Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-02-1107-m4
Date:
November 20, 2002
Status:
Medical Fees

453-02-1107-m4

November 20, 2002

DECISION AND ORDER

_________ (Petitioner) seeks reimbursement of $293.00 from Continental Casualty Company (Continental) for out-of-pocket expenses incurred in a March 13, 2001 physician’s office visit. The stipulated Maximum Allowable Reimbursement (MAR) is $194.00. The Administrative Law Judge (ALJ) denies the Petitioner’s request for reimbursement in excess of the MAR and orders Continental to reimburse the Petitioner the sum of $194.00 within 20 days of a final decision by the Texas Workers’ Compensation Commission (Commission) if the Commission finds the Petitioner’s compensable injury extends to or includes the lumbar spine.

By Order dated June 13, 2001, the Commission found the Petitioner sustained a compensable injury[1] on May 25, 2000.[2] On the day the compensable injury was sustained, the Petitioner visited an emergency room. Ten months later on March 13, 2001, the Petitioner, as a new patient, was seen by John C. Milani, M.D. for evaluation of low back and left leg pain. The Petitioner paid Dr. Milani a total of $293.00, $110.00 for the office visit and $183.00 for an X-ray.[3] The MAR for the office visit is $74.00 and the MAR for the X-ray is $120.00, for a total of $194.00. Continental, in a separate proceeding before the Commission, has challenged whether the compensable injury extends to or includes the lumbar spine. The appropriate authority to decide the extent of injury issue is the Commission.

The rule applicable to this docket, Commission Rule 133.305(n), provides that when an insurance carrier raises a dispute on the extent of injury, the Medical Review Division (MRD) of the Commission shall decide the medical dispute and refer the extent of injury issue to the appropriate authority for adjudication. By Order dated October 31, 2001, the MRD ordered Continental to pay $194.00 in reimbursement if the compensable injury extends to or includes the lumbar spine (MRD Decision). The Petitioner timely requested a hearing before the State Office of Administrative Hearings (SOAH) and on January 14, 2002, Administrative Law Judge (ALJ) Howard S. Seitzman convened the SOAH hearing. The SOAH docket thereafter was abated pending resolution by the Commission of the extent of injury issue. The parties have filed status reports during the period of abatement. As of this date, the extent of injury issue remains pending at the Commission.

The ALJ has allowed the Petitioner sufficient time to litigate his extent of the injury claim at the Commission and is of the opinion that the SOAH docket should be resolved. The reimbursement issue raised by Petitioner on appealCmay an individual obtain reimbursement in excess of the MARCis solely a question of law. The Petitioner has not demonstrated any legal basis for the Petitioner to recover from Continental an amount in excess of the MAR.[4] Continental did not appeal the October 31, 2001 MRD Decision. Therefore, the ALJ denies the Petitioner’s request for reimbursement is excess of the MAR and will require Continental to reimburse the Petitioner the sum of $194.00 within 20 days of a final decision by the Commission if the Commission finds the Petitioner’s compensable injury extends to or includes the lumbar spine.

I. Findings of Fact

  1. _________ (Petitioner) suffered a compensable injury on________.
  2. Ten months later on March 13, 2001, the Petitioner, as a new patient, was seen by John C. Milani, M.D. for evaluation of low back and left leg pain.
  3. The Petitioner paid Dr. Milani a total of $293.00, $110.00 for the office visit and $183.00 for an X-ray.
  4. The Maximum Allowable Reimbursement (MAR) for the office visit is $74.00 and the MAR for the X-ray is $120.00, for a total of $194.00.
  5. The Petitioner’s request for medical dispute resolution was received by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) on September 6, 2001.
  6. By Order dated October 31, 2001, the MRD ordered Continental to pay $194.00 in reimbursement if the compensable injury extends to or includes the lumbar spine.
  7. By letter received by the Commission on November 20, 2001, the Petitioner filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  8. Notice of the hearing was sent December 12, 2001.
  9. On January 14, 2002, Administrative Law Judge (ALJ) Howard S. Seitzman convened the hearing in the SOAH proceeding.
  10. The Petitioner appeared pro se and Continental Casualty Company (Continental) appeared through its counsel, David L. Swanson.
  11. Continental, in a separate proceeding before the Commission, has challenged whether the compensable injury extends to or includes the lumbar spine.
  12. Following the January 14, 2002 hearing, the SOAH docket was abated pending resolution by the Commission of the extent of injury issue.
  13. During the abatement period, the parties filed status reports.
  14. As of this date, the extent of injury issue remains pending at the Commission.
  15. By Order dated October 17, 2002, the ALJ lifted the abatement and allowed the parties until November 14, 2002, to file legal briefs on the reimbursement issue and to file proposed orders.
  16. The Petitioner filed a brief and proposed order on November 15, 2002.
  17. The record closed on November 15, 2002.

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. Commission Rule 133.305(n) is applicable to this docket and provides that when an insurance carrier raises a dispute on the extent of injury, the MRD shall decide the medical dispute and refer the extent of injury issue to the appropriate authority for adjudication.
  5. The Petitioner has the burden of proof in this matter pursuant to 28 Tex. Admin. Code §148.21(h).
  6. The issue presented in the SOAH docket is whether an individual can obtain reimbursement in excess of the Maximum Allowable Reimbursement (MAR).
  7. _________failed to prove his entitlement to reimbursement in excess of the MAR.
  8. The Petitioner’s request for reimbursement in excess of the MAR should be denied.
  9. The Petitioner’s reimbursement of $194.00, the MAR for an initial office visit and X-ray, is dependent upon the Petitioner’s compensable injury extending to or including the lumbar spine.
  10. The Commission’s June 13, 2001 decision finding the Petitioner’s May 25, 2000 injury was compensable did not decide whether the compensable injury extended to or included the lumbar spine.
  11. The appropriate authority to decide the extent of injury issue is the Commission.

ORDER

IT IS, THEREFORE, ORDERED that the Petitioner’s request for reimbursement of $293.00, an amount is excess of the MAR, is DENIED. IT IS FURTHER ORDERED that Continental Casualty Company is to reimburse the Petitioner the sum of $194.00 within 20 days of a final decision by the Commission if the Commission finds the Petitioner’s compensable injury extends to or includes the lumbar spine.

Signed AT AUSTIN, TEXAS the 20th day of November 2002.

HOWARD S. SEITZMAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. While the Commission’s Compensability Order found the “medical evidence supports the conclusion that Claimant sustained bruising to his left hip and a back strain” the extent of the injury was expressly not decided. (Ex. 1 at Bates Stamped Page 62).
  2. Ex. 1 at Bates Stamped Pages 60-64.
  3. Ex. 1 at Bates Stamped Page 12.
  4. Whether or not the Petitioner has a claim against the treating physician is not an issue in this proceeding.
End of Document
Top