Manager and Worker

WORKERS' COMPENSATION INSURANCE 

The Florida Workers' Compensation Law is called “self-executing” because benefits are provided “in real time,” without the necessity of making a claim or awaiting a post-hearing award. If the employee has properly reported a compensable accident and continues his required behaviors, he receives indemnity benefits (meaning money to replace lost wages or earning capacity) until he reaches his maximum medical improvement ("MMI"). After reaching his MMI, if his injury is fully resolved and is not permanent, he receives no more indemnity benefits. If his injury is permanent but allows a return to some type of work, then he receives impairment benefits. If his injury is permanent and prevents him from ever returning to work, he receives permanent total disability checks, possibly for a lifetime.

Workers' compensation is an insurance plan provided by Florida employers. The plan is monitored by the State of Florida Department of Financial Services Division of Workers' Compensation.  The State of Florida Division of Administrative Hearings Office of the Judges of Compensation Claims supervises the division. All Florida employees are covered by workers' compensation beginning with their first day on the job, full-time or part-time. Employers must obtain coverage, and they may do so in various ways. 

 

Any covered individual who is injured within the course and scope of his employment receives benefits under his employer's workers' compensation policy for medically necessary care and treatment that arises out of that injury, even if injured during a break or while performing a task outside of his usual job tasks. Exceptions from coverage are limited to extreme conduct, such as attempted suicide or a fight where the injured employee was the aggressor. 

 

A compensable injury can arise from a specific event such as a strike, a blow, or a slip and fall. Or it may arise from catching an occupational disease or an exposure to an occupational hazard. It can also arise by accelerating or aggravating a disease or condition, such as by repetitive trauma when, for example, a typist slowly develops carpal tunnel syndrome or a truck loader slowly develops a degenerative disc disease in his spine.

A claimant has the burden to prove entitlement to workers' compensation benefits. But, once a claimant has established compensability of an injury, the Employer/Carrier cannot challenge the connection between the work accident and the injury. The Employer/Carrier may only question the causal connection between the injury and the requested benefit. The Employer/Carrier bears the burden of proof to demonstrate a break in the chain of events, such as the occurrence of a new accident, or that the requested treatment was due to a condition unrelated to the injury which the Employer/Carrier had accepted as compensable. For example, a "break" is understood to occur when the work-related cause drops to 50% or less of the total cause of the need for the requested benefit.

In general, the first thing an injured worker must do is report his injury to his employer. This “notice” requirement is satisfied by the employee personally signing the State of Florida's approved Form DWC-1a, “Notice of Injury,” on the same day as the accident. But the requirement can also be satisfied by providing actual notice to the employer within thirty days. This can be accomplished by the employee verbally telling one of his supervisors.

The employee's responsibilities do not end after he reports his injury. Misbehavior has penalties. Failure to use an available safety appliance or obey a legal safety rule reduces compensation by 25%. Drug use at a drug-free workplace might bar all compensation. Refusal to cooperate in applying for Social Security benefits suspends permanent total disability (PTD) benefits. Failure to turn in certain forms, such as a requested affidavit of post-accident wages, the “Request for Social Security Disability Benefits Information” or the “Authorization Request for Unemployment Compensation Information,” may lead to suspension of benefits.

 

Failure to submit proper wage loss forms bars temporary partial disability (TPD) and wage-loss benefits. Failure to answer a request to report earnings or income suspends benefits for the duration of that failure. Refusing training and education that is recommended by a vocational evaluator and considered necessary by the Division may cause a reduction in weekly compensation benefits. Failure to attend the judge's expert medical advisor's examination creates a forfeiture of benefits for the duration of that failure. Failure to pay child support can lead to an income deduction order against the compensation payments. Receiving an overpayment from the carrier might result in a reduction of future benefits to recoup the overpayment. Most of all, a claimant who makes a false, misleading, or even incomplete statement for the purpose of obtaining any workers' compensation benefit forever loses entitlement to all past, present, and future workers' compensation benefits arising out of that workplace injury.

The Florida Workers' Compensation Law is called “self-executing” because benefits are provided “in real time,” without the necessity of making a claim or awaiting a post-hearing award. If the employee has properly reported a compensable accident and continues his required behaviors, he receives indemnity benefits (meaning money to replace lost wages or earning capacity) until he reaches his maximum medical improvement ("MMI"). After reaching his MMI, if his injury is fully resolved and is not permanent, he receives no more indemnity benefits. If his injury is permanent but allows a return to some type of work, then he receives impairment benefits. If his injury is permanent and prevents him from ever returning to work, he receives permanent total disability checks, possibly for a lifetime.

Before MMI, workers' compensation pays 100% of the medical care that is medically necessary and related to the worker's injury. After MMI, the injured worker pays a $10 co-pay, but he otherwise continues to receive all medically necessary and causally related medical care, possibly for a lifetime.

The worker may lose all benefits if the statute of limitations runs out. The statute of limitations is two years. That means the employee has two years to bring his claim, from the date a reasonable person should have known of the accident. Even once the claim is brought, the statute may still run out if the claimant stops receiving benefits. It cannot run out during the two years after his workplace accident, and the claimant can extend this two-year period by an additional year each time he either visits a doctor with the insurance carrier's payment and approval or is paid an indemnity check due to his workplace injury. The period cannot be shorter than two years from the date of the accident.

Temporary indemnity benefits are only available to injured workers whose injury causes them to miss more than seven days of work. Under all classifications of temporary benefits, the checks are paid bi-weekly, and appropriate offsets may be taken by the carrier for income such as Social Security disability or unemployment compensation. If the employee dies because of his workplace accident, his estate receives funeral expenses. If he has qualifying dependents, they might receive indemnity payments.

Other benefits available in many cases include reimbursement for mileage to and from medically necessary doctor appointments, penalties or interest on benefits unpaid or paid late, retraining, and vocational assistance.

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