award of the van without discussion. However, we find that the judge of compensation claims erred in denying payment of the hospital bill for a medically necessary surgical procedure on the grounds that it was not properly requested prior to the surgery and not authorized.
Claimant, a paraplegic injured in an industrial accident, had one unsuccessful penile implant and sought another. Though he did not specifically request the surgery, his desire to have this procedure was communicated to the carrier’s authorized representative, Ms. Brenda White, by the claimant and one of his doctors. Further, the carrier was aware that claimant’s treating physician felt the surgery would benefit claimant substantially, and knew that claimant had been referred to Dr. La-sky for the purpose of having the operation. Correspondence between the doctors and the carrier’s health service representative, while not affirmatively demonstrating authorization for the surgery, by the same token does not reveal a categorical refusal by the carrier. The surgery was successfully performed almost a year after the carrier became aware of claimant’s desire for the surgery. Both of claimant’s doctors opined that the surgery was reasonably, medically necessary. The carrier paid the doctor’s bill for this surgery but refused to pay the hospital bill.
Pursuant to section 440.13(2)(a) and (b), Florida Statutes, the employer is required to furnish the claimant medically necessary treatment which includes a prosthesis, and should the employer fail to provide such treatment after request, the claimant may seek such treatment at the expense of the employer, the reasonableness and necessity to be approved by the judge of compensation claims. However, the claimant is not entitled to recover such expense unless he has requested the employer to furnish same and the employer has failed, refused or neglected to do so, or if the nature of the injury requires such treatment and the employer has knowledge of the injury and does not provide the treatment. Under the circumstances, it was error for the judge of compensation claims to hold that claimant’s failure to make an express request of the employer/ carrier for this surgery was fatal to his claim, since the carrier knew of his need for the surgery but failed to provide it. Lance v. Witters Construction, 270 So. 2d 4 (Fla.1972).
Alternatively, we find that the carrier should be estopped from claiming that this surgery was not authorized where the carrier knew of claimant’s desire for the surgery, and that arrangements were being made for it, but failed to act or make any investigation with regard thereto for approximately a year, leading claimant to believe there was no objection to the surgery. Furthermore, the carrier paid the doctor’s bill for the surgery, a fact inconsistent with the carrier’s position that this surgery was not authorized. Miller v. The Tribune Company, 275 So. 2d 242 (Fla.1973); Irigoyen v. Aircraft Services, Inc., 544 So. 2d 1054 (Fla. 1st DCA 1989); see also Engle v. Deerborne School, 226 So. 2d 681 (Fla.1969), and Carnegie Gardens v. Mize, 538 So. 2d 1313 (Fla. 1st DCA 1989).
Finally, because the taking of Dr. Lasky’s deposition was necessary for the prosecution of this claim, the judge of compensation claims erred in failing to order payment of this taxable cost.
AFFIRMED in part, REVERSED in part, and REMANDED for further proceedings.
WENTWORTH and WIGGINTON, JJ., concur.
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Nickolls v. Univ. OF Fla. & Div. of Risk Mgmt., 606 So. 2d 410 (Fla. 1st DCA 1992)…ecific request for a particular surgical procedure did not relieve the E/C from its obligation to pay a resulting hospital bill therefor, in that the E/C was generally aware of the need for same, but failed to provide it. Reynolds v. Oakley Constr., 561 So. 2d 1298 (Fla. 1st DCA 1990). In the case at bar, the E/C was aware of claimant’s continuing complaints of pain from the medical reports it had received from the treating physicians, and it can hardly claim prejudice due to the lack of a specific claim for t…
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Imperial Elec. v. Reeves, 647 So. 2d 199 (Fla. 1st DCA 1994)…s that claimant did not request psychiatric care from the E/C until after this first treatment. Nor were claimant’s psychiatric problems known or apparent to the E/C at the time. § 440.13(2)(b), Fla.Stat. (1989); see Reynolds v. Oakley Construction, 561 So. 2d 1298 (Fla. 1st DCA 1990). We affirm that part of the JCC’s order requiring the E/C to pay for treatment by Dr. Gonzalez after the initial treatment. See Dubois Farms, Inc. v. Paul, 566 So. 2d 923 (Fla. 1st DCA 1990). There is competent, substantial evide…
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Janiene Zahradnick v. Casual Corner & Liberty Mut. Ins. Co., 620 So. 2d 792 (Fla. 1st DCA 1993)…notice, as of August 1990, of claimant’s need for treatment from an osteopathic physician, the E/C were then obliged to either provide such care or obtain a ruling that such care was not in claimant’s best interests. Reynolds v. Oakley Construction, 561 So. 2d 1298 (Fla. 1st DCA1990); Teimer v. Pixie Playmates, 532 So. 2d 37 (Fla. 1st DCA1988), rev. den., 539 So. 2d 475 (Fla.1989). The E/C’s failure to do this rendered them responsible for unauthorized care by Dr. Napier. Teimer. We reject the E/C’s argument t…
Authorities Cited
- Anne K. Engle v. Deerborne Sch., 226 So. 2d 681 (Fla. 1969)
- In re Transition Rule 7, 270 So. 2d 4 (Fla. 1972)
- Lance v. Witters Constr., 270 So. 2d 4 (Fla. 1972)
- Carnegie Gardens & United Self Insured Servs. v. Mize, 538 So. 2d 1313 (Fla. 1st DCA 1989)
- Irigoyen v. Aircraft Servs., Inc., 544 So. 2d 1054 (Fla. 1st DCA 1989)
- Miller v. The Tribune Co., 275 So. 2d 242 (Fla. 1973)