Benefits for a compensable injury are defined as medical benefits, income benefits, death benefits, or burial benefits. TLC Section 401.011(5). The AP has jurisdiction in cases involving disputes over income benefits, death benefits, and burial benefits. 28 TAC Section 140.1(1) and (2). The AP also has jurisdiction to determine whether an IE is entitled to medical benefits based on a finding of compensability; however, the AP does not have jurisdiction to determine what medical treatment is reasonable and necessary for an IE's compensable injury in the past or in the future or the amount to be paid for such treatment. TLC Section 413.031 and 28 TAC Section 133.305.
Jurisdiction over Claims/Issues.
The decision of the AP regarding benefits is binding during the pendency of an appeal for judicial review. TLC Section 410.205(b). In Lopez v. Texas Workers' Comp. Ins. Fund, 11 S.W.3d 490 (Tex. App.-Austin 2000, pet. denied), the court held that TLC Section 410.205(b) clearly provides that the ultimate administrative ruling-whether granting or denying benefits-remains in effect until a final and enforceable judicial decision overturns it. APD 080713; APD 200483. During judicial review of the APD on any disputed issue relating to a workers' compensation claim, DWC retains jurisdiction of all other issues related to the claim. TLC Section 410.207; APD 080713; APD 200483. A party may show through court documents that judicial review is no longer pending.
The AP's jurisdiction is limited to issues decided at the CCH. TLC Sections 410.202(c) and 410.203; APD 91057. The AP will generally not consider issues raised for the first time on appeal. APD 040259. However, when information is presented on appeal to the AP that the IC participating in the CCH did not have coverage, the AP may remand for the ALJ to determine who the correct IC is. APD 070475; APD 050802; APD 182321.
[Cross-reference: Issue Not Previously Raised (P02)].
Proper Appointment of DD Issue.
[Cross-reference: Other Procedural Issues (P00)]
Dr. R was appointed as the DD to determine if the IE has reached MMI and, if so, assign the IE's IR. The issue before the ALJ was whether Dr. R was properly appointed as the second DD and, if not, whether his report should be invalidated and whether the IE should be reexamined. The ALJ found that the issue of whether Dr. R was properly appointed as the second DD does not affect benefits, and that ALJs do not have jurisdiction to hear a sole issue that does not affect benefits. TLC Section 410.002. Therefore, the ALJ determined that she had no jurisdiction to decide whether Dr. R was properly appointed as the second DD. The AP reversed the ALJ's determination and stated the issue of whether Dr. R was properly appointed as the second DD does affect the IE's benefits. If an IE has disability under TLC Section 408.101, pursuant to TLC Section 408.102(a), TIBs continue until the IE reaches MMI. TLC Section 408.121(a) provides in part that an IE's entitlement to IIBs begins on the day after the date the IE reaches MMI. TLC Section 408.0041(a) provides, in part, that at the request of the IC or IE, or on the commissioner's own order, the commissioner may order a medical examination to resolve questions about MMI, IR, and other matters. TLC Section 408.0041(f) provides in part that unless otherwise ordered by the commissioner, the IC shall pay benefits based on the opinion of the DD during the pendency of any dispute. Because the DD's opinion on MMI or IR does affect benefits, the ALJ had jurisdiction in this case. The AP rendered a new decision that DWC does have jurisdiction to resolve the issue and remanded the case back to the ALJ to determine whether Dr. R was properly appointed as the second DD. APD 090135.
Jurisdiction over Subclaimants.
A person may file a written claim with DWC as a subclaimant if the person has provided compensation, either directly or indirectly, to or for an IE or legal beneficiary. The person must also have sought and been refused reimbursement from the IC. TLC Section 409.009; APD 052857-s. A Texas workers' compensation IC may be a subclaimant. APD 052857-s. A subclaimant as described in TLC Section 409.009 is a party to a claim concerning workers' compensation benefits. 28 TAC Section 140.6(b); APD 190929.
In an appeal to the AP, an IC argued that the ALJ lacked jurisdiction over a subclaimant who had failed to meet the requirements of TLC Section 409.009 by demonstrating that it had made a claim for reimbursement and that the IC had denied the claim. The AP found that the ALJ did not lack jurisdiction over the subclaimant. The AP also found that a party's failure to satisfy the requirements of TLC Section 409.009 relates more to a challenge of a health care provider's status as a subclaimant, and that the IC's failure to raise the issue at the CCH resulted in a waiver of that issue. APD 011962-s. In APD 081065-s, a subclaimant health care insurer was found to have standing to seek adjudication of a dispute when compensability was denied, and the IE has declined to pursue a claim. The subclaimant had standing under TLC Section 409.009 because it indirectly provided compensation for the IE and it sought and was refused reimbursement from the IC. The authorized representative of the subclaimant health care insurer did not have standing under TLC Section 409.009. It did not meet the requirements of TLC Section 409.009 because the evidence did not establish that the authorized representative had provided compensation directly or indirectly to the IE. APD 081065-s. See APD 080576-s where a subclaimant health care insurer's standing to seek adjudication of the dispute under TLC Section 409.0091 was an issue at the CCH and on appeal to the AP. The AP determined that the subclaimant did not have standing under TLC Section 409.0091 because TLC Section 409.0091 did not apply under the facts of that case.
[Cross-reference: Other Procedural Issues (P00)].