Wednesday, February 15, 2012

FL Case Demonstrates Importance of Medical Evidence

Workers' compensation, it has been said, is an indemnity benefit delivery system with a medical component.

I've always had difficulty with that statement and have been of the opinion that it is the reverse that is true - that workers' compensation is a medical delivery system with an indemnity component.

The reason for my opinion is because the first thing that happens to invoke the jurisdiction of workers' compensation is either an injury or disease, both medical issues instituting the delivery of medical care. In addition the cost of medical is the single biggest cost component in work comp systems.

The import of the medical component is further solidified by the simple fact that the indemnity component can not live without a medical opinion - it is a physician's statement as to disability that precipitates the payment, or cessation, of indemnity.

This point was made abundantly clear by a recent Florida case where the First District Court of Appeals (1st DCA), which hears all workers' compensation appeals in the state, ruled that a letter memorializing an alleged conference with a doctor was not medical evidence thus necessitating reliance on the only medical evidence on record, thereby mandating temporary total disability indemnity benefits.

In Urquiza v. Don Greene Poultry et al., No. 1D11-3300, 02/14/2012, published, Urquiza sustained a work-related injury on July 7, 2009, while employed by Don Greene Poultry. As a result of his compensable physical injuries, he began experiencing psychiatric difficulties, and his employer's insurance carrier authorized psychiatric treatment through Compass Health Systems.

The first doctor who treated Urquiza opined that Urquiza was not in a condition to return to work, and after the doctor left Compass Health's employ in 2010, a second doctor who took over the treatment of Urquiza agreed with the first doctor’s opinion.

A claims adjuster assigned to Urquiza's case testified that she never received any medical records from Compass Health changing Urquiza's no-work status, but the insurance carrier reclassified him as only partially disabled as of Sept. 15, 2010, based on an alleged conference with the first Compass Health doctor.

The discussion from this conference was memorialized in a letter from the carrier's insurance company to the doctor and signed by the doctor.

Urquiza objected to the admission of this letter at trial, contending it was not authenticated and it was impermissible hearsay. The Judge of Compensation Claims (JCC) sustained his objection, but, apparently based on the suggestion in the letter that Urquiza could return to work part-time, engaged in an analysis of his credibility as to whether he had been informed that he could re-enter the workforce.

Based on this analysis, the JCC concluded Urquiza was not credible and denied his request for total disability benefits for September through Nov. 23, 2010.

On appeal the 1st DCA said that because the letter was not medical evidence, and the issue of disability must be made on the basis of medical evidence. The only medical evidence consisted of the opinion testimony from the second Compass Health doctor to treat Urquiza, which was that he remained totally disabled from the time of her first assessment.

"Thus, the record is devoid of medical evidence to support the suggestion that … claimant was sufficiently improved psychiatrically to return to any sort of work, or that he was advised of the same," the 1st DCA reasoned.

The lesson for all in claims - you must have admissible medical evidence to support your claims management decisions.workers compensation, work comp, injured worker


  1. I couldn't agree more! I would add that in order for claims people to be effective, they need to UNDERSTAND the medical evidence and the impact on the claim. Too many adjusters I see lack the training and resources to be discerning consumers of medical services. The result is runaway costs and "condition creeps" that go unchecked.

  2. Thank you Kris. Understanding evidence, and the rules of evidence in particular, is not typically taught to adjusters. Consequently incorrect assumptions are made. Runaway costs and condition creeps are what happens.

  3. David, excellent article. With your permission I would like to re-post this on my ClaimCompass site ( Please let me know if that would be okay. Thanks.

  4. You're welcome to republish Steve. Thanks for asking!