Florida Court Agrees Firefighter Not Entitled to Reimbursement for Back Surgery
A Florida appellate court has affirmed a decision of a Judge of Compensation Claims (JCC) holding that an injured firefighter was not entitled to reimbursement for additional surgical expenses related an admitted back injury where, prior to the surgery, he had entered into a stipulation with the employer/carrier (E/C) that designated a new “authorized” physician and required that any further surgical intervention be authorized by the new physician, yet the firefighter underwent additional surgery from his prior “deauthorized” surgeon without seeking the approval of the new physician [Tejeda v. City of Hialeah, 2021 Fla. App. LEXIS 16124 (1st DCA, Dec. 29, 2021)]. The court also disagreed with the firefighter’s characterization of the situation as a “reimbursement dispute,” which would have given exclusive jurisdiction to the Department of Financial Services (DFS).
Background
Claimant, a firefighter, sustained injuries to his back in a work-related motor vehicle crash. The E/C accepted the injuries as compensable. Claimant underwent various procedures for his back, including surgeries with Dr. Brusovanik. In 2017, Dr. Vanni was designated as the new authorized physician, and Dr. Brusovanik was deauthorized. The parties stipulated:
If Dr. Vanni opines that Claimant does require further surgical invention, the Employer/Servicing Agent will authorize same, and the Claimant will decide whether he wants to undergo such procedure.
In June 2020, despite Dr. Brusovanik being deauthorized as a treating physician, and without an opinion from Dr. Vanni, Claimant underwent spinal fusion surgery with Dr. Brusovanik. Claimant filed a petition for benefits seeking payment of the surgery bill and copayments as medically necessary. After a contested hearing, the JCC determined that the surgery was medically necessary. But the JCC also determined that the 2017 stipulation was binding on Claimant and denied reimbursement. Claimant appealed, contending in relevant part that the 2017 stipulation made his “reimbursement dispute” subject to the jurisdiction of the DFS, not the JCC.
Appellate Court: Who Had Jurisdiction?
The appellate court disagreed with Claimant’s position. It noted that § 440.13(1)(q), Fla. Stat., defined a reimbursement dispute was defined as “any disagreement between a health care provider or health care facility and carrier concerning payment for medical treatment,” and that the DFS had exclusive jurisdiction to decide any matters concerning reimbursement under § 440.13(11)(c), Fla. Stat. While it was certainly clear that the E/C met the statutory definition of carrier, it was equally clear that Claimant did not meet the statutory definition of a health care facility or health care provider. A dispute between Claimant and the E/C therefore did not meet the statutory definition of a “reimbursement dispute.” The court added that since this was not a reimbursement dispute as defined by chapter 440, the JCC had jurisdiction to adjudicate the claim.
Binding Stipulation
The court noted that in interpreting the meaning of a stipulation, a JCC may be required to interpret contracts to decide if workers’ compensation coverage exists. Moreover, a stipulation properly entered into and relating to a matter upon which it is appropriate to stipulate is binding upon the parties and upon the Court. Based on the foregoing, the court said the JCC committed no error in deciding that he could interpret the meaning of the stipulation.