All Things Texas Workers' Compensation

Facebook Linkedin

Title: 

453-02-3673-m5

Date: 

April 1, 2003

Type: 

Retrospective Medical Necessity

453-02-3673-m5

DECISION AND ORDER

I. PROCEDURAL HISTORY

The Insurance Company of the State of Pennsylvania (Petitioner) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission ordering reimbursement to Suhail Al-Sahli, D.C. (Provider) in the amount of $9,478 for a work hardening program.

The Administrative Law Judge convened a hearing on March 18, 2003. The Petitioner was represented by Steven M. Tipton, attorney. The Provider appeared pro se. At the conclusion of the hearing, the record was closed.

II. EVIDENCE AND BASIS FOR DECISION

The documentary record in this case consisted of the 266-page certified record of the MRD proceeding (Exh. 1); a 14-page table of disputed services (Exh. 2); a 40-page packet of amended explanations of review (Exh. 3); and the final judgment in Cause No. 2001-33774, Insurance Company of the State of Pennsylvania vs. Stacy Mills, from the District Court of Harris County, 61st Judicial District.

The issue presented is whether the Petitioner is relieved of any responsibility to reimburse the Provider by the judgment in the District Court case. The Petitioner brought suit against the Claimant to determine whether she was entitled to designate the Provider as her treating doctor. A jury answered “No” to the question. The Court found that Claimant was not entitled to change her treating doctor to the Provider, and ordered that Claimant was not entitled to any medical benefits associated with the care and treatment rendered by the Provider.

Based on the evidence, the ALJ concludes that the Petitioner’s appeal should be granted. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law.

III. FINDINGS OF FACT

  1. On_______, the Claimant suffered a compensable injury to her neck and shoulder during severe turbulence while working as a ________.
  2. The Claimant’s injury is covered by worker’s compensation insurance written for the Claimant’s employer by the Insurance Company of the State of Pennsylvania (Petitioner).
  3. The Claimant’s request to the Texas Worker’s Compensation Commission to change treating doctors to Suhail Al-Sahli, D.C. (Provider) was approved.
  4. The Petitioner contested the change of treating doctors to the Provider.
  5. The Provider treated the Claimant’s injury with a work hardening program from November 20, 2000, through July 24, 2001.
  6. The Petitioner brought suit against the Claimant to determine whether the Claimant was entitled to change her treating doctor to the Provider.
  7. A jury in Cause No. 2001-33774, Insurance Company of the State of Pennsylvania vs. Stacy Mills, in the District Court of Harris County, Texas, 61st Judicial District, answered that the Claimant was not entitled to change her treating doctor.
  8. The Court ordered in the Final Judgment issued on December 30, 2002, in the case referred to in Finding of Fact No. 7, which the Claimant was not entitled to any medical benefits rendered by the Provider.
  9. The Petitioner timely requested dispute resolution by the Medical Review Division of the Texas Workers’ Compensation Commission (Commission).
  10. On June 12, 2002, the Commission’s Medical Review Division issued its Findings and Decision agreeing with the Provider, and the Petitioner timely appealed.
  11. The Commission sent notice of the hearing to the parties on July 25, 2002. The hearing notice informed the parties of the matter to be determined, the right to appear and be represented by counsel, the time and place of the hearing, and the statutes and rules involved.
  12. The hearing was held on March 18, 2003, and all parties appeared and participated.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (TWCC) has jurisdiction to decide the issues presented pursuant to Tex. Lab. Code Ann. § 413.031.
  2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a Decision and Order, pursuant to Tex. Lab. Code Ann. § 413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov’t Code §2001.052 in that it 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 section of the statutes and rules involved; and a short plain statement of the matters asserted.
  4. The Petitioner has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Lab. Code Ann. § 413.031.
  5. Based on Findings of Fact Nos. 6 – 8 and Conclusion of Law No. 4, the Petitioner is not required to reimburse Provider.

ORDER

IT IS, THEREFORE, ORDERED that the Insurance Company of the State of Pennsylvania shall not be required to reimburse Suhail Al-Sahli, D.C., for the amount claimed.

Issued this 1st day of April 2003.

MICHAEL J. BORKLAND
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS