GQ Corner
Q. Is there a Texas workers’ compensation Labor Code, rule, or Appeals Panel decision that states an injured employee has lifetime medical benefits?
A. The concept of lifetime medical is not one specifically indicated in the statute or rules. Instead, that is extrapolated from the statute. If there is a compensable injury, then we know the claimant is entitled to medical benefits.
Texas Labor Code Section 408.021 provides that 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.”
There is no time limit on medical benefits, meaning that as long as the healthcare is reasonably required and related to a compensable injury, then it is possibly payable. Hence, a claimant is theoretically entitled to medical benefits for life.
Q. If claimant is receiving aid, such as welfare, food stamps, or victim fund support, is that counted as PIE?
A. The Appeals Panel has specifically held that unemployment compensation benefits are not PIE. We believe all governmental benefits will be similarly interpreted.
Q. I have injured worker who was grinding parts and felt something go into his eye. The safety employee saw the foreign body in the eye and took him to the doctor. They took out 3 foreign bodies (new) but then there was one foreign body deep in the eye. The claimant was referred to specialist, and the specialist advised that this foreign body looked healed over and asked about prior injury and the claimant stated that 4-5 years ago he had a foreign body in his eye. He had no pain or issues with that old foreign body. It was left alone but the claimant was told that he really should be seen under his personal insurance to get it removed. The claimant told me in a statement that it was an old injury and it was not hurting or causing him any problems. The only problem he has is the new foreign bodies that were removed and he is on eye drops.
I feel like I need to dispute anything to do with the old foreign body. Do you agree? What wording should I use? (On a PLN-11?)
A. You can dispute the old foreign body if you would like to, but I don’t believe that it is necessary unless and until the claimant seeks treatment for it, is taken off of work for it, or tries to claim it as part of the new claim. A PLN-11 disputing extent of injury is not required to be filed unless the carrier is denying a medical bill for extent of injury; if so, the PLN-11 must be filed either prior to or concurrently with the submission of the EOB that denies the bill.
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