Florida law requires an insurance company to accept or deny a workers’ compensation claim after they are reported within 14 days after an accident, or a Petition for Benefits is filed.
The 120-day pay and investigate rule is the best tool in an insurance company’s toolbox when there are questions that require further investigation in a claim.
If you have questions about how to employ this rule, please contact one of the qualified Florida workers’ compensation attorneys at Goldberg Segalla.
Employers and carriers know Florida law requires an insurance company to accept or deny a workers’ compensation claim after one is reported within 14 days after an accident, or a Petition for Benefits is filed.
While we can understand why a quick turnaround would be required to place benefits in the hands of injured workers who need them, what should the employer or carrier do if there are questions about the validity of the accident or injury?
Florida Statute 440.20(4) provides an answer: “[i]f the carrier is uncertain of its obligation to provide benefits or compensation, the carrier shall immediately and in good faith commend investigation of the employee’s entitlement to benefits under this chapter and shall admit or deny compensability within 120 days after the initial provision of compensation or benefits as required under subsection (2) or statute 40.192(8). Additionally, the carrier shall initiate payment and continue provision of all benefits and compensation as if the claim had been accepted as compensable, without prejudice and without admitting liability.”
Using the 120-day pay and investigate rule is the best tool in an insurance company’s toolbox when there are questions that require further investigation in a claim. While this rule requires that the employer/carrier pay benefits while it investigates, this allows a longer period in which compensability of an accident or pre-existing personal condition could be denied after the initial reporting of a work accident. It is indisputably one of the best ways to provide more time to gather evidence to answer any outstanding questions about a case or injured worker.
It is best practice to issue written correspondence to the injured worker and their attorney, notifying them the claim or condition has been accepted under this specific rule, so that proper notice is provided of the potential for using this defense in the future. If the insurance company fails to send a letter to the injured worker, the ability to later deny the requested benefits may be an issue. Actual notice is incredibly important to using this defense properly and if the claim is later denied, benefits cannot be clawed back from the injured worker. However, extra time to investigate a case can be incredibly helpful to the insurance company to ensure no defenses are waived and no issues with estoppel arise, resulting in a more costly claim in the future.