We have all seen Petitions for Benefits (PFB) that request a litany of things. But have you even found yourself asking what specifically the PFB is requesting? Florida Statute §440.02(40) states that PFBs must be plead with specificity meaning referrals for any specialist must be attached, bills for payment/compensability must be attached or the specific AWW adjustment must be geared towards an actual wage amount. Knocking any one of these things out of a PFB via Motion to Dismiss for Lack of Specificity can help gather information. More importantly, it can cut down on exposure for potentially prevailing on an issue. Let’s look at some examples of requests we should keep a keen eye on when responding to PFBs.
The applicable part of Florida Statute §440.02(40) reads:
“”Specificity” means information on the petition for benefits sufficient to put the employer or carrier on notice of the exact statutory classification and outstanding time period of benefits being requested and includes a detailed explanation of any benefits being received that should be increased, decreased, changed, or otherwise modified. If the petition is for medical benefits, the information shall include specific details as to why such benefits are being requested, why such benefits are medically necessary, and why current treatment, if any, is not sufficient. Any petition requesting alternate or other medical care, including, but not limited to, petitions requesting psychiatric or psychological treatment, must specifically identify the physician, as defined in s. 440.13(1), that is recommending such treatment. A copy of a report from such physician making the recommendation for alternate or other medical care shall also be attached to the petition. A judge of compensation claims shall not order such treatment if a physician is not recommending such treatment.”
Especially in the first PFB, requests for payment of a bill for a hospital visit is very likely. Hospital/emergency room bills can be very expensive if the injury is serious and are rarely cheap regardless. When a request for payment or compensability of a medical bill is made, be sure the actual bill and dictated medical notes are attached before accepting payment. The amount of the bill, and treatment rendered, may help gauge exposure for a compensable claim. Additionally, claimants will also try the more subtle trick of requesting compensability of the treatment and not payment of the bill. Claimant’s Counsel will then argue that they are not asking for payment of the bill but just compensability of the treatment. The fact is, we know that they want the bill paid and will inevitably request the same right after compensability is accepted. Judges in the Miami area have typically agreed that requesting compensability of the treatment is tantamount to requesting payment of the bill.
Claimant’s counsels will also pretend to be doctors, by requesting treatment with some sort of specialist, such as an orthopedic, without the required referral. Without the required documentation, the claimant is not entitled to specialist treatment, and we can easily get the request dismissed. This is something that is very common but can be knocked out early if caught in time. Skipping the primary care provider stage is something claimants are keen on doing since a referral is not always warranted. An additional tip is that referrals for psychiatrist and psychologist are not the same. A psychiatrist is a M.D. and able to prescribe medications, enact restrictions and additional referrals. Psychologists have less leeway and are more related to physical therapists who do not hold such sway over the claimant’s course of treatment. Keeping a claimant out of a specialist’s care when they have not been referred to one, can greatly cut down medical exposure including the potential for surgical recommendations.
A request for an adjustment of the Claimant’s AWW is also very common but can be easily dismissed. Although most claimant’s have access to their wage documents and payroll information, claimant’s counsel likes to erroneously request upwards adjustments to the AWW to increase indemnity exposure. However, without a specific amount listed, this claim can be dismissed relatively easily by pointing this discrepancy out to the judge via motion. Even though this is easily overcome by claimant’s counsel by simply listing any amount, this could potentially save you down the road if any adjustment to the AWW is made.
Another helpful tip that we commonly see down in Miami is the “fake” attachment. Just because there are documents attached to the PFB does not mean the required documentation is present. I have personally seen countless times claimant’s counsel attaches something that has nothing to do with any of the requested benefits. Even worse, I have also seen numerous claimant’s counsels simply attach another version of the PFB or their good faith effort as the medical/exempt documents trying to trick you into thinking bills or referrals are attached. These sneaky claimant tricks are subtle but can easily be avoided with a keen eye. Knocking out even one or two requests from a PFB can help mitigate attorney fee exposure. When responding to PFBs, remember to check the attachments and never give claimant’s counsel the benefit of the doubt.