Greetings, I just presented a Florida CEU this morning and thought this would be a good refresher for everyone.
Not responding to a PFB is the same as denying the requested benefits EXCEPT in two key circumstances:
- The Statute of Limitation has expired. In this case you must respond to the PFB and state the SOL has run or you potentially waive the defense. Even though it is a denial in other circumstances, not answering the PFB does not give you the SOL defense.
- The 120-day rule. If you have elected to pay and investigate the compensability of a claim, you must affirmatively deny the claim with a DWC-12 or a PFB response before the 120 days expire.
- The initial provision of a benefit starts the clock. (Your clock is NOT started by the date of accident, the claimant reporting a claim, a PFB, etc…only providing a benefit).
- Within 14 days of the initial provision of a benefit, you have 3 choices; deny the claim, accept the claim or pay and investigate compensability for up to 120 days.
- If for example, a PFB is filed on day 100 after the first walk-in visit, not responding is not a denial for 120-day purposes. You actually have to issue a denial. If you go beyond 120 days without a denial, you could be estopped from denying compensability (unless there is information you could not discover with a reasonable investigation within 120, fraud, or other possible reason).
If you ever have any specific questions about this, feel free to reach out to me.
Morgan Indek | Managing Partner