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At a Glance:
Title:
11175
Date:
August 16, 2011
Status:
Medical Fees

11175

August 16, 2011

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.

ISSUES

A contested case hearing was held on July 29, 2011, to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of Medical Fee Dispute Resolution (MFDR) that Petitioner/Subclaimant is not entitled to $692.80 for a functional capacity evaluation dated June 01, 2009, (97750-FC); is not entitled to $91.92 for an established office visit dated September 16, 2009, (99213); and is entitled to $15.00 for reimbursement for a work status report dated January 26, 2010 (99080-73)?

PARTIES PRESENT

Petitioner failed to appear for the contested case hearing and did not respond to the Division’s 10-day letter. Carrier appeared and was represented by KP, attorney. Claimant did not appear and his appearance was excused.

BACKGROUND INFORMATION

Although properly notified, Petitioner failed to appear for the contested case hearing scheduled for 9:00 a.m. on July 29, 2011. A letter advising the hearing had convened and the record would be held open for ten days to afford Petitioner the opportunity to respond and request the hearing be rescheduled for presentation of evidence on the disputed issue was mailed to Petitioner on August 2, 2011. Petitioner failed to respond to the letter. On August 16, 2011, the record was closed. Having failed to appear and offer evidence in support of the claim, Petitioner failed to show entitlement to the relief sought.

Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.

FINDINGS OF FACT

  1. Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
  2. On (Date of Injury), Claimant was the employee of (Employer).
  3. On (Date of Injury), Claimant sustained a compensable injury.
  4. The Division sent a single document stating the true corporate name of the Carrier and the name and street address of Carrier’s registered agent for service with the 10-day letter to the Provider at the Provider’s address and to the Claimant at Claimant’s address of record. That document was admitted into evidence as Hearing Officer Exhibit Number 2.
  5. On June 08, 2011, Medical Fee Dispute Resolution determined Petitioner/Subclaimant is not entitled to $692.80 for a functional capacity evaluation dated June 01, 2009, (97750-FC); is not entitled to $91.92 for an established office visit dated September 16, 2009, (99213); but is entitled to $15.00 for reimbursement for a work status report dated January 26, 2010 (99080-73).
  6. Petitioner failed to appear for the July 29, 2011, contested case hearing and did not respond to the Division’s letter offering the opportunity to have the hearing rescheduled.
  7. Petitioner did not have good cause for failing to appear at the July 29, 2011, contested case hearing.

CONCLUSIONS OF LAW

  1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
  2. Venue is proper in the (City) Field Office.
  3. The preponderance of the evidence is not contrary to the decision of Medical Fee Dispute Resolution (MFDR) that Petitioner/Subclaimant is not entitled to $692.80 for a functional capacity evaluation dated June 01, 2009, (97750-FC); and is not entitled to $91.92 for an established office visit dated September 16, 2009, (99213). The preponderance of the evidence is also not contrary to the decision of Medical Fee Dispute Resolution (MFDR) that Petitioner/Subclaimant is entitled to $15.00 for reimbursement for a work status report dated January 26, 2010 (99080-73).

DECISION

The preponderance of the evidence is not contrary to the decision of Medical Fee Dispute Resolution (MFDR) that Petitioner/Subclaimant is not entitled to $692.80 for a functional capacity evaluation dated June 01, 2009, (97750-FC); and is not entitled to $91.92 for an established office visit dated September 16, 2009, (99213). The preponderance of the evidence is also not contrary to the decision of Medical Fee Dispute Resolution (MFDR) that Petitioner/Subclaimant is entitled to $15.00 for reimbursement for a work status report dated January 26, 2010 (99080-73).

ORDER

Carrier is liable for the $15.00 in reimbursement for the work status report dated January 26, 2010 (99080-73), but is not liable for the remaining reimbursement at issue in this case. Claimant remains entitled to medical benefits for the compensable injury in accordance withSec.408.021.

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

NEW HAMPSHIRE INSURANCE COMPANY

CORPORATION SERVICE COMPANY

701 BRAZOS STREET, SUITE 1050

AUSTIN, TX 78701-3232.

Signed this 16th day of August, 2011.

KEN WROBEL
Hearing Officer

End of Document
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