Insurer not off hook for claim over suspected worker intoxication
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A Florida appeals court ruled Friday that an insurer’s failure to meet the 120-day deadline to deny the compensability of an injury claim waived the insurer’s intoxicated-worker rights.
“We find no competent substantial evidence that the (employer/insurer) demonstrated material facts, relevant to the issue of compensability, which they could not have discovered through a reasonable investigation during the 120-day, pay-and-investigate period of the statute,” the Florida 1st District Court of Appeals ruling states.
On Aug. 22, 2015, an employee at Neptune Fish Market fell on the right side of his body while emptying garbage in the outside dumpster, later testifying he slipped on a piece of fish. The owner was informed of the accident that day, but he never reported the accident to his workers compensation insurer, according to documents in Edward Paradise v. Neptune Fish Market/RetailFirst Insurance Co.
After being taken by ambulance to a Veterans Administration hospital, which provides care for U.S. service veterans at low to no cost, the employee was diagnosed with a fractured right hip and eventually underwent surgery. His recovery was complicated by repeated infection and he ultimately had five surgeries with the last resulting in removal of his right hip joint. He was hospitalized almost continuously from the date of the accident through November 2016.
Nearly a year later, on May 12, 2016, the worker filed the first notice of the injury with the Fish Market’s insurer, which elected to pay and investigate under Florida’s 120-day rule. That investigation ran from May 25, 2016, to Sept. 22, 2016, but the insurer did not file a notice denying compensability of the workplace injuries until Dec. 14, 2016, court records state.
In the notice of denial, the insurer asserted that no compensation was due because “claimant's injuries were primarily occasioned by intoxication,” according to court documents.
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