“Only those who will risk going too far can possibly find out how far one can go” - T.S. Eliot
Must we go too far to discover just how far we can go…… Pushing the envelope… challenging limits of our abilities…..ultimately can make us stronger and better. However, there is always a risk of failure. For those of us who navigate through the often murky waters of Florida’s worker’s compensation system, we often look for the logical and reasonable to help us make risk adverse decisions to the best interests of our clients.
In the context of workers’ compensation, unfortunately, there is no clear-cut rule to determine whether the geographical location of a new authorized medical provider is acceptable based on time and distance, i.e. not too far. Chapter 440, case law, or the administrative rules do not reference any express limitation on travel time to authorized medical providers.
Rather, the only rule pertaining to such a limitation stems applies to the context of managed care. 59-A-24.003(6), F.A.C., indicates that the “average travel time” for treatment with a primary care provider or at a hospital shall be no more than 30 minutes and the “average travel time” associated with specialty physician services shall be no more than 60 minutes under “normal circumstances”.
Many judges of compensation claims look to this administrative rule governing managed care cases for guidance in determining whether the required travel to a physician is reasonable and appropriate. However, existing case law and even recent JCC decisions do not provide any clear consensus as to how to determinate whether the required travel is reasonable and, thus, justifiable.
In reviewing the following recent JCC decisions, the local courts have considered a myriad of criteria in determining the geographical reasonableness of driving distances, seemingly based on a “totality of the circumstances” approach.
Manuel Sanchez v. American Airlines and Sedgwick CMS, OJCC#: 16-029714, Miami District, October 4, 2017:
The E/C authorized an orthopedic for the wrist in Doral, FL and an orthopedic for the back in Hollywood. The claimant did want to drive to Hollywood, FL as he felt it would take him 1.5 to 2.0 hours. The E/C offered to provide the claimant with transportation although the claimant was not subject to any driving restrictions. The JCC felt that the E/C met its burden of proving the authorized treatment was medically necessary. As such, the burden shifted back to the claimant to establish that there was more competent orthopedic care available which was closer to his home.
In sum, the JCC felt that the claimant did not present enough evidence that the required travel was unreasonable or unnecessary. The JCC considered factors such as the distance involved, whether the claimant had to travel to and from work, the length of time of the commute, the injured body part, namely how the travel time affects the injured body part, as well as any restrictions on driving. The JCC denied the claimant’s request for an alternative orthopedic closer to home.
David Lowry v. ADH Plumbing and Amerisure Insurance, OJCC#15-029296, West Palm Beach District, November 22, 2017:
The claimant lived in Delray Beach, worked in Boyton Beach (Palm Beach County), and drove a company vehicle while on the job. The E/C authorized a podiatrist in Plantation (Broward County) which was about 60 minutes from the claimant’s place of employment. The claimant alleged this physician was too far.
In making a determination that the selected doctor in Planation was unreasonable, the JCC considered a totality of the circumstances and the following factors: the injured worker did not have any driving restrictions, that there was an expectation of follow up care versus a one-time evaluation, and, most importantly, that the claimant was the sole provider for his family so that missed time would cause a hardship.
The JCC found that the most critical factor is determining reasonableness was the hardship imposed on the claimant. He would have had to drive to another county in the opposite direction of his home to work route. The court felt that the selection of this physician did not adhere to the legislative intent of 440.015, Fla. Stat. to “assure the quick and efficient delivery of… medical benefits to an injured worker and to facilitate the workers’ return to gainful employment”.
Bladimir Abreu v. Southeast Personnel Leasing and Packard Claims, OJCC#17-006434, Miami District, January 23, 2017:
The E/C authorized a new physician in Broward County, although the claimant lived in Miami-Dade County. The new physician was 35 miles from the claimant’s residence. The claimant argued that the travel time was excessive and caused him to lose time from work. Here the JCC concluded that he did not have the authority to grant a new physician based solely on allegations of an inconvenience. As such, the E/C’s selection of the new physician was deemed reasonable.
Carlos Font v. American Airlines and Sedgwick CMS, OJCC#13-012793, Melbourne District, November 20, 2017:
The E/C authorized a new physician who had an office in Aventura open 2 days a week. This physician’s office was located 36 miles from home. The claimant did not have any restrictions on driving but testified to increased symptoms to his low back when driving long distances. The claimant’s employer did not allow him to miss work for doctor’s appointments and therefore the court measured distance from his residence as opposed to from his place of employment.
The JCC noted that if the claimant establishes that the amount of travel time associated with the new physician is unreasonable, the burden shifts to the E/C to prove that the authorized treatment is medically necessary.
The JCC opined that the E/C could use any method to select a physician as long it did not cause an unreasonable burden unto the claimant due to time or distance or cause discomfort in making the trip. Here, the claimant presented objective medical findings involving his low back.
Here, the E/C/SA did not provide evidence as to the necessity or reasonableness of their selection. As such, the selected physician was held to be unreasonable.
Of note, these decisions do not pertain to authorization of all physicians, such as an IME. The 1st DCA held in Miller v. Jupiter Medical Group, 928 So.2d 485 (Fla. 1st DCA 2006) that there is no limitation as per Section 440.13(5), Fla. Stat. regarding the geographical location of an IME (noting there is no limitation in the statute but rather a reasonableness requirement subject to the discretion of the JCC”). Furthermore, the JCC has no authority to actually transfer care to another physician but rather only to determine the reasonableness of the chosen physician.
As per existing case law, the 1st DCA considered the following factors in determining whether the travel time associated with authorized medical treatment was reasonable: evidence of painful conditions impacting the ability to travel extended distances and a lack of evidence showing that the authorized treatment is medically necessary. See, Commercial Carrier Corp. v. Fox, 400 So.2d 154 (Fla. 1st DCA 1981); Wright v. Golf Drive Residence, 412 So.2d 884 (Fla. 1st DCA 1982); and Kessler v. Community Blood Bank, 621 So.2d 539 (Fla. 1st DCA 1993).
In sum, while there is no set law or rule governing the method on which to determine if driving distances to authorized medical providers are reasonable, the more recent JCC decisions and existing case law suggest that the following factors should be taken into consideration:
-actual distance and estimated driving time to/from the claimant’s residence, which should generally average less than an hour;
-whether the geographical location would negatively impact the ability to obtain suitable and necessary medical care;
-whether the claimant is subject to any driving restrictions or whether the claimant has difficulty with driving due to the subject work injury;
-offers of transportation from the E/C to the authorized physician’s office;
-whether the compensable injury or body part has affected the claimant’s ability to travel extended distances;
-the amount of follow up treatment and medical services anticipated by the authorized medical provider;
-whether the associated travel will cause a significant impact on the claimant’s ability to work and earn wages; and
-the unavailability of similar medical services within the reasonable proximity of the claimant’s residence.
Without any such precise formula to assist in determining the reasonableness of driving distances and travel time, one can only hope that a consideration of a totality of the circumstances and facts as noted above will ultimately serve the best interests of a self-executing worker’s compensation system and prevent unfavorable rulings against employer/carriers, such as a finding of an unjustifiable refusal of authorized medical care and treatment.