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 June 28, 2018, with the record closing on August 2, 2018, 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 employer or appellant (carrier) properly provided respondent 2 (claimant) with the information required by Insurance Code §§ 1305.005 and 1305.451; (2) the Texas Department of Insurance, Division of Workers’ Compensation (Division) has jurisdiction to determine the medical fee disputed by (Dr. R) for the date of service of June 9, 2017; and (3) the carrier is liable to pay for the maximum medical improvement (MMI) and impairment rating (IR) evaluation by Dr. R, a non-network doctor, because the claimant was referred to him by the treating doctor for such evaluation.

The carrier appealed the ALJ’s determination that it is liable to pay Dr. R for the MMI and IR evaluation at issue. The carrier states the ALJ added the issue on his own motion and that it was improper to do so as this was not a justiciable issue. Respondent 1 (subclaimant) responded, urging affirmance of the ALJ’s determination. The appeal file does not contain a response from the claimant.

The ALJ’s determinations that the employer or carrier properly provided the claimant with the information required by Insurance Code §§ 1305.005 and 1305.451, and the Division has jurisdiction to determine the medical fee disputed by Dr. R for the date of service of June 9, 2017, have not been appealed and have become final pursuant to Labor Code § 410.169.

DECISION

Reversed and rendered by striking.

The parties stipulated, in part, that the claimant sustained a compensable injury on (date of injury), and that, on that date, the employer provided workers’ compensation insurance coverage through the carrier. The evidence reflects that the carrier provided health care to the claimant through a workers’ compensation health care network, the Texas Star Network. The evidence also reflects the claimant’s treating doctor, (Dr. G), a network doctor, referred the claimant to Dr. R, a non-network doctor who is the subclaimant in this case, for an examination to determine MMI and IR. Dr. R examined the claimant on June 9, 2017, and certified on June 19, 2017, that the claimant reached MMI on May 30, 2017, with a one percent IR.

At the CCH, the ALJ, on his own motion and over objection by the carrier, added the following issue:

Is the [c]arrier liable to pay for the [MMI/IR] evaluation by [Dr. R], a non-network physician, because [the] [c]laimant was referred to him by the treating doctor for such evaluation?

The ALJ writes in the statement of the case portion of the decision that he added the issue “to reflect to [the] correct issue raised by the positions of the parties in this case. . . .” The ALJ held the record open for the parties to have the opportunity to provide briefs on the added issue. After receipt of the parties’ briefs, the ALJ closed the record on August 2, 2018, and later issued a decision and order.

The ALJ concluded that the carrier is liable to pay for the MMI/IR evaluation by Dr. R, a non-network doctor, because the claimant was referred to him by the treating doctor for such evaluation. A dispute over payment for providing an MMI/IR examination is a medical fee dispute which is adjudicated through the Division’s Medical Fee Dispute Resolution program (Chapter 413, Medical Review, of the Labor Code) or the network’s internal complaint resolution process (Chapter 1305, Workers’ Compensation Health Care Networks, of the Insurance Code). Accordingly, we reverse by striking the ALJ’s Conclusion of Law No. 3 and the decision that: “[t]he [c]arrier is liable to pay for the MMI/[IR] evaluation by [Dr. R], a non-network physician, because [the] [c]laimant was referred to him by the treating doctor for such evaluation.”

The true corporate name of the insurance carrier is TEXAS MUTUAL INSURANCE COMPANY and the name and address of its registered agent for service of process is

RICHARD J. GERGASKO, PRESIDENT

6210 EAST HIGHWAY 290

AUSTIN, TEXAS 78723.

Veronica L. Ruberto
Appeals Judge

CONCUR:

Carisa Space-Beam
Appeals Judge

Margaret L. Turner
Appeals Judge

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 October 15, 2013, with the record closing on November 4, 2013, in [City], Texas, with [hearing officer] presiding as hearing officer. The hearing officer resolved the disputed issues by deciding that: (1) neither the appellant (carrier) nor the employer properly provided respondent 1 (claimant) with the information required by Texas Insurance Code Section 1305.451; (2) the Texas Department of Insurance, Division of Workers’ Compensation (Division) does not have jurisdiction to determine if the claimant is required to comply with the network requirements; and (3) therefore, the issue regarding whether the claimant is required to comply with the network requirements cannot be determined. The carrier appeals the hearing officer’s determination that neither the carrier nor the employer properly provided the claimant with the information required by Insurance Code Section 1305.451, contending that the information provided to the claimant by the employer satisfied the requirements of the statutes and rules. Respondent 2 (subclaimant) responded, urging affirmance of the disputed determination. The appeal file does not contain a response from the claimant to the carrier’s appeal. The hearing officer’s determination that the Division does not have jurisdiction to determine if the claimant is required to comply with the network requirements, and therefore, the issue regarding whether the claimant is required to comply with the network requirements cannot be determined was not appealed and has become final pursuant to Section 410.169.

DECISION

Reversed and rendered.

Insurance Code Section 1305.451(a) states that an insurance carrier that establishes or contracts with a network shall provide to employers, and the employer shall provide to its employees, an accurate written description of the terms and conditions for obtaining health care within the network’s service area. Additionally, Insurance Code Section 1305.451(b) contains specific requirements regarding the description that must be provided to employees.

The evidence establishes that the claimant was hired by the employer on June 11, 2010. The evidence further indicates that on the date of hire, the claimant signed a Workers’ Compensation Health Care Network Employee Acknowledgement Form and received an information packet entitled Important Information for Employees Regarding Medical Treatment for a Work-Related Injury or Illness which contained all of the information required by Insurance Code Section 1305.451. The hearing officer, in the Background Information section of her decision, stated that the evidence did not establish that the information provided to the claimant contained a list of network providers as required in Insurance Code Section 1305.451(b)(12). However, the evidence shows that an electronic link to the provider list is provided to the claimant on page two of the information packet. Furthermore, 28 TEX. ADMIN. CODE § 10.60(c)(3) (Rule 10.60(c)(3)) provides that the notice of network requirements may be in an electronic format provided a paper version is available upon request. The evidence does not indicate that the claimant requested a paper version from the carrier or the employer.

In this case, since the evidence indicates that the information provided to the claimant satisfied the requirements in Insurance Code Section 1305.451, we reverse the hearing officer’s determination that neither the carrier nor the employer properly provided the claimant with the information required by Insurance Code Section 1305.451, and we render a new decision that the employer properly provided the claimant with the information required by Insurance Code Section 1305.451.

The true corporate name of the insurance carrier is THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT and the name and address of its registered agent for service of process is

CORPORATION SERVICE COMPANY

d/b/a CSC-LAWYERS INCORPORATING 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