GQ Corner
Q) The claimant sought and received non-emergency treatment out of network despite the fact that his is a network claim. However, it appears the claim employer failed to provide the claimant with documentation notifying him of network applicability. Under these circumstances, must I pay the medical bills from the out of network provider?
A) Yes. Texas Insurance Code Section 1305.005 requires an employer to provide an employee with documentation notifying him or her of network applicability not later than the third day after the date on which the employee was hired. If this did not occur and the claimant did not receive notice of network applicability either before or after the claim injury, he will not be deemed subject to the network and you will be deemed liable for medical treatment as if there was no network.
Q) The claimant was recently placed at MMI with a 5% impairment rating and wants to know whether he can be paid (1) monthly, as opposed to weekly, or (2) simply accept the impairment income benefits in a lump sum. Can he do so?
A) The parties may agree to the monthly payment schedule. See Rule 130.11. Similarly, an employee may elect to “commute” (or collect impairment income benefits in a lump sum fashion) if the employee has returned to work for at least three months, earning at least 80% of his average weekly wage. See Rule 147.10.
Q) The claimant recently saw a designated doctor for evaluation of MMI and impairment rating. The designated doctor “back-dated” MMI to a date several months prior to the examination. This in effect created an overpayment of temporary income benefits, which were being issued on an ongoing basis for several months after the MMI date certified by the designated doctor. May I take a credit for these benefits against the impairment income benefits that are due based on the impairment rating assigned by the designated doctor?
A) Under these circumstances, you may re-designate the overpayment of temporary income benefits as impairment income benefits, thereby taking a credit of the former against the latter.
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