DIVERSIFIED MAINTENANCE SYSTEMS, INC., AND TRAVELERS INSURANCE COMPANY, APPELLANTS,
v.
FRANCISCO SOTO FUERTE, APPELLEE
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Florida appellate court reversed a workers' compensation judge's award allowing a claimant to choose a primary care provider from the entire provider network, holding that the managed care agreement's terms govern provider selection and the claimant's petition should have been dismissed because the employer/carrier limited rather than denied treatment.
When an employer/carrier limits a claimant's choice of primary care provider pursuant to the terms of a managed care arrangement without denying treatment, the claimant's petition for benefits should be dismissed because the MCA terms govern resolution, not the workers' compensation judge.
[1] In a workers' compensation case, when an employer/carrier limits a claimant's choice of primary care provider pursuant to a managed care arrangement without denying treat…
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Join FLexlaw to unlock all legal intelligenceA workers' compensation claimant requested an alternate primary care provider under a managed care arrangement and was dissatisfied when the employer/…
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In this workers’ compensation case, Claimant requested an alternate primary care provider (PCP) under the parties’ managed care arrangement (MCA), but was dissatisfied when the Employer/Carrier (E/C) agreed to authorize one of only three PCPs whose names it provided Claimant. Claimant then filed a petition for benefits seeking to choose a PCP from any of the multiple PCPs participating in the provider network. The E/C now appeals from the order of the Judge of Compensation Claims (JCC) awarding authorization of a PCP “from among the provider network” and entitlement to attorney’s fees and costs for the prosecution of that benefit. Because the question presented has been resolved by Mack v. Westminster Suncoast Manor, 929 So.2d 610 (Fla. 1st DCA 2006), we reverse the order. Specifically, in both cases, although the JCC had jurisdiction over the petition for benefits because the claimant exhausted the grievance procedure, the terms of the MCA govern resolution of the petition. Here, as in Mack, because the E/C did not deny treatment but only limited the claimant’s choice of provider in the manner prescribed by the applicable MCA, Claimant’s petition should have been dismissed.
REVERSED.
ROBERTS, CLARK, and WETHERELL, JJ., concur.