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Texas Workers' Compensation Ins. Fund v. Serrano
February 13, 1998
962 S.W.2d 536
Texas Supreme Court
Published Opinion

Texas Workers' Compensation Ins. Fund v. Serrano

Supreme Court of Texas.



Jose SERRANO and Graciela Chairez, individually and as next friend of Alonzo Serrano, Jose Serrano, and Guadalupe Serrano, Respondents.

No. 97–0288.


Feb. 13, 1998.

Attorneys & Firms

*537 Mike Mills, McAllen, for Petitioner.

Frank Costilla, Brownsville, for Respondents.



TEX. LAB.CODE § 417.002(a). The single question before us is whether the carrier must prove that the amount of benefits paid was reasonable and necessary before it is entitled to reimbursement. The court of appeals answered yes. ––– S.W.2d ––––. We disagree.

Jose Serrano sustained disabling on-the-job injuries when he was pinned between a truck and trailer. Serrano, his wife, and his three minor children sued the truck owner, the truck driver, and the trailer owner. Texas Workers’ Compensation Insurance Fund, the compensation carrier, intervened to assert its subrogation rights for $247,604.20 in medical benefits and $3,200.14 in indemnity benefits paid to or on behalf of Serrano. Plaintiffs settled with the truck owner and truck driver for $750,000. (Plaintiffs later settled with the trailer owner also for $450,000, but that matter is not before us.) The district court approved the settlement and apportioned the proceeds $250,000 to Serrano, $200,000 to his wife, and $100,000 to each of his three children. Out of Serrano’s share plaintiffs’ attorneys were paid $72,912.50 in fees, and the Fund was reimbursed $3,200.14. The district court refused to reimburse the medical benefits paid by the Fund because although the Fund proved the total amount paid, it failed to prove that each amount paid was reasonable and necessary. The court ordered the undistributed balance of Serrano’s share of the settlement paid into the registry of the court pending this appeal, and severed this dispute from the original action. *538 The Fund then appealed, complaining both of the denied reimbursement of medical benefits paid, and of the allocation of the settlement proceeds among the plaintiffs. The court of appeals affirmed. ––– S.W.2d ––––.

As the court of appeals acknowledged, 927 S.W.2d 597, 603 (Tex.1996)(emphasis added).

The court of appeals based its contrary conclusion on the Act’s definitions of “medical benefit”—“payment for health care reasonably required by the nature of a compensable injury”, Section 417.002(a) by limiting it to only reasonable and necessary amounts paid.

The courts of appeals have consistently held that a carrier is entitled to reimbursement from third-party recovery for amounts paid. E.g., E.V.R. II Assocs., Ltd. v. Brundige, 813 S.W.2d 552, 555 (Tex.App.—Dallas 1991, no writ) (overruling a challenge to a jury question about the “total amount [the carrier] paid the plaintiff as a result of the injury”). We are not aware of a court that has held as the court of appeals did in this case.

TEX. LAB.CODE § 413.017(1). The medical bills introduced in this case show on their face that amounts paid were in accordance with commission guidelines. On the record presented, the Fund was entitled to reimbursement.1

The court of appeals did not address the Fund’s complaints regarding the allocation of the settlement, and the parties have not fully briefed those issues in this Court, and subsequent events in settling the entire litigation may be pertinent. Accordingly, the Court grants the Fund’s application for writ of error and, without hearing oral argument, reverses the judgment of the court of appeals and remands the case to that court for further proceedings. TEX.R.APP. P. 59.1.



There is no assertion here that reimbursement is claimed for any payments made fraudulently or by mistake.

End of Document