Medical treatment With WC claims, the employer is responsible for providing medical treatment. The injured worker should not delay in getting a doctor’s appointment from the employer or insurance company. The injured worker cannot just go to their private doctor or a doctor of their choice; instead, the insurance company must authorize the doctor who is to treat the injured worker. The Employee Assistance and Ombudsman Office The Employee Assistance and Ombudsman Office (EAO) will assist the injured worker, at no cost, with questions or concerns they may have about their WC claim. EAO relies on a team structure to successfully accomplish its mission. Each team focuses on a specific area of statutory responsibility in order to effectively assist injured workers. The EAO distributes WC information; proactively contacts injured worker’s to inform them of their rights and responsibilities and educates them about its services; and works to resolve disputes between injured workers and carriers to avoid unnecessary expenses, costly litigation or delay in the provision of benefits. The First Report of Injury Team identifies, and contacts injured workers with more than seven (7) days of work lost due to the job injury. This contact takes place within two (2) business days of the Division’s receipt of a First Report of Injury. This team will advise the injured worker of their responsibilities and inform them of EAO’s various services. The Ombudsman Team is responsible for assisting injured workers to resolve complex disputes. The team conducts fact finding reviews, analyzes claim files, researches case law, promotes open communication between Disputes between parties If a dispute arises with the insurance company it is wise to talk about the problem with the adjuster or their supervisor . If the dispute is not resolved, the WC hotline can be contacted. If the insurance company still will not agree to pay the benefits that the worker believes they are entitled to, they can file a Petition for Benefits with the Office of the Judges of
parties, and generally helps parties to understand their statutory responsibilities. In the Fiscal Year of 2014-2015, the First Report of Injury Team contacted 29,116 injured workers by telephone and 3,511 employers/carriers when the team was unable to reach injured workers. In the same fiscal year, out of the 373 disputes received, 94% were resolved by the Team. During the same Fiscal Year 2014-2015, the Ombudsman Team was involved in resolving 91% of the 754 disputes received. The medical bill disputes totaled $22,995 in previously unpaid medical bills. These statistics illustrate the commitment of the department to help injured workers and resolve disputes between parties. Several offices are located around the state and EAO’s website is http:// www.myfloridacfo.com/division/WC/employee/default.htm . Re-Employment Assistance If an injured worker on WC is unable to return to work because of permanent work restrictions resulting from on-the-job injury, they may obtain information or assistance from the Bureau of Employee Assistance and Ombudsman Office/Reemployment Services Section at the following website, by phone, or by email. Bureau of Employee Assistance and Ombudsman Office/ Reemployment Services Section Website: http://www.myfloridacfo.com/division/WC/ employee/reemployment.htm Telephone: (800) 342-1741 - option 4 Email: wcres@myfloridacfo.com For assistance on how benefits are calculated, call the WC hotline at 1-800-342-1741. Compensation Claims. The injured worker may wish to hire an attorney to represent them in this action. The following graphic depicts the flow of a WC claim in Figure 1. The second flowchart describes the process of dispute resolution, Figure 2. These charts were both obtained from Florida’s WC System Guide issued in July of 2014.
Figure 1: Flow of Workers’ Compensation Claim
EMPLOYER Injury report to Employer
INJURY
The Insurance Company must pay the first installment of compensation, if injured worker misses more than 7 days from work that is immediate and continuous with 14 days after the employer has knowledge. Additional payment made bi-weekly until employee returns to work or benefits are exhausted.
INSURANCE COMPANY Employer required to report to Insurance Company within 7 days of knowledge.
INSURANCE COMPANY Pays Claim.
YES
NO
DENIAL The Insurance Company must deny a claim within 120 days. The Insurance Company is required to pay benefits until the date the claim is denied.
ACCEPT DENIAL OF THE COMPENSABILITY OF THE CLAIM
Case Closed
YES
NO
PETITION for BENEFITS If the employee disagrees, he/she may within 2 years from the date of accident file a Petition for Benefits. (NOTE: The 2-year limit pertains only to contesting the compensability of the claim.)
CARRIER RESPONSE The Insurance Company must pay or respond to the Petition within 14 days of receipt of the Petition specifically denying those benefits they will not provide.
MEDIATION Mediation is held within 130 days of filing the Petition.
Final Hearing (Within 90 days after the Pre-Trial Hearing)
Workers’ Compensation Judge
Pre-Trial Hearing
SETTLED?
NO
YES
Case Closed
ACCEPTS DECISION
Case Closed
YES
NO
An appeal must be filed within 30 days from the date the WC Judge signs the order.
1st District Court of Appeal
Page 15
Book Code: NTFL1024
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