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Denial of Workers’ Compensation Medical Benefits Can Be Legally Challenged

Posted on Friday, July 31, 2015
Blog, Workers' Compensation

Your ability to receive medical benefits under Florida workers’ compensation is dependent on strict guidelines–guidelines that can, nevertheless, be challenged in court. According to the Florida Division of Workers’ Compensation, your employer may have to provide you with medical treatment, but it is your responsibility to quickly report any on-the-job illness, or injury. And, the doctor who aids you at the scene of the workplace mishap may not be the doctor who continues your treatment under your employer’s insurance plan. Likewise, be sure to advise hospital emergency-room personnel–if they are your “first responders”– to forward your records to your employer, and/or your insurance carrier.

Florida Workers’ Compensation laws declare, also, that you can only receive initial, ongoing and “specialist” medical care for a (supposed) on-the-job injury if insurance-company physicians declare this “medically necessary.” However, the term “medically necessary” is subject to interpretation, and you can, therefore, present a legal challenge whenever the carrier denies medical help you feel is crucial.

The types of medical care usually offered by workers’ compensation for physical-health problems–doctor’s visits, hospitalization, therapy, exams/tests and prescription medications–also apply to “mental and nervous injuries,” as described by Florida Statute 440.093. In order for “mental/nervous” treatments to be covered, though, your mental “stressors” must be directly attributable–by at least 50%–to the “compensable physical injury” that occurred while you were working. This 50% is used in comparison with any other possible causes of your mental-health issues. And, the term “directly attributable” is another that can be viewed differently by you, and by your insurance company.

Your “mental and nervous injuries,” therefore, must be proven by clear and convincing medical evidence, and this evidence can only be provided by a licensed psychiatrist–not a psychologist–who can give your condition a unequivocal diagnosis by employing the criteria now extant in the DSM-IV, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.

Asserts Florida laws: A mental injury that results from stress, fright or excitement are not an “accidental injury,” even if it was, you believe, engendered from an on-the-job incident. Workers’ Compensation, in other words, must see a trauma to your physical body in order to permit your employer’s insurance to help you to heal. –Can this “nervous injury” interpretation be legally challenged? Yes!

But can the insurance company claim, in a situation such as this, that your “mental challenges” existed prior to your current employment? Yes!

Some physically injured employees have, conversely, been accused of mental malingering, when in fact; the trauma they experienced was real–just not easily diagnosable.

This overview of actual, nameable and feasible workplace injuries–which may be denied by Florida Workers’ Compensation–should convince any employee with questions to seek legal help.