Once Again, 2nd Opinion Medical Necessary if Doctor Recommends It

Wednesday, March 31, 2010 | 0

By Michael Rabinowitz
Banker Lopez Gassler

If you play baseball with blinders, than you will only see half of the field and expect to get beaned in the head.  At least that ’s what my grandpa told me.  The same can be applied to claims adjusting.  In this case, the fact that the Legislature removed Claimant’s right to a second opinion does not mean a Claimant can never receive a second opinion.

Case in point, Florida Detroit v. Nathai.  Here the Florida 1st District Court of Appeal found Claimant was entitled to a second opinion.

In that case, Claimant suffered a compensable knee and foot injury and was treated by an orthopedist, authorized by the E/C.  The doctor viewed Claimant’s condition as “devastating” and “life altering,” opining that Claimant may never have use of his foot again.  Determined to find a a course of treatment that would enable him to use the foot again, Claimant wanted a second opinion and filed a PFB for one shortly after.

The E/C promptly denied the petition, based on the statute.  However, during the deposition of the doctor, he testified that a second opinion was medically necessary to determine whether Claimant could ever return to work again.   The JCC concluded that the evidence supported a second opinion.  The First DCA agreed.

Now I know many adjusters are throwing their hands in the air at such a ruling, but the reasoning is sound.  The First DCA previously ruled that as long as a Claimant can present competent substantial evidence that a second opinion is medically necessary then the courts must grant it, just like any other medical treatment recommendation.

This is fine enough, but what can a Carrier do to limit exposure.  Most doctors will have no issue with saying a second opinion is medically necessary.  This gives them cover over their treatment.   They key for Carriers then is to conference with the doctors ahead of time, either through a nurse case manager, a pre-formed questionnaire, or through an attorney to determine the medical necessity of a second opinion.  If not, a case like this can open up a lot of doctor shopping for Claimant’s, thereby increasing exposure to each one of your claims.

So, what if a doctor recommends a second opinion for a Claiamnt because it’s medically necessary?  What to do?  Easy.  As I wrote earlier, treat it just like a request in change in doctors.  Quickly set a second opinion with a trusted physician and close up your exposure loop.  The quicker you can respond to these little obstacles, the quicker you can settle the claim and ultimately close the file.

If you ignore it?  Well, then expect to be beaned in the head. 

Michael Rabinowitz is an attorney for Banker Lopez Gassler in Tampa. This column was reprinted with his permission from his blog, which can be found here:
http://workerscompblog.wordpress.com/