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At a Glance:
Title:
453-01-2609-m5
Date:
June 28, 2002
Status:
Retrospective Medical Necessity

453-01-2609-m5

June 28, 2002

DECISION AND ORDER

This case is a dispute over whether reimbursement is appropriate for certain office visits and treatment rendered to C.H. (Claimant). Between June 7, 2000, and October 9, 2000, Claimant underwent treatment for exposure to toxic chemicals. Claimant billed Fort Worth Independent School District (Carrier) for the treatment. Carrier denied reimbursement to Claimant for this treatment. Claimant seeks reimbursement. The amount in controversy is $5,958.37.

The hearing was conducted on May 1, 2002, at the State Office of Administrative Hearings (SOAH), 300 West Fifteenth Street, Austin, Texas, before Administrative Law Judge (ALJ) Steven M. Rivas. Donald W. York, attorney, represented the Petitioner. Juan Mireles, an Ombudsman, assisted the Claimant. Claimant also appeared and testified on her own behalf. The Commission's staff did not participate in the hearing.

The ALJ concludes the Claimant is entitled to a total of $5,958.37 reimbursement.

I.

DISCUSSION

Background Facts

On_____________, Claimant C.H., sustained a compensable injury while working as a 7th grade science teacher. On that date, Claimant began to feel the affects of being exposed to toxic chemicals in the classroom where she taught. It was later revealed, formaldehyde and other unknown chemicals were stored in the same classroom Claimant and her students attended. Following her initial onset of symptoms, Claimant continued to suffer from exposure-related ailments. Eventually, Claimant came under the care of Clarence Brooks, M.D., her treating doctor. Dr. Brooks attempted to alleviate Claimant's maladies with a series of medication and treatment, to no avail. After finding no success with conventional treatment, Dr. Brooks referred Claimant to the Environmental Health Center where she came under the care of William Rea, M.D. Dr. Rea treated Claimant between June 7, 2000, and October 9, 2000. The treatment given to Claimant alleviated Claimant's symptoms caused by exposure to the stored chemicals. Claimant paid for this treatment using her own funds. Claimant billed Carrier for Dr. Rea's treatment. Carrier denied reimbursement as medically unnecessary. Claimant filed a request for Medical Dispute Resolution (MDR) with the Medical Review Division (MRD). The MRD held Claimant was entitled to reimbursement in the amount of $5,958.37. Carrier appealed and filed a request for hearing before the State Office of Administrative Hearings (SOAH).

B. Applicable Law

The Texas Labor Code contains the Texas Workers= Compensation Act (the AAct) and provides the relevant statutory requirements regarding compensable treatment for workers= compensation claims. In particular, Tex. Lab. Code Ann. ' 408.021 provides in pertinent part:

(a) An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that:

  1. cures or relieves the effects naturally resulting from the compensable injury;
  2. promotes recovery; or
  3. enhances the ability of the employee to return to or retain employment.

Analysis

As part of her treatment, Dr. Brooks, Claimant's treating doctor, referred Claimant to Dr. Rea when it became apparent Claimant's condition was not improving under Dr. Brooks= treatment. Dr. Rea administered a battery of treatment measures on Claimant. One such procedure required Claimant to sit inside a sauna in order to generate perspiration of internal toxins. Claimant testified her symptoms began to disappear under Dr. Rea's care.

Carrier argued it should not reimburse Claimant primarily because Dr. Rea employs unconventional methods in his practice. Carrier's expert witness testified that although Dr. Rea genuinely attempts to relieve patients of their ailments, his procedures are not based on accepted scientific or medical standards. Carrier's witness went on to comment Dr. Rea's practices are questionable and not reliable.

Dr. Rea testified that he has utilized his methods on hundreds of claimants within the workers= compensation program and that he has experienced successful results. Claimant additionally testified she was relieved of her exposure symptoms as a result of Dr. Rea's treatment.

Under Tex. Lab. Code Ann. ' 408.021, an employee who sustains a compensable injury is entitled to all health care that cures or relieves the effects naturally resulting from the compensable injury. Since Dr. Rea's treatment relieved the effects of Claimant's compensable injury, Claimant is entitled to reimbursement.

Despite Carrier's position that Dr. Rea's practices are unreliable and questionable, there is no disputing that Claimant's condition improved as a result of Dr. Rea's care. Under the statute, a Claimant is entitled to health care that relieves the effects of a compensable injury. Dr. Rea's treatment relieved the effects of Claimant's chemical exposure, therefore, Carrier should reimburse Claimant the fees of the treatment.

II.

FINDINGS OF FACT

  1. Claimant, C.H., suffered a compensable injury on ___________.
  2. Claimant suffered from exposure to toxic chemicals stored in the classroom where she taught.
  3. Claimant came under the care of Clarence Brooks, M.D. who became her treating doctor.
  4. Under Dr. Brooks treatment, Claimant's symptoms persisted.
  5. Dr. Brooks referred Claimant to the Environmental Health Center where she came under the care of William Rea, M.D.
  6. Dr. Rea treated Claimant between June 7, 2000, and October 9, 2000.
  7. Dr. Rea's treatment alleviated Claimant's symptoms caused by exposure to the stored chemicals.
  8. Claimant paid for this treatment using her own funds. Claimant billed Fort Worth Independent School District (Carrier) for Dr. Rea's treatment.
  9. Carrier denied reimbursement as medically unnecessary.
  10. Claimant filed a Request for Medical Review Dispute Resolution with the Texas Workers= Compensation Commission (the Commission), seeking reimbursement for the treatment rendered to Claimant by Dr. Rea.
  11. On February 14, 2001, the Commission's Medical Review Decision (MRD) found Claimant was entitled to reimbursement of $5,958.37.
  12. Carrier appealed and filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  13. Notice of the hearing was sent April 15, 2002.
  14. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  15. The hearing was held May 1, 2002, with Administrative Law Judge Steven M. Rivas presiding and representatives of the Carrier, and Claimant participating. The hearing was adjourned the same day.
  16. Carrier failed to offer sufficient evidence that Claimant is not entitled to reimbursement for the medical services to Claimant by Dr. Rea.

III.

CONCLUSIONS OF LAW

  1. The Texas Worker's Compensation Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
  2. The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. ' 413.031(d) and Tex. Gov=t Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov=t Code Ann. ' 2001.052.
  4. The Carrier, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code ' 148.21(h).
  5. Pursuant to the foregoing Findings of Facts and Conclusions of Law, Provider is entitled to reimbursement for the services rendered to Claimant between June 7, 2000, and October 9, 2000, in the amount of $5,958.37.

ORDER

IT IS, THEREFORE, ORDERED that Claimant, C.H., is entitled to reimbursement of $5,958.37 from the Carrier, Fort Worth Independent School District, for the services rendered to Claimant between June 7, 2000, and October 9, 2000.

Signed this 28th day of June, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

End of Document
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