GQ Corner

Q. I have a claimant that fell while going down some steps and landed on her left side, breaking her eye glasses. She had to get the glasses repaired because she cannot see without them. Are we obligated to reimburse her for the repairs?

A. No. Under Section 406.031, a carrier is only “liable for compensation for an employee’s injury.” “Injury” is damage or harm to the physical structure of the body. The term “physical structure of the body” means “the whole, to the complex of perfectly integrated and interdependent bones, tissues and organs which function together by means of electrical, chemical and mechanical processes in a living, breathing, functioning individual. … [T]he structure should be considered that of a living being – not as a static, inanimate thing.” Bailey v. American General Ins. Co., 279 S.W.2d 315 (Tex. 1955). Eyeglasses are not part of the physical structure of the body and I am assuming by your question that a new prescription was not necessary to treat any injury to the eyes resulting from the accident. If that were the case, the answer may be different.

Q. I have a claimant who suffered an allergic reaction to strawberry filling in a chocolate cake. The cake was purchased by another employee for a co-worker’s birthday. This event was not, in any way, sponsored by the employer. The claimant was taken by ambulance to the ER. 1 day lost time. Please confirm whether this claim would be compensable under the comfort doctrine.

A. The test is whether the injury would not have occurred “but for” the conditions and obligations of employment. These cases are very fact specific and the results can change depending on the slightest change in the facts. What I believe helps your case is that this is not necessarily where the injured worker has to eat lunch during the work day. There is no work requirement to celebrate a co-employee’s birthday. Based on that, I believe you would have a reasonable basis to dispute.

Q. We have a general question regarding pre-payment on an injection that is being requested by a provider. We received a request for a platelet-rich plasma injection from a treating provider. The request is currently in utilization review, however, if it is approved, the provider has requested a pre-payment of $600 prior to scheduling. They indicated that this is for the injection kit they have to order. When I asked them if this was in fee schedule, they said no. My question is, then, are we obligated to pay the pre-payment? My concern is that they are billing above fee schedule and did not submit the pre-payment request on a HCFA 1500.

A. You are never obligated to pre-pay for medical treatment. To state it another way, the liability and process for paying for medical treatment is outlined in the rules and statute and no provision provides that you have to prepay. No obligation can be placed on a carrier that is not based in the statute.