FIRST DCA HOLDS THAT 120-DAY PAY AND INVESTIGATE RULE DOES NOT BAR DEFENSE BASED ON MAJOR CONTRIBUTING CAUSE
By Thomas P. Vecchio
The First DCA recently held that an employer/carrier (EC) could deny treatment for an injury based on major contributing cause (MCC), even though more than 120 days passed after the initial acceptance of compensability.
The Claimant sustained a compensable knee injury in September 2008. She was provided authorized orthopedic surgery. In July 2009, the Claimant injured the same knee at home. She went to her authorized orthopedic surgeon, who initially concluded that she merely aggravated her compensable knee injury. After reviewing the MRI, however, the surgeon determined that the Claimant sustained a new meniscal tear as a result of the July 2009 accident at home.
Upon inquiry from the EC, the doctor indicated that the 2008 accident was not the MCC of the new meniscal tear, and the Claimant would have reached maximum medical improvement (MMI) from her compensable injury had she not suffered her new accident at home. The EC therefore denied treatment for the meniscal tear that occurred at home.
The JCC ruled against the EC, however, holding that the EC failed to deny compensability of the claim within 120 days after the initial provision of benefits. Neither the Claimant nor the EC had raised or argued the 120-day rule one way or the other. The JCC held that based on the 120-day rule, the EC was barred from denying compensability of the injury the Claimant sustained at home, and was therefore required to pay for treatment of the meniscal tear the Claimant sustained at home.
The First DCA reversed and held that the EC was not bound by provisions of the 120-day rule. The First DCA first addressed a due process issue by noting that the JCC could not bind the parties to the 120-day rule when it was not raised as a defense by the EC, or argued by the Claimant that the EC missed the 120-day deadline.
The more relevant issue, however, was the Court's distinction between compensability and the need for treatment. The First DCA held that even if the EC did not deny the new injury within 120 days of the accident that occurred at home, the EC could still present evidence showing that the Claimant's need for treatment was unrelated to the compensable workplace injury. The 120-day rule applies only to compensability. The 120-day rule does not prohibit the EC from denying medical treatment when the need for such treatment is unrelated to the compensable accident.
The EC initially thought it was paying for care and treatment related to the compensable September 2008 accident. It was later discovered that the July 2009 accident which occurred at the Claimant's home was the MCC of her new torn meniscus. The 120-day rule does not prevent an EC from denying benefits on the basis of major contributing cause, even if it is prevented from raising a compensability defense under the 120-day rule.
Analysis
The Court draws a fine distinction between compensability of the claim and MCC in this opinion. Even if a claim is deemed compensable, an employer/carrier may still raise an MCC defense by showing that the need for treatment is not related to the compensable injury. An employer/carrier could readily acknowledge that a compensable injury occurred in the course and scope of employment, but deny medical care even after 120 days have elapsed between the initial provision of benefits and the denial.
The Court cited a 2006 case holding that the 120-day rule applies "solely to the concept of compensability," as distinguished from major contributing cause and causal relationship between the industrial accident and the need for treatment. If the employer/carrier does not properly raise a compensability defense within the appropriate timeframes, the EC can still deny benefits on the grounds that the need for medical treatment is unrelated to the compensable workplace accident.
