Wintz v. Goodwill
| Decision Date | 24 March 2005 |
| Docket Number | No. 1D04-3127.,1D04-3127. |
| Citation | 898 So.2d 1089 |
| Parties | Joyce WINTZ, Appellant, v. GOODWILL and Summit Claims Management, Appellees. |
| Court | Florida District Court of Appeals |
David Koenig, of Barbas, Koenig, Nunez, Sanders & Butler, Tampa, for Appellant.
Larry Cangro, of Matusek, McKnight, Poluse & Cangro, P.A., St. Petersburg, for Appellees.
In this appeal from the order of the Judge of Compensation Claims (JCC) denying compensability of Claimant's hand condition, Claimant raises two arguments. First, after invoking the pay and investigate provisions of section 440.20(4), Florida Statutes (2003), the E/C failed to conduct a "good-faith" investigation into the claim and was unable to produce a copy of their notice of denial. Second, the causal connection between Claimant's employment and injury was established by her unrefuted testimony and medical evidence, and therefore, the JCC erred in rejecting the evidence. We disagree with both arguments and affirm.
Claimant notified the carrier that she suffered a work-related injury to her right hand and wrist. Claimant alleged the injury occurred from a combination of a specific incident of pulling a rack of clothes at work and a repetitive work injury. The unsigned notice of injury listed the date of injury as April 24, 2003. The carrier filed the notice of injury and sent Claimant a letter invoking its right to "pay and investigate" the claim, pursuant to section 440.20(4), Florida Statutes. Subsequently, Claimant asserted the injury actually occurred on March 24, 2003.1 After this, the carrier sent an investigator to speak with Claimant. During the meeting, Claimant apparently told the investigator she injured her hand while pulling a rack of clothes. However, Claimant also reported she suffered pain in her wrist and neck for a "couple of years" prior to the date of accident.
The treating physicians provided varying diagnoses, ranging from carpal tunnel syndrome and DeQuervain's tenosynovitis to fibromyalgia, cervical radioculpathy, or arthritis.
After receiving medical reports from physicians who examined Claimant in March and May 2003, the carrier, in June 2003, notified both Claimant and the treating physician that further authorization for care would be denied because Claimant's condition was not due to a work-related accident, but was idiopathic and personal in nature. The denial was within the 120 days allowed by statute.
Carriers invoking the "pay and investigate" option under section 440.20(4), Florida Statutes, "shall immediately and in good faith commence investigation of the employee's entitlement to benefits" and must admit or deny compensability within 120 days after initial provision of compensation or benefits; employees must be notified in writing that the carrier has elected this option. See § 440.20(4), Fla. Stat. Carriers failing to deny compensability within 120 days after initial provision of benefits waive the right to deny compensability unless material relevant facts could not have been discovered during the 120 day period. See id.
Claimant argues the E/C failed to adequately investigate and points out several acts the E/C could have taken to further investigate the claim. Two specific areas of investigation suggested by Claimant are: an inquiry into the changing dates of injury she provided, and contacting the various doctors to clarify their opinions. The requirement of an "immediate and good faith" investigation does not mandate that every investigative act that can be taken is, in fact, taken. It is merely a requirement that the E/C be prepared to decide, within 120 days, what position they wish to take on a given claim, and be accountable for that decision. Obviously, the E/C's decision is not without consequences. If a claim is denied that should have been accepted, the E/C is sanctioned with penalties, interest, and attorney's fees. Likewise, a failure to controvert within 120 days waives the right to controvert the claim, even if a valid defense exists, if the facts giving rise to the defense could have been discovered within the 120 day period.
Cases holding that carriers are precluded from denying compensability under the "pay and investigate" statute, including those cited by Claimant, are factually distinguishable.2 In those cases, meritorious defenses were waived because the carriers did not controvert the claim within 120 days and the relevant facts justifying the denial could have been discovered within 120 days. An inquiry into the investigative steps an E/C took is not necessary unless the carrier fails to timely controvert the claim and alleges the material relevant facts could not have been discovered within the 120 days. Clearly, if a carrier fails to timely controvert the claim, and has not shown there were material relevant facts that would establish valid defenses, that could not have been discovered within 120 days, then it has not conducted a good-faith investigation.
Here, in contrast, evidence was presented that the claim had been controverted within 120 days from an April 2003 walk-in clinic appointment (the first date on which the carrier provided compensation/benefits). Although a copy of the denial could not be located, Claimant admitted receiving such a notice, and other evidence was offered showing a denial was made and Claimant called the carrier to discuss the denial.3 Thus, the E/C complied with the statute, and the JCC properly allowed the E/C to continue with its defense of the claim. Therefore, we must determine whether the JCC erred by rejecting evidence Claimant argues is dispositive to the resolution of her claim.
As her second point on appeal, Claimant insists she was entitled to benefits because the JCC did not point to evidence refuting Claimant's assertion of a work injury. Claimant misconstrues her evidentiary burden.
"A causal relationship between employment and an...
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