Worker's Compensation

III. BENEFITS UNDER THE 1994 FLORIDA WORKERS' COMPENSATION ACT

TREATING PHYSICIAN
No health care provider can provide treatment to an injured employee without prior authorization from the employer or workers' compensation insurance carrier. Further, a health care provider may not refer the employee to another health care provider, diagnostic facility, therapy center, or other facility without prior authorization from the carrier.

CHIROPRACTIC CARE
As of January 1, 1994, chiropractic care has been significantly limited. The Law states that chiropractic services in excess of 18 treatments or provided eight weeks beyond the date of the initial chiropractic treatment, whichever comes first, shall be considered not medically necessary. However, the carrier may authorize additional treatment.
For injuries occurring prior to January 1, 1994, chiropractic care is provided by the workers' compensation carrier as long as it is considered to be reasonable and medically necessary by an authorized treating physician.

PRESCRIPTIONS
You may only claim drugs prescribed by your authorized doctor to aid in the treatment of your injury.
The employer or it's workers' compensation carrier is responsible for the payment of the injured employees prescriptions either by reimbursing the employee directly, assigning a prescription card to the employee, or setting up a prescription account with an authorized pharmacy. If the employee needs to be reimbursed for payment of a prescription, a prescription reimbursement form must be completed and submitted to the carrier for payment. You may obtain these forms directly from the carrier.

ATTENDANT CARE
The employer shall provide appropriate professional or nonprofessional attendant care performed only at the direction and control of a physician when such care is medically necessary. This care is beyond the scope of household duties. Family members may provide nonprofessional attendant care, but may not be paid for care that falls within the scope of household duties and other services normally and gratuitously provided by family members. Family members include a spouse, father, mother, brother, sister, child, grandchild, father-in-law, mother-in-law, aunt or uncle. It does not include a girlfriend or boyfriend.

The family member who provides attendant care is entitled to payment. The value of such attendant care must be determined as follows:
a. If the family member is not employed, the per-hour value equals the federal minimum hourly wage.
b. If the family member is employed and elects to leave that employment to provide attendant or custodial care, the per-hour value of that care equals the per-hour value of the family member's former employment, not to exceed the per-hour value of such care available in the community.
A family member or a combination of family members providing attendant care cannot be paid for more than a total of 12 hours per day.

SECOND OPINION EVALUATIONS OR CHANGE IN TREATING PHYSICIANS
If the injured employee is unhappy with his/her authorized treating physician, he/she must make a formal request to the employer/carrier for a change in treating physicians and/or a second opinion evaluation.

INDEPENDENT MEDICAL EXAM (IME)
In any dispute concerning medical benefits, or disability relating to a work-related injury, the carrier or the employee may select an independent medical examiner.
If the injured employee fails to appear for the independent medical examination without good cause and fails to advise the physician at least 24 hours cancellation notice, the employee cannot recover compensation for any period during which he has refused to submit to an examination. Further, the injured employee must reimburse the carrier 50 percent of the physician's cancellation or no-show fee.

TRANSPORTATION
The injured worker is entitled to mileage reimbursement for medical treatment. This only includes visits to your authorized doctor or therapy which are as a result of a compensable workers' compensation injury. The date, place and a total round trip mileage must be stated on a mileage reimbursement form which can be provided to you directly from the carrier.

EMPLOYER'S FAILURE TO PROVIDE REQUESTED MEDICAL CARE TREATMENT
The Workers' Compensation Law states that if the employer fails to provide treatment or care after request by the injured employee, the employee may obtain such treatment at the expense of the employer, if the treatment is compensable and medically necessary. However, there must be specific request for the treatment, and the employer or carrier must be given a reasonable time period within which to provide the treatment or care.

PAYMENT OF MEDICAL FEES
The Workers' Compensation Law states that a health care provider may not collect or receive a fee from an injured employee within the State of Florida. For injuries occurring after January 1, 1994, after an injured employee reaches maximum medical improvement, the employee is obligated to pay a co-payment of $10 per visit for medical services.
MANAGED CARE IN 1997
Effective January 1, 1997, the employer is required to furnish medically necessary remedial treatment, care and attendance to the injured employee solely through managed care arrangements. It is crucial that you obtain the manage care documentation and follow the necessary grievance procedures prior to the filing of a Petition for Benefits.

B. INDEMNITY (WAGE) BENEFITS UNDER THE 1994 FLORIDA WORKERS' COMPENSATION ACT
Under the Workers' Compensation Law, the employer is required to compensate the injured employee during any period of disability. There are six different types of disability benefits which this booklet will address--(1) Catastrophic Temporary Total Disability; (2) Permanent Total Disability (PTD); (3) Temporary Total Disability (TTD); (4) Temporary Partial Disability (TPD); (5) Permanent Impairment Benefits; (6) Supplemental Benefits.
Each of these benefits considers the injured employee's average weekly wage on the date of accident. Therefore, it is important that there is a clear understanding what is considered an employee's "average weekly wage."

AVERAGE WEEKLY WAGE
Your average weekly wage is based upon your reported earnings and certain fringe benefits for the 13 weeks prior to your date of accident. Such fringe benefits may include health insurance benefits paid by your employer, housing, car allowance, etc. Also, if you had another job at the time of your injury, your average weekly wage may include this income as well.

CATASTROPHIC TEMPORARY TOTAL DISABILITY
In order to be entitled to these benefits, an authorized workers' compensation doctor must say that the injured employee cannot work at all due to the loss of an arm, leg, hand or foot or if the employee is paraplegic or quadriplegic.
These benefits provide the injured employee compensation of 80% of their Average Weekly Wage up to $700.00.
These benefits are paid biweekly, but can only be received for 26 weeks. Thereafter, the employee is deemed temporary total disabled and begins to receive such benefits described below.

PERMANENT TOTAL DISABILITY (PTD)
To be entitled to permanent total disability benefits, the injured employee's doctor must state that the injured employee is unable to return to work because of a catastrophic injury or an injury that would qualify the injured employee for Social Security benefits.
A permanently and totally disabled employee receives just two-thirds of his or her Average Weekly Wage up to the maximum amount as determined by the Division of Workers' Compensation.
The injured Employee must apply for Social Security benefits and cannot be receiving Unemployment Compensation.
Permanent and Total Disability benefits are payable until the injured employee dies or is no longer permanently and totally disabled.

TEMPORARY TOTAL DISABILITY (TTD)
An injured employee is entitled to Temporary Total Disability benefits when his or her workers' compensation doctor states that the injured employee cannot presently work at all.
A temporary total disabled employee receives just 66 2/3% of his or her Average Weekly Wage up to the maximum amount determined by the Division of Workers' Compensation and are paid biweekly.
These benefits are payable for a total of 104 weeks in combination with Temporary Partial Disability benefits OR until injured employee reaches Maximum Medical Improvement ("MMI").

TEMPORARY PARTIAL DISABILITY (TPD)
If the injured employee is able to return to work on a modified basis such as light duty and is earning less than 80% of his or her Average Weekly Wage, the injured employee is entitled to Temporary Partial Disability benefits. These benefits are calculated determining (80% of Average Weekly Wage minus current employee income) not to exceed 2/3 of the Average Weekly Wage.
These benefits are only payable for a total of 104 weeks in combination with Temporary Total Disability benefits OR until injured employee reaches Maximum Medical Improvement ("MMI").
The workers' compensation carrier and/or his or her attorney is required to provide the injured worker with Employee Earnings Report forms. These forms should be submitted once a month to the carrier by the employee reflecting any and all monies the employee has received during the said period.

PERMANENT IMPAIRMENT BENEFITS
Once the injured employee reaches Maximum Medical Improvement ("MMI"), all temporary benefits end.
In order to receive Permanent Impairment Benefits, the injured employee's physician must say that the injured employee has sustained a permanent impairment rating as a result of the work related injury and has reached maximum medical improvement (MMI).
An injured employee can be placed at MMI by his authorized treating physician or after a total of 104 weeks of temporary total disability/temporary partial disability benefits have been paid.
Should the physician assign an impairment rating, the injured employee is entitled to impairment benefits paid at the rate of 50% of his/her compensation rate (compensation rate is 66 2/3 of the average weekly wage).
The injured employee is only paid three weeks of permanent impairment benefits for every percentage point the physician determines he/she is impaired. For example, if the physician assigns a 5% impairment rating, the injured employee receives permanent impairment benefits for 15 weeks (3 x 5). If the physician assigns a 0% impairment rating, the injured employee is not entitled to permanent impairment benefits.
These benefits are payable whether or not the injured employee returns to work after he/she has reached MMI.

SUPPLEMENTAL BENEFITS
These benefits are payable when Permanent Impairment Benefits end. However, they are only payable if the injured employee's impairment rating is 20% or greater and employee is unable to return to work or is earning less than 80% of his Average Weekly Wage.
The injured employee entitled to Supplemental Benefits receives only 80% of (80% of Average Weekly Wage on Date of Accident minus current employee income) not to exceed two-thirds of Average Weekly Wage. The calculation is similar to Temporary Partial Disability.

COMPENSATION FOR DEATH
If death results from a work-related accident within one year thereafter or follows continuous disability and resulted from the work-related accident within five years thereafter, the employer/insurance carrier is required to pay death benefits.
The employer/insurance carrier shall pay actual funeral expenses not to exceed $5,000.00. Further, the employer/insurance carrier shall be the family of the deceased employee up to two-third of the deceased employee's average weekly wage depending on the type of dependent (spouse, child, parent, etc.).
The maximum the employer/insurance carrier has to pay to the family for the death of an employee is $100,000.

EFFECT OF SOCIAL SECURITY BENEFITS
The workers' compensation statute contains a provision which allows the employer/carrier an offset against disability benefits in certain situations when the claimant receives either social security retirement or social security disability benefits. These provisions where intended to prevent a claimant from being paid twice and ending up with more income while on disability than while employed.