DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder.

ISSUE

Prior to the medical contested case hearing scheduled for 1:30 P.M. on April 15, 2009, the parties reached an agreement on the following issue:

Is the preponderance of the evidence contrary to the decision of the Independent Review

Organization that Claimant is not entitled to left shoulder excision of os acromiale for

the compensable injury of ____________?

PARTIES PRESENT

Petitioner/Claimant did not appear in person but was represented by DTR, attorney, who appeared in person.

Respondent/Carrier was represented by CF, attorney, who appeared in person.

AGREEMENT

The parties reached an agreement in writing. The agreement resolves only the issue to be decided at this hearing: it does not resolve all issues with regard to this claim and is not a settlement.

In this decision, the Agreement section includes findings of fact and the Decision section constitutes the conclusions of law.

The Hearing Officer found:

A.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.

B.The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.

C.On ____________, Claimant, who was the employee of (Employer), sustained a compensable injury.

D.Carrier delivered to Claimant a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.

The parties agreed as follows:

The preponderance of the evidence is not contrary to the decision of the Independent Review Organization that the requested left shoulder excision of the OS acromiale is not medically necessary.

DECISION

The preponderance of the evidence is not contrary to the decision of the Independent Review

Organization that Claimant is not entitled to left shoulder excision of the OS acromiale for the

compensable injury of ____________.

ORDER

Carrier is not liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

The true corporate name of the insurance carrier is ILLINOIS NATIONAL INSURANCECOMPANY and the name and address of its registered agent for service of process is

CORPORATION SERVICE COMPANY

701 BRAZOS SUITE 1050

AUSTIN, TEXAS 78701

Signed this 15th day of April, 2009.

CAROLYN F. MOORE
Hearing Officer