TERRY PEARSON, APPELLANT,
v.
BH TRANSFER AND CHARTIS CLAIMS, INC., APPELLEES

Fla. 1st DCA | 2015-05-27
No. 1D14-4560
WOLF, ROWE, and SWANSON, JJ., concur.
163 So. 3d 1280 Florida District Court of Appeal, First District (2015)

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Synopsis

In this workers' compensation appeal, the court reversed the Judge of Compensation Claims' denial of authorization for spinal surgery, holding that the insurance carrier forfeited its right to contest medical necessity by failing to respond to the claimant's written request within the statutory timeframe required by Florida law.


Holding

The court held that under section 440.13(3)(i), an employer or carrier forfeits the right to contest the medical necessity of an authorized doctor's referral for medical treatment if it fails to respond within the required timeframe. Because the carrier failed to timely respond to the claimant's request, it forfeited its right to contest medical necessity.


Headnotes

[1] A workers' compensation carrier forfeits the right to contest the medical necessity of a requested service if it fails to respond to the request within the statutory time…

[2] A carrier's failure to timely respond to a written request for a referral from an authorized treating physician results in a forfeiture of the right to contest the reason…

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Key Quotes

“Under sections 440.13(3)(d) and (i), an employer or carrier 'forfeits the right to contest' the medical necessity of an authorized doctor's referral for (additional) medical treatment, unless the employer or carrier responds to the authorized, doctor's written request for a referral within the time allowed.”

Establishes the core legal principle that failure to respond timely results in forfeiture of the right to contest medical necessity

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Facts & Procedural History

Terry Pearson, a workers' compensation claimant, filed a petition for benefits requesting authorization for spinal surgery recommended by his authoriz…

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Opinion of the Court
PER CURIAM.

PER CURIAM.

In this workers’ compensation appeal, Claimant, Terry Pearson, argues that the Judge of Compensation Claims (JCC) erred when he denied Claimant’s request for authorization of spinal surgery on grounds that the surgery was not medically necessary. Because the JCC’s interpretation of section 440.13(3)(i), Florida Statutes (2011), was erroneous, we reverse.

Claimant filed a petition for benefits requesting authorization for the surgical procedure recommended by his authorized treating physician and attached to the petition a copy of the doctor’s office note recommending the procedure. More than ten days after receipt of the written request, Chartis Claims, the carrier, filed its response to the petition. The JCC denied the request on the grounds that the procedure was not medically necessary. However, this Court has previously held that section 440.13(3)(i) requires a. carrier to respond to a request within a specific time-frame or forfeit its right to contest the medical necessity of the requested service. Andino-Rivera v. Se. Atl. Beverage Co., 132 So.3d 1191, 1193 (Fla. 1st DCA 2014) (“Under sections 440.13(3)(d) and (i), an employer or carrier ‘forfeits the right to contest’ the medical necessity of an authorized doctor’s referral for (additional) medical treatment, unless the employer or carrier responds to the authorized, doctor’s written request for a referral within the time allowed.”); City of Panama City v. Bagshaw, 65 So.3d 614, 615-16 (Fla. 1st DCA 2011) (same); Elmer v. Southland Corp., 5 So.3d 754, 756 (Fla. 1st DCA 2009) (same). Here, the carrier failed to timely respond to the request; thus, it forfeited the right to contest whether the referral was reasonable and medically necessary.

We, therefore, REVERSE the order on appeal and REMAND for entry of an order awarding the requested surgery.

WOLF, ROWE, and SWANSON, JJ., concur.


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