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At a Glance:
Title:
453-01-2923-m5
Date:
January 22, 2002

453-01-2923-m5

January 22, 2002

DECISION AND ORDER

This case is a dispute over the decision by Lumbermen’s Mutual Casualty Company (Carrier) to not reimburse _____________ (Petitioner) $302.13 for co-payments for doctor visits, medication, and copying expenses.

The Administrative Law Judge (ALJ) finds that Carrier is not liable to reimburse Petitioner for the services rendered. Specifically, the ALJ notes that Petitioner voluntarily chose to see a physician other than her approved treating physician, without obtaining prior approval under TWCC rules. Therefore, the charges for Petitioner’s treatment and prescribed medications resulting from such treatment are not reimbursable. Moreover, Petitioner is not entitled to recover for the charges she incurred to provide copies to the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) as part of the dispute resolution process. There are no rules providing for reimbursement to a party for such charges associated with the MRD dispute resolution process, and the parties are expected to bear those costs themselves. For the foregoing reasons, and as set forth below in the Findings of Fact and Conclusions of Law, Petitioner’s request for reimbursement is denied.

I. Findings of Fact

  1. ______________ (Petitioner) suffered an injury on or about ___________. At all times relevant herein, Lumbermen’s Mutual Casualty Company (Carrier) was the workers’ compensation insurance carrier for Petitioner.
  2. As part of her treatment, Petitioner selected Ed Kieke, D.C., as her treating physician. In January 2000, Petitioner received epidural steroid injections as part of her treatment by Dr. Kieke.
  3. Petitioner continued to experience pain as a result of her injury and requested additional treatment from Dr. Kieke. Dr. Kieke informed her that he could not perform additional treatment because he had no authorization from the Carrier; however, pre-authorization was not needed for the necessary treatment.
  4. Petitioner did not ask the Commission to assign her another treating physician for her injury.
  5. On April 29, 2000, Petitioner went to Memorial Herman-Katy Hospital for treatment for back and leg pain that she attributed to her injury of __________. At the hospital, Petitioner was seen by Jose Diaz, M.D. Petitioner paid a $100 co-payment for her admission to the hospital and submitted the remainder of the charges to her private insurance HMO.
  6. On May 18, 2000, Petitioner saw Dr. Lisa Chan for treatment of her back and leg pain. Dr. Chan was Petitioner’s primary care physician through her private insurance HMO. On June 14, 2000, Petitioner saw Dr. Diaz for additional treatment, and Dr. Diaz referred Petitioner to Dr. Ali Azimpoor, a neurology surgeon, for specialized consultation for her back and leg pain. Petitioner saw Dr. Azimpoor on July 6, 2000. Finally, on August 15, 2000, Petitioner saw Dr. Diaz one more time for her back and leg pain. For each of these visits, Petitioner paid a $10 co-payment, for a total of $40 out-of-pocket for the four visits. None of these physicians were Petitioner’s designated treating physician for her worker’s compensation injury, nor was Petitioner specifically referred to them by her designated treating physician.
  7. As a result of her various doctors’ visits described above, Petitioner was prescribed numerous medications. Between August 1, 2000, and September 25, 2000, Petitioner obtained five prescriptions for pain medications. For each of these prescriptions, Petitioner paid a $10 co-payment, for a total of $50 out-of-pocket for the five prescriptions.
  8. For the medical services and prescriptions described above, Petitioner submitted a claim to Carrier for reimbursement. Carrier denied reimbursement on the basis that Petitioner had not obtained the treatment through her selected workers’ compensation treating physician.
  9. Petitioner a filed a Request for Medical Dispute Resolution with the Commission, seeking reimbursement. In preparation for the dispute resolution process, Petitioner obtained medical records from Memorial Herman-Katy Hospital and incurred $112.13 in charges to obtain such documents. In the dispute resolution process, Petitioner sought reimbursement of $302.13 for the doctors’ visits, prescriptions, and copying charges.
  10. On April 6, 2001, the Commission’s Medical Review Division (MRD) determined that Petitioner was not entitled to reimbursement of any amount.
  11. On April 18, 2001, Petitioner filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  12. Notice of the hearing was sent May 18, 2001.
  13. 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.
  14. The hearing was held January 7, 2002, with Administrative Law Judge Craig R. Bennett presiding and representatives of the Carrier and Petitioner participating. The hearing was adjourned the same day.
  15. The evidence submitted in this case fails to establish that Petitioner’s symptoms and condition constituted an emergency justifying her obtaining treatment from a non-designated physician.

II. Conclusions of Law

  1. The 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. SOAH 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 Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. Under the Act, Petitioner was required to make an initial selection of her treating physician and then obtain treatment from that selected physician alone, except in emergency circumstances or upon referral by the treating physician. If Petitioner was dissatisfied with her initial choice of treating physician, then she could have notified the Commission and requested authority to select an alternate physician. Tex. Lab. Code Ann. §408.022. Petitioner is not entitled to reimbursement for charges associated with receiving treatment from a physician other than her treating physician or a physician properly referred by her treating physician.
  6. Petitioner is not authorized under statute or rule to be reimbursed for charges incurred in obtaining documents for the dispute resolution process before the Commission’s MRD.
  7. Petitioner has not met her burden of proving she was entitled to reimbursement for the disputed charges.
  8. Petitioner’s request for reimbursement in the amount of $302.13 should be denied.

ORDER

IT IS, THEREFORE, ORDERED that the request by __________ for reimbursement in the amount of $302.13 from Lumbermen’s Mutual Casualty Company for medical and copying charges incurred between April 29, 2000 and November 16, 2000, is DENIED.

Signed January 22, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CRAIG R. BENNETT
Administrative Law Judge

End of Document
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