Court of Appeal Affirms Ruling That Late‑Asserted Major Contributing Cause Defenses Are Waived

The First District Court of Appeal recently issued a per curiam affirmed (PCA) ruling concerning the perennial issue of major contributing cause and the right to deny treatment for pre-existing conditions. As a PCA, this case has no precedential authority. However, the case serves as a reminder of best practices regarding issuance of denials and 120 letters when pre-existing conditions are at issue.

In Budd, the employee was injured after having a gun held to her head and being pulled from her car. She was thrown to the ground and struck the left side of her body, including her knee. Initial hospitalization included x-rays that revealed degenerative joint disease and advanced end stage arthritis. One month later, an MRI that was authorized by the employer/carrier revealed degenerative joint disease and osteoarthritis.

The employer/carrier then authorized an orthopedic surgeon for an evaluation. Again, the doctor diagnosed the claimant with advanced end-stage arthritis of the knee and a chronic partial ACL tear. The doctor recommended treatment including an injection, which the employer/carrier authorized, and ultimately, a total knee replacement.

Well after 120 days of the authorized orthopedic evaluation and injection, the employer/carrier questioned the major contributing cause of the need for knee surgery. The authorized treating orthopedic physician opined that 60% of the need for the surgery was pre-existing, while only 40% was attributable to the accident. The claimant retained an independent medical examination, claiming that the major contributing cause of the need for surgery was industrial accident.

The claims adjuster testified that the employer/carrier never issued a DWC-12 Notice of Denial as to any pre-existing condition or put the provider on notice that any pre-existing condition was not authorized for treatment.

The Judge of Compensation Claims (JCC) found that the employer/carrier was on notice of the pre-existing end-stage arthritis after the initial orthopedic evaluation. Nonetheless, they chose to authorize treatment for the same through the time that the doctor recommended the total knee replacement, well after 120 days from the evaluation. The JCC ruled, and the DCA affirmed, that the employer/carrier failed to meet its burden to show a break in the chain of causation as to the need for specific treatment once compensability of a condition had been accepted and treated. The employer/carrier was therefore responsible for the total knee replacement surgery.

This case illustrates the importance of issuing Notices of Denial or at least 120 letters whenever diagnostic findings or authorized provider opinions reveal pre-existing conditions that may require treatment. Failure to do so may result in waiver of defenses.