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At a Glance:
Title:
15035-nnr
Date:
March 24, 2015

15035-nnr

March 24, 2015

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. For the reasons discussed herein, the Hearing Officer determines that the preponderance of the evidence is contrary to the decision of the Independent Review Organization (IRO) that Claimant is not entitled to conversion for right shoulder arthroplasty to reverse total shoulder arthroplasty with a three day inpatient stay for the compensable injury of (Date of Injury). The Hearing Officer determines, pursuant to the parties’ agreement, that Claimant is entitled to conversion for right shoulder arthroplasty to reverse total shoulder arthroplasty with a three day inpatient stay for the compensable injury of (Date of Injury).

ISSUES

A contested case hearing was held on March 23, 2015 to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the IRO that the claimant is not entitled to conversion for right shoulder arthroplasty to reverse total shoulder arthroplasty with a three day inpatient stay for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Claimant appeared and was assisted by DM, ombudsman. Respondent/Carrier appeared and was represented by PS, attorney.

AGREEMENT

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 that 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:

  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 of the Texas Department of Insurance, Division of Workers’ Compensation.
  3. On (Date of Injury), Claimant was the employee of the (Employer), Employer.
  4. On (Date of Injury), Employer provided workers’ compensation insurance as a self-insured Carrier.
  5. On (Date of Injury), Claimant sustained a compensable injury.
  6. The preponderance of the evidence is contrary to the Decision of the IRO dated September 6, 2014, that conversion for right shoulder arthroplasty to reverse total shoulder arthroplasty with a three day inpatient stay is not reasonable and necessary for treatment of the compensable injury of (Date of Injury).
  7. DECISION

Claimant is entitled to conversion for right shoulder arthroplasty to reverse total shoulder arthroplasty with a three day inpatient stay for the compensable injury of (Date of Injury).

ORDER

Carrier is ordered to pay benefits in accordance with this decision, the Texas Workers’ Compensation Act, and the Commissioner’s Rules. Accrued but unpaid income benefits, if any, shall be paid in a lump sum together with interest as provided by law.

The true corporate name of the insurance carrier is (SELF-INSURED), and the name and address of its registered agent for service of process is

CITY ATTORNEY

ADDRESS

CITY, TEXAS ZIP

Signed this 24th day of March, 2015.

BRITT CLARK
Hearing Officer

End of Document
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