GQ Corner
Q. Claimant was taken off of work, post-injury, by a provider who is not in the health care network (HCN) in this claim. Can I dispute disability on that basis?
A. We have recently received several inquiries regarding the eligibility for Temporary Income Benefits (TIBs) when the opinion on an employee’s ability to work comes from a doctor who is not authorized to treat the injured employee, and whether the employee’s choice to see a non-network provider affects the payment of TIBs. It is important to provide a clear understanding of the relevant factors in determining TIBs.
First and foremost, it is essential to recognize that the payment of TIBs is not contingent on the opinion of any specific doctor or whether that doctor is authorized to treat the claimant. TIBs are based solely on the employee’s disability and their journey toward maximum medical improvement. Disability, in this context, refers to the inability to secure and maintain employment at the preinjury wage, irrespective of a doctor’s statements or authorizations. It is even possible for an employee to establish disability without having seen a healthcare provider.
The Texas Supreme Court, in the case of Liberty Mutual v. Adcock, emphasized that temporary benefits (unlike lifetime benefits) are only paid as long as specific conditions, such as medical conditions, continue to exist. These conditions require ongoing assessment to determine if the employee has attained the necessary level of improvement mandated by statute. The court stated that eligibility for TIBs necessitates periodic evaluation due to their continuous nature.
The decision to grant or deny TIBs, therefore, depends on a comprehensive examination of various pertinent factors, including the nature of the compensable injury, co-morbidities, current medical records showcasing improvement, and return-to-work guidelines established by the division. The status or authorization of the doctor providing an opinion does not bear any relevance in this context.
Consequently, if an employee is recognized as disabled while receiving treatment from a network doctor, the only way to absolve the carrier from the obligation to pay TIBs prior to that period is by demonstrating that the employee’s condition worsened contemporaneously with the treatment from the network provider, rendering them newly incapable of securing and retaining employment at the preinjury wage.
In summary, the payment of TIBs is determined solely by the employee’s disability status and their progress towards maximum medical improvement. The opinion of a doctor, regardless of their authorization or network affiliation, does not trigger any obligation or exemption for the carrier to provide benefits. It is crucial to consider all relevant factors and medical evaluations when making decisions about TIBs, focusing on the employee’s ability to work and their level of disability.
FOLIO
