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What's Hot in Workers' Comp

Treatment with authorized provider tolls statute of limitations, although treatment occurred without employer/carrier’s knowledge and was billed to private health insurance, as it was similar in nature to previously authorized treatment.

Ortiz v. Winn-Dixie, Inc., No. 1D2021-0885, Fla. 1st DCA 2024, DCA#: 1D2021-0885, Decision date: Dec. 23, 2024

February 1, 2025

by Blake J. Hood

The First District Court of Appeal issued another opinion in the ongoing statute of limitations saga triggered by the 2023 opinion in Ortiz v. Winn-Dixie, Inc., 361 So. 3d 889 (Fla. 1st DCA 2023) (Ortiz I). The new opinion, also written by Judge Tanenbaum, in Ortiz v. Winn-Dixie, Inc., No. 1D2021-0885, (Fla. 1st DCA 2024) (Ortiz II), supersedes the original. Far from clarifying the issue, Ortiz II leaves many questions unanswered. 

Ortiz I introduced the “two-year master countdown timer” and “tolling timer” concepts in explaining how to construe the time bars for filing petitions for benefits as set forth in section 440.19, Florida Statutes. In so doing, Ortiz I held the one-year tolling provision in section 440.19(2)—prompted by furnishing medical care or paying compensation—does, in fact, apply within the first two years following an accident, something prior case law held otherwise. Thus, under Ortiz I, if an employer/carrier provided benefits immediately following an accident, the initial two-year master timer would never even start ticking, and claimants could effectively “bank” that time. 

By contrast, Ortiz II makes no mention whatsoever of the master countdown/tolling timers. Rather, the new majority opinion focuses only on whether the specific treatment the claimant received qualified as medical care “furnished” by the employer/carrier and was sufficient for the one-year tolling provision in section 440.19(2). Ortiz I held it did not qualify and upheld the judge of compensation claim’s dismissal of the claim. Ortiz II now holds it did qualify and, thus, allowed the claimant’s claims to proceed.

Following the claimant’s accident, the employer/carrier authorized treatment, ultimately requiring the removal of her right kidney. The employer/carrier then authorized and paid for care over many years in the form of annual “kidney follow-ups” with a urologist. At one point in 2019, however, the authorized doctor began sending his medical bills to the claimant’s personal health insurance. The claimant testified she used her health insurance because someone at her doctor’s front desk told her to do so. When the employer/carrier reached out to this doctor’s office after not having received any bills for quite some time, they were advised of the billing situation. Because one year had elapsed from the last visit it paid for, the employer/carrier asserted a statute of limitations defense and denied further care.

The Ortiz II majority noted, the employer/carrier had entered into a broad stipulation accepting compensability of the injury and had not limited their acceptance of compensability for the kidney to any set of symptoms or diagnoses. Since the claimant presented evidence showing that the nature of the treatment both before and after the billing switch was essentially the same, the employer/carrier had to show “a break in causation” such that the treatment of the urological condition was no longer related to the loss of her kidney. In the court’s opinion, the disputed visits were of a piece with the care the employer/carrier had authorized for years. The court further stated the doctor’s decision to bill the claimant’s personal insurance for the contested visits did not alter the analysis. It was not for the doctor to decide whether the visits fit within the employer/carrier’s authorization. It noted, the court repeatedly held that “who gets billed has no legal bearing on the tolling question.” 

Because the question of whether the “two-year master countdown timer” ever started ticking was not squarely before the court and not raised by the parties, Ortiz II removed that discussion from the majority opinion. Left unanswered, then, for the parties and practitioners is the effect of providing benefits at the beginning of a claim and whether claimants can carry that time forward. Judge Tanenbaum wrote a lengthy, separate and concurring opinion, arguing in detail why his calculation methodology in Ortiz I is the correct reading of the statute. Judge Bilbrey’s short and concurring opinion clarifies that Judge Tanenbaum’s concurring opinion has no precedential value and, if the question arises again, “his reasoning may be found to be persuasive or may be discarded.”

Superficially, Ortiz II is not a groundbreaking case. It simply holds that employers/carriers cannot present “Get Out of Jail Free” cards and then deny further care by showing that claimants treated with authorized providers unbeknownst to the employers/carriers or that the visits were not billed to the employers/carriers for over one year, so long as the visits were of a piece with previously authorized care. 

The real significance of Ortiz II is what it leaves unsaid. For now, parties, practitioners and, of course, judges are left wondering if we once again live in the simple “two-year/one-year” calculation method of pre-Ortiz I or whether the court will ultimately adopt the more complicated Ortiz II methodology at some point in the future after all. 


 

What’s Hot in Workers’ Comp, Vol. 29, No. 2, February 2025, is prepared by Marshall Dennehey to provide information on recent legal developments of interest to our readers. This publication is not intended to provide legal advice for a specific situation or to create an attorney-client relationship. We would be pleased to provide such legal assistance as you require on these and other subjects when called upon. ATTORNEY ADVERTISING pursuant to New York RPC 7.1 Copyright © 2025 Marshall Dennehey, all rights reserved. No part of this publication may be reprinted without the express written permission of our firm. For reprints or inquiries, or if you wish to be removed from this mailing list, contact tamontemuro@mdwcg.com.

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Ohio Supreme Court Holds That a Binding Appraisal Award May Not Be Set Aside Absent Specific Evidence of Manifest Mistake or Fraud

On July 23, 2026, the Ohio Supreme Court issued a rare opinion on the binding effect of an appraisal award in a property insurance policy.  The Court in One Church held: A binding appraisal award will not be set aside unless an error is so palpably wrong that it undermines the intent of the agreement, such as corruption or gross mistake, not a mere error of judgment—To plead a claim of mistake with particularity as required by Civ.R. 9(B), facts alleged in a complaint must constitute the elements of mistake—Allegation that additional, hidden damage was discovered after appraisal award failed to state a claim of mistake that could justify setting aside binding appraisal.  The case arose out of a claim brought by One Church against its insurer, Brotherhood Mutual Insurance Company for roof damage from a storm. Pursuant to the terms of the insurance policy, the parties agreed to submit the matter to appraisal. The two appraisers inspected the building, and both appraisers agreed that the damages were $313,271.98. The insurer paid the agreed appraised amount.  Thereafter, the insured submitted a claim for an additional $206,663.09 in damages. The insured argued that these additional damages were not discovered until after the repairs began, and that they should be permitted to submit an additional claim, even though there had already been a binding appraisal of damages. The insurer refused to pay the additional damages, and the insured sued for breach of contract and bad faith.  In the trial court, the insurer moved to dismiss for failure to state a claim, arguing that the binding appraisal award barred any further claims. The insured took the position that additional hidden damages could not be discovered until after the repairs began, and therefore there was a mutual mistake. The trial court dismissed the case on the insurer’s motion, because there was no “evidence of fraud, misfeasance, or mistake”. The Court of Appeals agreed that appraisal awards are generally binding, but noted that an appraisal award can be set aside for fraud or manifest mistake. The Court of Appeals reversed and remanded the case to the trial court, finding that the insured had pled mistake with sufficient particularity. The insurer appealed to the Ohio Supreme Court. On appeal, the Ohio Supreme Court reversed the Court of Appeals, and reinstated the trial court decision dismissing the case for failure to state a claim upon which relief can be granted. The Supreme Court found that since the insured had already demanded appraisal, and the appraisal award was binding, “something more than error of judgement, such as corruption in the arbitrator, or gross mistake” must be pled with particularity, and proven for the insured to override the appraisal award. Since the complaint did not allege fraud or manifest mistake with sufficient particularity, something more than a mere error of judgment, the complaint was insufficient to state a claim.  The complaint in this case did not challenge the appraisal award. It pled that additional damages were discovered that were not apparent when the appraisal was done. It did not specify “who discovered the damages, how they were discovered, where they were found, why they were previously hidden, or why they rise to the level of a manifest mistake that the “appraiser would have corrected...had it been called to his attention”. Id at ¶22 citing Lakewood Mfg. Co. v. Home Ins. Co. of New York, 422 F.2d 796, 798 (6th Cir. 1970). Cases deciding the effect of appraisal awards are unusual. The Ohio Supreme Court’s decision in One Church relies primarily on 19th century case law for its conclusion. This emphasizes the fact that there is minimal case law deciding the effect of binding appraisal clauses in property insurance policies, and makes this case all the more significant. A lengthy dissent was written by Justice Fisher, who would have affirmed the Court of Appeals decision reversing and remanding the case for a decision on the merits. Of course, the decision works both ways, and an insurer dissatisfied with a binding appraisal award will likewise be without further recourse absent evidence of corruption, fraud, misfeasance, or manifest mistake, which must be pled with particularity. To constitute manifest mistake, “the mistake must be of such character that the arbitrator or appraiser would have corrected it had it been called to his attention.”  Lakewood Mfg. Co. v. Home Ins. Co. of New York, 422 F.2d 796, 798 (6th Cir. 1970).  The majority opinion does not specifically identify what would have been sufficient to plead mistake with particularity, or if the insured could have amended the complaint to overcome the deficiencies. The dissent argues that this was not really a case alleging mistake, but rather a question of contract interpretation. The insured did not challenge the appraisal, but argued that the hidden damage was not part of the appraisal, and the appraisal only covered the known damages.  However, this argument did not carry the day with the majority.  *Thomas F. Glassman, a shareholder in Marshall Dennehey’s Cincinnati office, filed a brief in the Ohio Supreme Court on behalf of the Ohio Association of Civil Trial Attorneys, in support of the insurer’s position.

Result

No-Cause Jury Verdict Secured in Wrongful Death Trial

We successfully obtained a no-cause jury verdict in a 13-day wrongful death trial. The decedent, a 59-year-old man, was admitted to the emergency room on February 15, 2019, with complaints of abdominal pain, decreased appetite, and constipation, despite the use of laxatives. The patient did not complain of any nausea, vomiting, or diarrhea. He had a significant medical history including diabetes, hypertension, prior coronary artery stenting, morbid obesity (with past gastric bypass surgery), longstanding ventral hernia, and back pain. A CT scan revealed multiple hernias and a potential closed-loop bowel obstruction, leading to a surgery consultation. Our client, an emergency general surgeon, interpreted that the patient did not have a closed loop or any significant obstruction and recommended non-surgical management. The patient was approved to have clear liquids, and had a vomiting incident shortly after, but our client was not notified. The patient was returned to NPO status, and after improving overnight, he was returned to “clears” and additional medical and renal consults were ordered. Our client did not receive any communications from the residents/nurses of any changes in the patient’s condition. On February 18, 2019, two rapid responses were called due to increased heart rate and vomiting. It is believed that the vomiting resulted in aspiration, causing sepsis, ultimately leading to the patient’s death. During the trial, the plaintiff’s sole medical expert highlighted imaging on the wrong hernia, which called into question all of his opinions in the case. We made key objections related to the expert testimony, limiting what the allegations were, and preventing new allegations from being made. After approximately two and a half hours of deliberating, the jury returned a no-cause verdict.