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.
A contested case hearing was held on September 8, 2010 to decide the following disputed issue:
Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that the Claimant is not entitled to manipulation with possible left shoulder arthroscopy for the compensable injury of ___________?
Petitioner/Provider appeared by telephone and was represented by his assistant, BC. Claimant appeared and was assisted by SB, ombudsman. Respondent/Carrier appeared by telephone and was represented by BP, attorney.
The parties reached an agreement. The agreement resolves only those issues to be decided at this hearing. The agreement does not resolve all issues with regard to this claim and is not a settlement.
In this decision, this Agreement section includes findings of fact and the Decision section constitutes the conclusions of law.
The Hearing Officer found:
A.Self-Insured delivered to Claimant and Petitioner a single document stating the true corporate name of Self-Insured, and the name and street address of Self- Insured’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
The parties stipulated as follows:
- Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
- On ___________, the Claimant was the employee of (Self-Insured), employer.
- On ___________, employer had workers’ compensation insurance coverage through self-insurance.
- The Claimant sustained a compensable injury on ___________ while in the course and scope of her employment with (Self-Insured).
The parties agreed as follows:
- The preponderance of the evidence is contrary to the decision of the IRO that the Claimant is not entitled to manipulation with possible left shoulder arthroscopy for her compensable ___________ injury.
- The Claimant is entitled to, and the Self-Insured is liable for, an arthroscopiccapsulotomy with manipulation of her left shoulder for her compensable __________ injury, per the August 17, 2010 report of the Self-Insured’s selected required medical examination (RME) doctor, Dr. G.
Per the parties' agreement, the preponderance of the evidence is contrary to the decision of the IRO. The Claimant is entitled to, and the Self-Insured is liable for, an arthroscopic capsulotomy with manipulation of her left shoulder per the August 17, 2010 report of the Self-Insured’s RME doctor, Dr. G.
The Self-Insured is ORDERED to pay medical benefits in accordance with this decision, the Act and the implementing rules.
The true corporate name of the Self-Insured is (SELF-INSURED), and the name and address of its registered agent for service of process is
DR. S, SUPERINTENDENT
(CITY), TX (ZIP CODE)
Signed this 13th day of September, 2010.