The workers compensation system in Florida handled 257,667 claims in fiscal year 2018-2019, generating 3.8 million billing records that insurance carriers paid more than $531 million to settle.
Only 25,927 of those claims – just 10% — were denied and nearly half of those denials resulted in workers receiving benefits of some kind during the process.
Yet if you asked any of the parties involved – workers, employers, lawyers, insurance carriers and even judges – the majority would welcome a legislative broom to sweep away many of the laws and rules that degrade the system.
“Workers comp in Florida works about 80% of the time,” said Glen Wieland, a lawyer who has been practicing workers comp in Orlando for nearly 40 years. “If the worker needs a couple of stitches to sew up a cut or somebody turns an ankle doing something, they go to the doctor, get the treatment they need, go back to work and everybody’s happy.
“But if you’ve got a serious injury or there are some unusual circumstances involved with the accident … watch out! You have no idea how the system is going to treat you.”
Every state in the U.S. likes to brag/complain/whine and argue about how the workers compensation laws in their state are unique and unfair, but Florida states its case loudly with just one law: In workers comp cases, the Insurance carrier always picks your treating doctor.
Read that sentence again: The insurance carrier ALWAYS picks your treating doctor.
“Imagine if the same system applied to your health insurance,” Wieland said. “Imagine if every time you needed a doctor, the insurance company got to pick the doctor for you.
“What would Americans have to say about that? People would be outraged. There would be a revolt!”
Wieland probably is right, but there is no revolution brewing over workers compensation, at least not in the summer of 2020. Flaws and all, the workers compensation laws haven’t changed much in Florida the past 35 years. No one knows how they’ll change in the future, but access to medical care and the ability of the injured worker to have some voice in who treats their injuries are two areas that need to improve.
In the meantime, here are some ways to successfully comply with Florida’s workers compensation system.
How to File a Workers Comp Claim in Florida
The filing process for Florida is a simple, but critical first step in the workers compensation system. Three parties are involved – injured employee; employer; and insurance carrier – and each one’s responsibility is vital in making the process work.
It starts with the injured employee. Ideally, when a worker gets hurt in the workplace, he/she would inform their supervisor immediately, and, if necessary, go to the appropriate doctor, clinic or emergency room for medical treatment. However, the law says that you have 30 days from the date of the accident to report an injury.
In some cases, that makes sense because the worker may initially experience only mild discomfort with something like a cut or muscle pull and not seek immediate treatment. As time goes on, however, the cut could get infected or the muscle pull get aggravated and the employee suddenly realizes he/she needs treatment.
That’s why it makes sense to report an injury to a supervisor right away. Get it on record that something happened that may require medical attention. You will not regret it.
Employer’s Responsibility for Filing Claim
Once the employer has been notified of a work-related injury or illness, they have seven days to file a report to their insurance carrier with details about the injury.
The document should include the employer’s identification (name, address, business of the employer), plus identification information about the employee, including name, social security number, mailing address, phone number and occupation.
The report should include details about the cause of injury and specifics such as the month, day and hour, where it happened and any other relevant information about the accident.
The employer also must inform the insurance carrier within 14 days if the injured worker misses more than seven days of work because of the injury. On the eighth day missed, the employee is eligible for lost wages benefits.
If the employer chooses not to report an injury, which sometimes happens because the employer is worried about his rates going up, the employee can report it directly to the insurance carrier.
If an employee has questions about reporting, they can call the Florida Employee Assistance Office at 800-342-1741 or email email@example.com.
Insurance Carrier’s Responsibility with Claims Form
The insurance carrier steps in at this point and must file what is called the First Report of Injury with the Florida Division of Workers Compensation. Copies of the First Report of Injury should be mailed to the employee and employer to make sure the information reported is accurate.
Within three days of notification, the insurer must mail a brochure to the injured employee that clearly explains the rights, benefits and procedures for obtaining benefits under workers comp. The document must explain the obligations injured workers and their employers have under Florida law and the penalties for violating those laws.
The carrier should consistently update the injured employee’s file with any new medical reports showing the condition of the employee and wage statements if the employee is due indemnity pay during recovery.
Deadlines for Florida Workers Comp Claims
The deadlines for filing workers compensation claims in Florida are clear, but it should be noted that an injured employee has up to two years to file a claim for benefits.
Here are the deadlines for the various players involved in workers compensation:
Employee: It is best for employees to report an injury immediately, but the law allows 30 days from the time of the accident to report an injury to the employer.
Employer: The employer must file an injury report with the insurance carrier within seven days of being notified. Employers also must notify the insurance carrier within 14 days if the employee has missed seven days of work because of the injury.
Insurance carrier: The insurance carrier has 14 days to file the First Report of Injury, but has only three days from being notified of an injury to send a brochure to the injured employee that outlines their rights, benefits and procedures for obtaining benefits, as well as their legal obligations.
Occupational Diseases: If you are filing for death benefits due to occupational diseases, the death must have occurred within 350 weeks of the deceased’s last exposure to the source.
What to Do If Your Claim Is Denied
A total of 25,927 workers compensation claims were denied in Florida in 2018, but almost half of those denials – 10,891 – received benefits somewhere along the way. In other words, a denied claim is not the end of the line as far as receiving workers comp in Florida.
Those numbers were supplied by the Florida Department of Financial Services, which oversees the Division of Workers Compensation for the state of Florida and the Employer Assistance and Ombudsman Office (EAO).
The EAO is one of a few avenues you can take to appeal a claim. Workers must file the initial appeal within two years of the injury date. If the appeal is for medical treatment, it must be filed within a year of the last benefit payment or treatment date.
The other option is to hire an attorney, and that should be a serious consideration if you don’t already have one. The appeals process is not simple. Having some professional assistance to get through the labyrinth of rules and laws that apply to your case, will save you a lot of time and could help you receive all workers comp benefits due.
The last avenue available is to attempt to go through the filing process by yourself. It’s possible to do so, but no one involved in the process would suggest that your chances of a successful outcome are very high.
Reasons a Claim May Be Denied
There are plenty of reasons a workers compensation claim will be denied in Florida and not all of them are simply because the insurance carrier doesn’t want to pay. The old “Two Sides to Every Story” cliché comes to mind when listing reasons why a claim is denied.
Here are some of the most common reasons for denial:
- The injury did not take place at work
- The injury was caused by a pre-existing condition not related to the job
- The worker failed to meet reporting or filing deadlines
- The medical billing doesn’t match your description of the accident or injury
- The employer may dispute that the injury was work related
- The carrier may believe you’re exaggerating the seriousness of the injury
- The worker was under the influence of drugs or alcohol
- There were no witnesses to the accident that caused the injury
There is a lot of room for dispute on all sides of those eight reasons and disputes will happen. Fortunately, there is a process to appeal denial of claims.
Steps in Florida’s Appeals Process for Workers Comp Claims
The insurance carrier has 120 days from the time the injury was reported to tell the worker that a claim has been denied. When your workers comp claim is denied, there is a system set up to resolve the dispute. Here’s a walkthrough of what you’re facing on appeal of a workers compensation claim in Florida.
Step 1: Contact the Employee Assistance Office
The EAO counts itself as the first step in appealing a claims denial. The EAO says when it hears from an injured worker, it will contact the insurance company and see if it can resolve the issue to obtain benefits. If things go well, which is rare, the worker will receive benefits and the case will be closed. If not, we move on to …
Step 2: File a Petition for Benefits
When the insurance carrier denies the EAO’s intervention, the paperwork begins and things get complicated. The employee must file a “Petition for Benefits” within one year of the last indemnity payment or furnishing of remedial treat or care. The petition goes to the Offices of Judges of Compensation Claims, which has 40 days to set up a meeting between the insurance carrier, the worker and the worker’s attorney, if there is one. That leads to …
Step 3: Mediation
Mediation is where surveys say the vast majority of appeals cases are decided. A neutral third-party (usually a former judge or workers comp attorney) steps in to achieve a resolution. The mediator puts the two sides in separate rooms and walks back-and-forth between them to reach an agreement. Both sides have to want to reach a settlement. Both sides have to be willing to compromise. Both sides have to walk away feeling like they got a win. Statistics say that happens about half the time. If it doesn’t, it’s on to …
Step 4: Workers Comp Hearing
A hearing with the Office of the Judges of Compensation Claims (OJCC) is a time-consuming part of the process. It happens within 90 days after mediation failed, but no later than 210 days after the original Petition for Benefits was filed. It starts with a pre-trial hearing in which the two sides identify the issue they are disputing. A trial is scheduled within the next 90 days for the worker and insurance carrier to present their case to the judge, call witnesses (usually doctors), introduce evidence (usually medical reports) to support the claim, then wait for a judgment that could take as long as 30 days. The judge makes the decision. There is no jury involved. If both sides agree with the judge’s decision, case closed. If not, the case has one more step to go toward …
Step 5: Final Appeal
That happens with the First District Court of Appeal. The side disputing the outcome must file an appeal within 30 days of the final decision by the OJCC. It is the last stop on a journey that, in many cases, takes more than one year. The OJCC sends records of the case to the Court of Appeal, which then receives a written argument from both sides in the matter. The Court of Appeal may confirm the OJCC’s decision; it may overturn that decision; or it may send the case back to the OJCC for more findings.
So, the appeals process can work in either sides favor, but know before you start that it can be a time-consuming, emotionally-draining process. Know what you’re getting yourself into and what you want from the outcome.
As mentioned, there were 10,891 claims originally denied that ended up with payment. There also were 15,036 denials that received no payment. Be prepared.
Eligibility for Workers Comp in Florida
Nearly every employer in the state of Florida is required to provide employees with workers compensation insurance, though specific coverage requirements are based on the type of business you operate and how many employees you have.
For example, companies in the construction industry with one or more full-time or part-time employees, must have workers comp insurance. Corporate officers may exempt themselves, but no more than three officers may be exempted.
Any non-construction companies with four employees, full- or part-time, must have workers comp.
The rules for the agricultural industry are six or more regular employees and/or 12 seasonal employees who work more than 30 days and you must have workers comp insurance.
Out-of-state employers must notify their insurance company that they have employees working in the state of Florida and those employees must have a Florida workers compensation policy or have an endorsement added to the out-of-state policy that lists Florida in Section 3A. The same is true of contractors who hire out-of-state subcontractors.
Some common jobs that don’t qualify for workers compensation insurance include domestic servants in private homes; professional athletes; people performing community service as part of a court sentence.
You can search the Florida database of workers comp compliance to be sure your employer has workers comp insurance.
Benefits: What Does Workers Comp Cover in Florida?
There are three major categories of benefits in Florida’s workers compensation laws – medical; lost wages and death benefits – with several sub-categories that help determine how much you might receive and for how long.
Here is a look at each category of benefits and the sub-categories that influence how much is paid out and for how long.
When a worker gets hurt, everyone involved – business owner, fellow employees, insurance carrier – want exactly the same thing: Do what it takes to get him well and back to work.
Paying all medical necessary medical costs to achieve that is the foundation of workers compensation.
Medical benefits covered by workers comp in Florida:
- Medical treatment from an authorized doctor in an authorized facility
- If needed, use of an ambulance for transportation to the medical facility
- Any prescription drugs ordered by treating doctors
- Visits to doctor’s offices for continuing care
- Medical tests
- Hospitalization, if necessary
- Physical therapy
- Attendant care, if needed
- Mileage reimbursement for travel to appointments, procedures or pharmacies
In other words, all necessary costs to get an injured worker treated are paid for by workers compensation insurance. But that comes with some warnings of missteps that might cause your benefits to be denied.
For example, do not skip appointments. Do not go to your private doctor and expect to be reimbursed. Do not pay a bill for treatment that is sent to you. Send it to your employer or the insurance carrier to handle. If your accident requires you to go to an emergency room, tell the staff there you were hurt on the job, give them your company’s name and phone number or the number for the insurance company that handles workers comp for your company.
In fact, the best advice on medical benefits is this: If you aren’t sure about something, talk to the claims adjuster from the insurance company. There will be differences of opinion on what treatments, therapies, drugs, etc. are “necessary” to get a patient healthy again and that’s where problems start. Find out what the adjuster says and make your argument there.
Lost Wage Benefits
This probably is the most attractive benefit for injured workers for the obvious reason that the bills still have to be paid, even when you’re out of work. Unfortunately, this is not the pot of gold some employees envision.
Injured workers receive 66.7% of their weekly wages while out of work because of an injury. The maximum you may receive in the state of Florida is $971 a week. You would have to be making $1,455 a week to earn that maximum benefit.
“I don’t know anyone who can afford to lose one-third of their salary and think they’re going to stay on the same level economically,” Wieland said. “What if you just bought a house? Or a car? And now you’re trying to pay that monthly bill with one-third less income. Nobody can make that happen.”
Here’s a look at the various sub-categories for last wage payments.
Temporary Total Disability
This is when you receive 66.7% of your average weekly salary because your injury is so severe, you can’t return to work, at least for the foreseeable future. The lost wages benefit for temporary total disability is in the lawbooks to last for 104 weeks (two years), but a court case extended that to 260 weeks.
The Florida Supreme Court ruled in a 2016 case (Westphal vs. City of St. Petersburg) that limiting benefits to 104 weeks for a person who was totally disabled, but had not reached maximum medical improvement, was unconstitutional. The benefits were extended to 260 weeks.
If you are out only seven days or less, you won’t receive any lost wages compensation. You will start receiving lost wages benefits on the eighth day.
If you are out 21 or more days, you will be compensated for the first seven you missed.
If your injury is deemed critical, you may receive 80% of your regular wages for up to six months.
Temporary Partial Disability
Temporary partial disability benefits are payable when your doctor says you can go back to work, but only for limited duty with some restrictions.
That usually means you can’t do the job you were doing, or perhaps you can only do it for 4-6 hours a day, instead of eight and thus you’re not making the same income you were.
If you work less hours, or get assigned to a job that pays less than what you regular weekly pay was, there is a formula used so that you end up with slightly less than 80% of your former salary.
You may collect temporary partial disability benefits for 104 weeks (two years), which could be extended to 260 weeks if it’s combined with total temporary disability benefits.
Impairment Income Benefits
These benefits are paid to workers who doctors say have reached Maximum Medical Improvement, meaning they’ve tried all the treatments they can and you’re not going to get any better than this.
The formula used to determine how much you will receive is to take 75% of the rate you were receiving when you got 66.7% of your weekly pay. So, for example, if you usually made $600 a week, 66.7% of that would be $400. Now, multiply that by .75 and your weekly impairment benefit would equal $300.
So, before you got injured, you were making $600 a week and if you are given impairment benefits, it is for half that, or $300. And you only receive that for a limited time frame.
Doctors evaluate your capabilities and determine if you have lost use of some part (or parts) of your body, assign that a rating from zero to 100% that signifies how much of your whole body is lost to that impairment.
There could be more than one body part that is no longer functional. If there are multiple parts, you add the assigned percentages. So, for example, you may have lost use of one eye and one hand. The eye might be rated 10% and the hand 5% so your total impairment rating would be 15%.
That number is plugged into a formula that determines how many weeks you will collect the weekly impairment benefit of $300 that we calculated above. In this case, it would for 35 weeks, meaning the total you would collect would be $10,500 and your impairment benefits would run out.
Permanent Total Disability
When it is determined that an employee’s disability is judged to be permanent, he/she will received 66.67% of their average weekly wage until they reache the age of 75.
There are some severe injuries that are presumed to be examples of permanent total disability. Those injuries include paralysis, amputation of an arm, hand or foot; sever brain injury; second and third-degree burns on 25% or more of their total body; total blindness.
If the worker does not have one of those, he/she must prove that they are not able to engage in at least sedentary employment with a 50-mile radius of their home because of physical limitations.
The death benefits awarded to survivors could be considered the most controversial – and least rewarding – benefits of any offered through workers compensation. Wieland’s one-word comment on death benefits: “HORRIBLE!”
If a worker dies within one year of the date of the accident or within five years of continuous disability, compensation to the survivors is capped at $150,000. That’s not much, and it’s not even paid out in a lump sum.
The surviving spouse is paid 50% of the worker’s weekly salary until the $150,000 runs out. If there is a child involved the percentage would go up to 66.7% of the weekly salary.
So, if the worker made $600 a week, the surviving spouse would get $300 a week until the $150,000 cap was reached.
That would mean 500 weekly payments stretching through just under 10 years. Wieland said he had a recent case where the 75-year-old husband was working part-time at $200 a week when he died on the job. His wife’s death benefits were $100 a week, stretched over more than 28 years.
“She was going to have to live until she was more than 100 years old to collect the $150,000,” Wieland said. “That’s just ridiculous.”
Oh, and the death benefits also include $7,500 toward funeral costs.
Limits on Workers Comp Benefits in Florida
Florida’s time limits are consistent with those of most states around the country, though their maximum payment allowed is among the highest in the nation.
Here is a look at the limits on workers comp benefits in Florida.
- Workers on temporary total disability can receive benefits for up to 260 weeks at a maximum rate of $971 per week. The employee would have to be making $1,455 or more per week to reach the maximum payout. For comparison purposes, the maximum amount allowed in New York in 2020 was $966 per week.
- Workers receiving temporary partial disability also may receive benefits for 104 weeks. The weekly payout for temporary partial disability may not exceed 66.67% of the worker’s average weekly salary at the time of the accident.
- Workers receiving permanent total disability benefits receive it until they reach the age of 75 or until it is proven they are capable of performing at least sedentary employment within a 50-mile radius of their home. The amount of benefits follows the $971 per week maximum allowed by the state.
- Workers receiving impairment benefits have a time limit and payout based on a formula devised by the state’s Division of Workers Compensation. See Rule 440.15 number (3) (g) for details on how it is calculated.
Returning to Work Policy in Florida
The state of Florida, and presumably your employer, want you to return to work, even if you can no longer perform the job were doing at the time of the accident.
To help make that possible, there is a state Bureau of Employee Assistance and Ombudsman Office that helps workers with a long list of services that includes vocational counseling, job training and skills analysis, education and selective job placement.
You are required to fill out an application for the program that includes questions about your work history, education level, any permanent functional limitations you may have from the injury and other information.
A member of the Reemployment Services staff will conduct an interview with you, do a vocational assessment based on your skills and interests, and develop a plan for reemployment.
It was through this process, for example, that an injured maintenance worker in Miami showed his problem-solving skills in math, was sent to a college to learn accounting skills and eventually became an accountant at a public school.
Visit the state’s Reemployment Services page to find out if you’re eligible and how to receive their services.
- N.A. (ND) The 2019 Florida Statutes. Retrieved from http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0440/0440.html
- N.A. (2019, September) Workers’ Compensation System Guide. Retrieved from https://www.myfloridacfo.com/Division/WC/pdf/WC-System-Guide.pdf
- N.A. (2014, June 30) 69L-3.01915. Temporary Partial Disability Benefts (Dates of Accident on or After October 1, 2003). Retrieved from http://flrules.elaws.us/fac/69l-3.01915/
- N.A. (ND) Medical Benefits. Retrieved from https://www.myfloridacfo.com/division/wc/employee/Benefits/medical.htm
- N.A. (ND) Reemployment Services. Retrieved from https://www.myfloridacfo.com/division/wc/employee/reemployment.htm
- N.A. (ND) Workers Compensation Benefits. Retrieved from http://www.wcb.ny.gov/content/main/onthejob/wcBenefits.jsp
- N.A. (ND) Frequently Asked Questions. Retrieved from https://www.myfloridacfo.com/Division/WC/Employer/faq.htm
- O’Connor, A. (2016, June 9) Florida Supreme Court Strikes Down State Cap on Temporary Disability Benefits. Retrieved from https://www.insurancejournal.com/news/southeast/2016/06/09/411469.htm#:~:text=The%20Florida%20Supreme%20Court%20ruled,City%20of%20St.&text=The%20case%20involves%20a%20former,in%20a%202009%20workplace%20accident.