Securing Knee Surgery and Over $48K in Benefits After Insurer Denial
Background
The workers’ compensation claimant had worked in physically demanding jobs for nearly two decades without issue. In 2018, he joined his employer as a warehouse associate, where his duties included pushing heavy pallets and climbing ladders throughout each shift.
In 2019, he tripped over a mat at work and suffered serious injuries to both knees, his left wrist, left shoulder, and neck. While the employer initially authorized treatment, his worsening knee condition was later dismissed as “preexisting,” despite his clean medical record before the accident.
The Challenge
Despite multiple follow-ups, documented pain, and worsening mobility, the Employer/Carrier (E/C) refused to authorize the total right knee replacement that the worker’s treating physician deemed necessary.
They argued that:
- His knee condition stemmed from prior degenerative issues
- He had already reached Maximum Medical Improvement (MMI)
- His wage loss was not related to the accident
- Benefits had already been correctly paid
Meanwhile, at age 70, the injured worker was left without proper care, underpaid benefits, and forced to work night shifts in a less physically demanding role just to get by.
Our Strategy
Touby, Chait & Sicking, PL took on the complex claim and built a strong case on multiple fronts:
- Cited statutory deadlines to prove the E/C waived their right to deny surgery by failing to respond within 10 days
- Pointed out the absence of a required 120-day “pay and investigate” letter, which further prevented the E/C from disputing responsibility
- Corrected years of underpayment by raising the claimant’s average weekly wage (AWW) from $833.33 to $1,046.57
- Presented credible testimony from the claimant’s authorized orthopedic surgeon
- Refuted the independent medical examiner’s (IME) opinion, which lacked both long-term oversight and a meaningful relationship with the patient
The Result
The Judge of Compensation Claims ruled strongly in the injured worker’s favor:
- Authorized a total right knee replacement
- Awarded over $48,000 in back benefits, including:
- $17,779.45 in Impairment Income Benefits (IIBs)
- $3,444.65 in Temporary Partial Disability (TPD) for 2019
- $2,813.43 in TPD for 2020
- $5,678.59 in TPD from 2020 to 2024
- $1,821.71 in TPD after termination
- $11,649.58 in TPD while unemployed (including offsets)
- $5,445.41 in TPD while underpaid at a new job
- Ordered penalties and interest
- Required the E/C to pay the claimant’s legal fees and costs
Why It Matters
This case is a powerful example of how Touby, Chait & Sicking, PL fights tirelessly for injured workers—even years after an injury and against aggressive insurance denials.
Our team:
- Navigated legal complexities with deep knowledge of Florida Workers’ Compensation law
- Demonstrated unmatched commitment to our client’s well-being
- Ensured accountability when the system failed to respond on time
When others turn you away, we step in. Contact Touby, Chait & Sicking, PL today at (305) 257-9472.