This appeal arises pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 401.001 et seq. (1989 Act). A contested case hearing was held on August 18, 2025, with the record closing on August 25, 2025, in (city), Texas, with (administrative law judge) presiding as the administrative law judge (ALJ). The ALJ resolved the disputed issues by deciding that: (1) the compensable injury of (date of injury), extends to concussion without loss of consciousness, traumatic brain injury, episodic seizure disorder, traumatic, photophobia, phonophobia, dysgeusia, and cervical strain; (2) the respondent (claimant) has not reached maximum medical improvement (MMI); (3) because the claimant has not reached MMI, no impairment rating (IR) may yet be assigned; (4) the claimant had disability from October 9, 2024, through August 18, 2025, resulting from the compensable injury of (date of injury); and (5) the claimant’s average weekly wage (AWW) is $1,410.31.
The appellant (carrier) appealed, disputing the ALJ’s determinations of extent of injury, MMI, IR, and disability. The carrier contended in its appeal that the designated doctor did not have all of the medical records. The claimant responded, urging affirmance of the disputed extent-of-injury, MMI, and IR determinations.
The ALJ’s determination that the claimant’s AWW is $1,410.31 was not appealed and has become final pursuant to Section 410.169.
DECISION
Reversed and remanded.
The parties stipulated, in part, that on (date of injury), the claimant sustained a compensable injury that extends to at least a head contusion; (Dr. T) was appointed by the Texas Department of Insurance, Division of Workers’ Compensation (Division) to address extent of injury, MMI, IR and disability/return to work; and the claimant’s AWW is $1,410.31. The claimant was injured while she was restraining an aggressive patient and was knocked to the ground, hitting her head.
EXTENT OF INJURY
The ALJ determined that the compensable injury of (date of injury), extends to concussion without loss of consciousness, traumatic brain injury, episodic seizure disorder, traumatic, photophobia, phonophobia, dysgeusia, and cervical strain based on the opinion of Dr. T, the designated doctor. In his report, Dr. T states:
What is missing in the clinical records is the [emergency department] physician evaluation on the [date of injury] at [healthcare provider] near [city]. We have made repeated efforts with the [claimant] signed records release to obtain that record without success. In the carrier’s analysis it was also noted that they had been unable to recover that specific record. We will enjoy any support to gain access to that document of the [emergency department] physician’s evaluation and management, will continue our efforts for same, and review and potentially amend this report when they are realized. [emphasis in original]
During the hearing, both parties recognized that Dr. T asked for the (healthcare provider) records, which were submitted into evidence by both parties, and suggested that the ALJ provide the missing records to him. The ALJ did not provide the requested record to Dr. T.
28 Tex. Admin. Code § 130.1(b)(4)(A) and 130.1(c)(3) (Rules 130.1(b)(4)(A) and 130.1(c)(3)) specifically require that the certifying doctor, including the designated doctor, review the medical records before certifying an MMI date and assigning an IR. In Appeals Panel Decision (APD) 062068, decided December 4, 2006, the Appeals Panel held that the 1989 Act and the Division rules require that the designated doctor conduct an examination of the claimant and review the claimant’s medical records. See also APD 130187, decided March 18, 2013, in which the designated doctor did not have the post-operative physical therapy medical records prior to making his first MMI/IR certification; therefore, his certification of MMI and IR could not be adopted. Rule 127.10(a)(1) provides, in part, that the treating doctor and insurance carrier shall provide to the designated doctor copies of all the injured employee’s medical records in their possession relating to the medical condition to be evaluated by the designated doctor. The evidence established that Dr. T did not have all of the claimant’s medical records for his examination, including the (healthcare provider) records that he specifically requested, before making a determination on extent of injury, one of the issues he was appointed to determine. See APD 132258, decided November 20, 2013, APD 182362, decided December 27, 2018, and APD 211980, decided January 21, 2022. Accordingly, we reverse the ALJ’s determination that the compensable injury of (date of injury), extends to concussion without loss of consciousness, traumatic brain injury, episodic seizure disorder, traumatic, photophobia, phonophobia, dysgeusia, and cervical strain and remand the extent-of-injury issue to the ALJ for further action consistent with this decision.
MMI AND IR
Since we have reversed and remanded the extent-of-injury issue, we reverse the ALJ’s determinations that the claimant has not reached MMI and an IR may not yet be assigned and remand the MMI and IR issues to the ALJ for further action consistent with this decision.
DISABILITY
Since we have reversed and remanded the extent-of-injury issue, we reverse the ALJ’s determination that the claimant had disability from October 9, 2024, through August 18, 2025, resulting from the compensable injury of (date of injury), and remand the disability issue to the ALJ for further action consistent with this decision.
SUMMARY
We reverse the ALJ’s determination that the compensable injury of (date of injury), extends to concussion without loss of consciousness, traumatic brain injury, episodic seizure disorder, traumatic, photophobia, phonophobia, dysgeusia, and cervical strain and remand the extent-of-injury issue to the ALJ for further action consistent with this decision.
We reverse the ALJ’s determinations that the claimant has not reached MMI and an IR may not yet be assigned and remand the MMI and IR issues to the ALJ for further action consistent with this decision.
We reverse the ALJ’s determination that the claimant had disability from October 9, 2024, through August 18, 2025, resulting from the compensable injury of (date of injury), and remand the disability issue to the ALJ for further action consistent with this decision.
REMAND INSTRUCTIONS
Dr. T is the designated doctor in this case. On remand the ALJ is to determine whether Dr. T is still qualified and available to be the designated doctor. If Dr. T is no longer qualified or available to serve as the designated doctor, then another designated doctor is to be appointed on the issues of extent of injury, MMI, IR, and disability from October 9, 2024, through August 18, 2025, for the (date of injury), compensable injury. On remand, the ALJ is to ensure that the required medical records are sent to the designated doctor pursuant to Rule 127.10, including the medical records from (healthcare provider) on (date of injury).
The parties are to be provided with the designated doctor’s new report and certification and are to be allowed an opportunity to respond. The ALJ is then to make a determination regarding extent of injury, MMI, IR, and disability consistent with this decision.
Pending resolution of the remand, a final decision has not been made in this case. However, since reversal and remand necessitate the issuance of a new decision and order by the ALJ, a party who wishes to appeal from such new decision must file a request for review not later than 15 days after the date on which such new decision is received from the Division, pursuant to Section 410.202 which was amended June 17, 2001, to exclude Saturdays and Sundays and holidays listed in Section 662.003 of the Texas Government Code in the computation of the 15-day appeal and response periods. See APD 060721, decided June 12, 2006.
The true corporate name of the insurance carrier is AIU INSURANCE COMPANY and the name and address of its registered agent for service of process is
CORPORATION SERVICE COMPANY
211 EAST 7TH STREET, SUITE 620
AUSTIN, TEXAS 78701-3218.
Cristina Beceiro
Appeals Judge
CONCUR:
Carisa Space-Beam
Appeals Judge
Margaret L. Turner
Appeals Judge