A Houston Court of Appeals has dismissed a case involving workers’ compensation benefits claim disputes with Texas Mutual Insurance Co. in a move that according to the insurer resolves “significant” workers’ comp related issues.
Texas Mutual reported that the case involved two disputes. One dispute focused on the extent of the injury attributable to a compensable claim; the other focused on the necessity of medical treatment requested for the injury. The Court dismissed the case based on the plaintiff’s failure to follow the rules for resolving these disputes.
The Court’s opinion affirms that disputes regarding extent of injury and medical necessity are separate questions requiring specific determinations by the Texas Department of Insurance, Division of Workers’ Compensation, which the Legislature has exclusively entrusted with these decisions. According to the Court, asking a jury to make those decisions instead disrupts the orderly processes of government.
The decision also protects injured workers by requiring careful consideration of surgical requests.
In this case, the doctor for the injured worker first requested authorization for a two-level spinal fusion — a highly invasive procedure. A second reviewing doctor believed that such a radical surgery was not medically necessary. A later request for a more conservative treatment (a single-level fusion) was granted. The surgery was performed a few days later.
“The Court is upholding the strong system of administrative remedies available before the Division of Workers’ Compensation,” Mary Barrow Nichols, general counsel and senior vice president for Texas Mutual, said. “This is an important victory for Texas workers and businesses because it reaffirms the protections they have under state law in the event of on-the-job injuries.”
Source: Texas Mutual Insurance Co.
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