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2016 Florida Statutes
Procedure for resolving benefit disputes.
Procedure for resolving benefit disputes.
440.192 Procedure for resolving benefit disputes.—
(1) Any employee may, for any benefit that is ripe, due, and owing, file with the Office of the Judges of Compensation Claims a petition for benefits which meets the requirements of this section and the definition of specificity in s. 440.02. An employee represented by an attorney shall file by electronic means approved by the Deputy Chief Judge. An employee not represented by an attorney may file by certified mail or by electronic means approved by the Deputy Chief Judge. The department shall inform employees of the location of the Office of the Judges of Compensation Claims and the office’s website address for purposes of filing a petition for benefits. The employee shall also serve copies of the petition for benefits by certified mail, or by electronic means approved by the Deputy Chief Judge, upon the employer and the employer’s carrier. The Deputy Chief Judge shall refer the petitions to the judges of compensation claims.
(2) Upon receipt, the Office of the Judges of Compensation Claims shall review each petition and shall dismiss each petition or any portion of such a petition that does not on its face specifically identify or itemize the following:
(a) Name, address, telephone number, and social security number of the employee.
(b) Name, address, and telephone number of the employer.
(c) A detailed description of the injury and cause of the injury, including the location of the occurrence and the date or dates of the accident.
(d) A detailed description of the employee’s job, work responsibilities, and work the employee was performing when the injury occurred.
(e) The time period for which compensation and the specific classification of compensation were not timely provided.
(f) Date of maximum medical improvement, character of disability, and specific statement of all benefits or compensation that the employee is seeking.
(g) All specific travel costs to which the employee believes she or he is entitled, including dates of travel and purpose of travel, means of transportation, and mileage and including the date the request for mileage was filed with the carrier and a copy of the request filed with the carrier.
(h) Specific listing of all medical charges alleged unpaid, including the name and address of the medical provider, the amounts due, and the specific dates of treatment.
(i) The type or nature of treatment care or attendance sought and the justification for such treatment. If the employee is under the care of a physician for an injury identified under paragraph (c), a copy of the physician’s request, authorization, or recommendation for treatment, care, or attendance must accompany the petition.
(j) Specific explanation of any other disputed issue that a judge of compensation claims will be called to rule upon.
The dismissal of any petition or portion of such a petition under this section is without prejudice and does not require a hearing.
(3) A petition for benefits may contain a claim for past benefits and continuing benefits in any benefit category, but is limited to those in default and ripe, due, and owing on the date the petition is filed. If the employer has elected to satisfy its obligation to provide medical treatment, care, and attendance through a managed care arrangement designated under this chapter, the employee must exhaust all managed care grievance procedures before filing a petition for benefits under this section.
(4) The petition must include a certification by the claimant or, if the claimant is represented by counsel, the claimant’s attorney, stating that the claimant, or attorney if the claimant is represented by counsel, has made a good faith effort to resolve the dispute and that the claimant or attorney was unable to resolve the dispute with the carrier.
(5) All motions to dismiss must state with particularity the basis for the motion. The judge of compensation claims shall enter an order upon such motions without hearing, unless good cause for hearing is shown. When any petition or portion of a petition is dismissed for lack of specificity under this subsection, the claimant must be allowed 20 days after the date of the order of dismissal in which to file an amended petition. Any grounds for dismissal for lack of specificity under this section which are not asserted within 30 days after receipt of the petition for benefits are thereby waived.
(6) If the claimant is not represented by counsel, the Office of the Judges of Compensation Claims may request the Employee Assistance and Ombudsman Office to assist the claimant in filing a petition that meets the requirements of this section.
(7) Notwithstanding the provisions of s. 440.34, a judge of compensation claims may not award attorney’s fees payable by the carrier for services expended or costs incurred prior to the filing of a petition that does not meet the requirements of this section.
(8) Within 14 days after receipt of a petition for benefits by certified mail or by approved electronic means, the carrier must either pay the requested benefits without prejudice to its right to deny within 120 days from receipt of the petition or file a response to petition with the Office of the Judges of Compensation Claims. The response shall be filed by electronic means approved by the Deputy Chief Judge. The carrier must list all benefits requested but not paid and explain its justification for nonpayment in the response to petition. A carrier that does not deny compensability in accordance with s. 440.20(4) is deemed to have accepted the employee’s injuries as compensable, unless it can establish material facts relevant to the issue of compensability that could not have been discovered through reasonable investigation within the 120-day period. The carrier shall provide copies of the response to the filing party, employer, and claimant by certified mail or by electronic means approved by the Deputy Chief Judge.
(9) A petition for benefits must contain claims for all benefits that are ripe, due, and owing on the date the petition is filed. Unless stipulated in writing by the parties, only claims which have been properly raised in a petition for benefits and have undergone mediation may be considered for adjudication by a judge of compensation claims.
History.—s. 25, ch. 93-415; s. 115, ch. 97-103; s. 16, ch. 2001-91; s. 31, ch. 2002-194; s. 22, ch. 2003-412; s. 3, ch. 2011-208.