This appeal arises pursuant to the Texas Workers’ Compensation Act, TEX. LAB. CODE ANN. § 401.001 et seq. (1989 Act). A contested case hearing (CCH) was held on November 2, 2001. The hearing officer determined that the issue before her had been resolved by an agreement reached at a benefit review conference (BRC) in December 2000, and that the respondent (claimant) was entitled to reimbursement for medical travel for treatment received “at the office of” her treating doctor.
DECISION
We reverse and remand.
The issue reported from the BRC was not precisely the issue stated at the CCH. Specifically, a dispute over whether the claimant was entitled to reimbursement for medical travel to and from three referral doctors was changed by the time of the CCH, to an issue as to whether reimbursement was appropriate for services provided “at the direction of” the treating doctor, including, apparently, the treating doctor’s own services. The travel claimed was for numerous visits made between January and the end of June in 2001. The hearing was extremely brief, with the claimant expressing a preference for a doctor in her own town but cogently describing how she happened to change to a treating doctor in a town over 20 miles away (one way). She indicated that her treating doctor, a medical doctor who was a pain specialist, had referred her to at least three chiropractors in his same office building. The claimant said she saw her treating doctor once or twice a month, but received chiropractic manipulation three times a week.
The hearing officer has held that a BRC agreement signed on December 19, 2000, about which no evidence was offered other than the agreement document, is binding and covers all charges sought here. We disagree, and accordingly reverse and remand for further proceedings to consider the applicability of Tex. W.C. Comm’n, 28 TEX. ADMIN. CODE § 134.6 (Rule 134.6) to the charges beginning January 2001 for which reimbursement is sought.
The dispute on the previous BRC agreement was stated as: “Entitlement to mileage reimbursement from residence to [TD’s name].” To the extent it could be argued that the agreement was intended to resolve future, as well as pending, reimbursements, the dispute was plainly focused on medical treatment rendered by the treating doctor. The fact that the dispute’s resolution is phrased in terms of reimbursement for travel to the treating doctor’s “office,” does not, in our opinion, reflect an intent to allow travel expenses to other doctors simply because they are physically located in the treating doctor’s office building. No evidence was offered that the agreement was intended to incorporate any such referrals. (We would observe that one sentence written on the agreement, beginning with “parties,” cannot be clearly read.)
As the appellant (carrier) also pointed out, the benefit review officer (BRO) who executed this December 2000 agreement with the parties was the same BRO who considered the issue underlying the present CCH: of whether reimbursement was also due for the chiropractic services. The BRO declined to apply the agreement to extend to reimbursement for the referral doctors. Because we cannot agree that the agreement applied to referral doctors, the hearing officer should have applied Rule 134.6 to those charges incurred on behalf of such treatment. We reverse and remand so that this can be done.
In addition, we cannot agree that the agreement is unambiguous as to whether it was intended to apply to future charges for travel to and from the treating doctor himself. While the issue is phrased in terms of a threshold question of “entitlement” to such reimbursement, the resolution also indicates that “submitted bills” are to be paid. This indicates that the dispute arose over refusal of the carrier to pay for expenses already incurred by the claimant for travel, not unknown claims to be made in the future. Because we do not agree that the BRC agreement is unambiguous on this point, the hearing officer may, on remand, develop further evidence of the substance of the dispute resolved and the intent of the parties when the BRC agreement was signed in December 2000.
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 hearing officer, 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 Texas Workers’ Compensation Commission’s Division of Hearings, pursuant to Section 410.202 (amended June 17, 2001). See Texas Workers’ Compensation Commission Appeal No. 92642, decided January 20, 1993.
The true corporate name of the insurance carrier is HIGHLANDS UNDERWRITERS INSURANCE COMPANY and the name and address of its registered agent for service of process is
JAMES HOOKER
10370 RICHMOND
HOUSTON, TEXAS 77042.
Susan M. Kelley – Appeals Judge
CONCUR:
Thomas A. Knapp – Appeals Judge
Robert W. Potts – Appeals Judge