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Recurring Problem; Does a Referral Go Stale?

by | Aug 23, 2015 | Firm News, Workers' Compensation

When an injured worker goes to the authorized treating physician and receives a referral for medical treatment or testing, the workers’ compensation carrier should immediately authorize and schedule the treatment or testing. Often times, the testing or treatment is scheduled within a reasonable time. However, there are certain situations where the insurance company fails, refuses, or neglects to honor the referral, and the treatment or testing goes unscheduled. This happens frequently with referrals to specialists, physical therapy, medications, MRIs, x-rays, etc. In these situations, it’s often times necessary to file a Petition for Benefits to pursue authorization of the treatment or testing. The next logical question is how long is too long to wait? If the referral was made a month ago, is it still needed? What about a year ago? Is the referral for treatment “stale” at this point? In other words, does the insurance company have to honor a referral written a year ago or do you need to go into the doctor for a new referral? This question was addressed by the First District Court of Appeal in Young v. American Airlines, 100 So.3D 1168 (2012).

In Young, the claimant sought approval of a referral to a cardiologist made several years earlier. The Trial Court denied the referral because there was “no current medical evidence” of the need. The First DCA rejected this finding and held there is no legal authority which indicates a recommendation or referral from an authorized doctor can become stale in the absence of a change in the claimant’s condition that would affect the need for the recommended benefit.[1]

This holding is good for injured workers for a few reasons. First, “current” is a difficult standard to determine. We often see delays of months for testing or referrals to specialists. Is current a month? Two months? Second, It would seem against logic to propose that an insurance company can delay authorization or scheduling treatment recommended by the authorized doctor selected by the insurance company, and then require you to go in to renew that referral again after the delay elapsed due solely to their failure to authorize it timely.

If the question is does a referral go stale? The First DCA has confirmed it does not, as long as there is no evidence of a change in the claimant’s condition that would affect the need for the recommended benefit. 

[1] Young v. American Airlines, 100 So.3D 1168 (2012).

Our firm has represented injured workers throughout Florida since 1989.

The workers’ compensation laws have changed frequently over the last few decades, eroding the workers’ compensation benefits available to individuals hurt on-the-job. There is no obligation when you call us for a consultation, but it is important you discuss your workers’ compensation rights with a qualified lawyer immediately. Our attorneys have never represented any workers’ compensation insurance company. At our firm, an experienced Tampa workers’ compensation attorney will handle your case from start to finish. Contact our office at 800-886-0659.