Greetings, my Tip of the Week last week touched on the 120-day rule and I got some good follow up questions, and requests for more detail about the 14 days, 120 days and Major Contributing Cause.  So I will attempt to lay it out without getting too far down any rabbit holes:

(The FL WC statute says you must respond to a PFB within 14 days, but that is a total separate issue from compensability decisions.)

A. 14 day/120-Day

1. The clock starts with the provision of a benefit.  After an accident is reported, the employer or adjuster sends the claimant to a walk-in for example. The date of the visit is the start point.  (If the employer sends them to the hospital because they had a heart attack that is arguably not a provision of a benefit unless they state it is for WC).  (The date of accident or the reporting the accident does NOT start the clock, it’s the provision of a benefit)

2. Within 14 days after the initial provision of a benefit, the adjuster must make one of 3 choices. 

• Deny the claim and owe nothing that occurred in those 14 days.  OR
• Accept the compensability of the claim. OR
• Opt to pay and continue to investigate compensability for up to 120 days.  If the decision is made on day 118 after the first benefit, a denial of the entire claim can be issued, but the adjuster must pay for everything up until that denial.   If no denial is issued within 120 days, the accident is accepted as compensable.   We can later challenge the compensability of any specific benefit, but the accident is compensable.  Two exceptions:

• Fraud, you could deny compensability if you later find fraud.  
• If there is info that you could not discover within 120 with a reasonable investigation.

B. Wait how does that work with Major Contributing Cause?

1. The accident is the event (the fall) and the injury is the result.  If you don’t deny the claim within 120 days, the accident itself is compensable but you can always deny future care if the accident does not remain the major contributing cause of the need for treatment (the claimant returned to baseline). Also:

• You can deny a surgery or any requested treatment if the accident is not the MCC/ preexisting.
• You can deny a specific treatment if it is not medically necessary
• You can deny indemnity for any appropriate reason.

C. Within 120 you need to make sure the claim should not be denied because of the following possibilities/issues that could affect compensability  (I’m sure I left one or two out).  You cannot argue any of these usually after 120 days.

• Going and Coming Rule
• Personal Comfort Doctrine
• Lunchtime/Off premises
• Not in Course and Scope
• Idiopathic.
• Recreational and Social Activities
• Does not arise out of employment
• Intoxication
• No physical injury
• Late reporting
• Deviations from Employment and Horseplay
• Traveling Employee issues
• Intentional Injury

Hope this helps.  We have CEU’s on the 120 day and also on these compensability topics if anyone is interested.

Sincerely,

Morgan Indek | Managing Partner