Koren v. City of Kissimmee/PGCS, ___So.3d___(Fla 1st DCA 6/10/26)
The majority opinion in Koren holds that the Judge of Compensation Claims (JCC) properly denied psychiatric treatment because the claimant did not challenge on appeal the JCC’s finding that the requested treatment was not medically necessary.
However, Judge K. Thomas authored a detailed concurrence agreeing with the result on the ground that the claimant failed to meet his burden of proving medical necessity. In doing so, Judge K. Thomas also emphasized an important principle: employer/carriers must expressly invoke the 120-day pay-and-investigate provision under Florida’s Workers’ Compensation Act if they intend to preserve their right to deny compensability. Merely authorizing evaluations, without explicitly invoking the 120-day rule, may be insufficient to preserve the right to deny compensability of specific injuries.
In Koren, the claimant sustained injuries to his upper lip, tooth, right knee, and right foot when a board gave way on a deck he was repairing for the employer/carrier. The accident was accepted as compensable, and multiple specialists were authorized to treat his physical injuries, including an ear, nose, and throat physician, dentist, orthopedist, and plastic surgeon.
The claimant later sought psychiatric treatment and attended an independent medical examination (IME) with a psychiatrist. The IME diagnosed adjustment disorder with mixed anxiety and depressed mood, opining that the condition was caused by “the actual appearance of the scar” resulting from the industrial accident. The IME recommended continued medication, including an antidepressant, as well as follow-up care with a psychiatrist and psychologist. Critically, however, the IME did not offer an opinion regarding the medical necessity of this treatment.
The claimant then filed a petition for benefits attaching the IME report and requesting authorization of psychiatric care. The employer/carrier responded by authorizing a psychiatrist, whom the claimant did, in fact, see. However, the employer/carrier neither denied the claim nor issued written notice invoking the 120-day pay-and-investigate provision.
The authorized psychiatrist subsequently opined that the claimant’s psychiatric condition was unrelated to the industrial accident and instead attributable to prior employment as a law enforcement officer and volunteer firefighter. The psychiatrist further concluded that the work accident was not the major contributing cause of the condition.
Although the employer/carrier stipulated to the authorization of the psychiatrist, it ultimately denied the claimant’s entitlement to psychiatric treatment. The JCC denied the requested benefit.
The majority opinion affirmed on the narrow ground that medical necessity had not been established. Judge K. Thomas’s concurrence, however, expands on the legal framework. Under Florida law, an employer/carrier presented with a claim must “pay, pay and investigate, or deny.” To avail itself of the 120-day pay-and-investigate protection, the employer/carrier must affirmatively and explicitly invoke that option, typically through a written 120-day letter. The statutory investigative period does not arise automatically upon the provision of care. Furthermore, an attempt to characterize authorization as a “one-time evaluation” does not avoid waiver, as even a single evaluation may constitute the provision of a compensable benefit.
By authorizing psychiatric care without invoking the 120-day provision, the employer/carrier in Koren effectively accepted compensability of the claimant’s PTSD condition. Nonetheless, it retained the ability to contest entitlement to ongoing treatment. While the employer/carrier failed to demonstrate a break in the causal chain, the claimant still bore the burden of proving that the requested treatment was medically necessary. Because the JCC found that the claimant failed to meet this burden, and the claimant did not challenge that finding either below or on appeal, the denial of psychiatric benefits was ultimately affirmed.
