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At a Glance:
Title:
22001-nnr
Date:
January 27, 2022

22001-nnr

January 27, 2022

DECISION AND ORDER

Claimant appealed the decision of the Independent Review Organization (IRO) in Case Number (Case Number). The hearing for this appeal was held on January 27, 2022. Pursuant to the agreement of the parties, the administrative law judge (ALJ) determines that:

The preponderance of the other medical evidence is not contrary to the IRO decision dated January 19, 2021, in IRO Case Number (Case Number).

ISSUE

At the hearing, Hector Q. Martinez, an ALJ, considered the following unresolved issue:

Is the claimant entitled to postoperative physical therapy for the left shoulder [3 times a week x 6 weeks], shoulder abduction orthosis [purchase x1], left shoulder arthroscopy with distal clavicle resection, left shoulder debridement (outpatient), and surgeon’s assistant for the compensable injury of (Date of Injury)?

PERSONS PRESENT

Claimant appeared by phone at the hearing on January 27, 2022, and in person representing him was HC, attorney. Insurance Carrier appeared at the hearing on January 27, 2022, and was represented by KG, attorney.

EVIDENCE PRESENTED

The following witnesses testified:

For Claimant: Claimant

For Insurance Carrier: None

The following exhibits were admitted into evidence:

Administrative Law Judge Exhibits: ALJ-1 through ALJ-3

Claimant Exhibits: None

Insurance Carrier Exhibits: None

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.

1. The parties agreed as follows:

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

B. On (Date of Injury), Claimant was the employee of (Employer), Employer.

C. On (Date of Injury), Employer provided workers’ compensation insurance through National Interstate Insurance Company, Insurance Carrier.

D. On (Date of Injury), Claimant sustained a compensable injury.

E. The requested treatment is for the (Date of Injury), compensable injury that includes at least a left shoulder sprain/strain.

F. The Independent Review Organization decision upheld and agreed with the insurance carrier’s denials of postoperative physical therapy for the left shoulder [3 times a week x 6 weeks], shoulder abduction orthosis [purchase x1], left shoulder arthroscopy with distal clavicle resection, left shoulder debridement (outpatient), and surgeon’s assistant for the compensable injury of (Date of Injury).

G. The Independent Review Organization decision dated January 19, 2021, was sent to the parties and was deemed to be received by January 24, 2021.

H. On February 3, 2021, Claimant filed an Appeal of the Independent Review Organization Decision (DWC049) with the Division of Workers’ Compensation. The appeal was filed within twenty days from the date the Independent Review Organization decision was sent to the parties.

2.The Administrative Law Judge found the following fact:

Insurance Carrier delivered to Claimant a document stating the insurance carrier’s true corporate name and the registered agent’s name. This document was admitted into evidence as ALJ-3.

The parties agreed to the following:

The preponderance of the other medical evidence is not contrary to the IRO decision dated January 19, 2021, in IRO Case Number (Case Number).

DECISION

The preponderance of the other medical evidence is not contrary to the IRO decision dated January 19, 2021, in IRO Case Number (Case Number).

ORDER

Insurance Carrier is not liable for the benefits at issue in this hearing and it is so ordered. Claimant remains entitled to medical benefits for the compensable injury in accordance with Texas Labor Code §408.021.

The true corporate name of the insurance carrier is NATIONAL INTERSTATE INSURANCE COMPANY, and the name and address of its registered agent for service of process is:

CORPORATION SERVICE COMPANY
211 EAST 7th STREET SUITE 620
AUSTIN TX 78701-3218

Signed this 27th day of January 2022.

Hector Q. Martinez
Administrative Law Judge

End of Document
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