Summary
describing procedure for requesting designated doctor
Summary of this case from Univ. of Tex. Sys. v. MenjivarOpinion
No. 04-15-00175-CV
05-11-2016
TEXAS MUTUAL INSURANCE COMPANY, Appellant v. Andrew S. MCGAHEY, Appellee
MEMORANDUM OPINION
From the 131st Judicial District Court, Bexar County, Texas
Trial Court No. 2013-CI-12185
Honorable Richard Garcia, Judge Presiding Opinion by: Karen Angelini, Justice Sitting: Karen Angelini, Justice Marialyn Barnard, Justice Luz Elena D. Chapa, Justice AFFIRMED
In the underlying lawsuit, Texas Mutual Insurance Company sought judicial review of the decision of an appeals panel of the Texas Department of Insurance Division of Workers' Compensation (formerly known as the Texas Worker's Compensation Commission) ("Division"). After considering competing motions for summary judgment, the trial court granted summary judgment in favor of Andrew McGahey. Texas Mutual appeals, asserting the trial court erred in granting the summary judgment because McGahey's eligibility for impairment income benefits terminated on the expiration of 401 weeks after the date of his injury, and McGahey did not seek impairment income benefits until 432 weeks after his workplace injury. We affirm the trial court's judgment.
BACKGROUND
On August 5, 2002, McGahey sustained a work-related injury entitling him to compensation under the Texas Workers' Compensation Act and began receiving temporary income benefits under the Act. On October 25, 2010, the Division sent McGahey notice that the Division had received a request for the assignment of a designated doctor to evaluate the date of McGahey's maximum medical improvement and his impairment rating. Dr. John Debender was the assigned designated doctor.
On November 15, 2010, Dr. Debender examined McGahey and completed a report of medical evaluation, certifying that McGahey reached maximum medical improvement on August 13, 2004, and assigning a 20% impairment rating. Texas Mutual requested an additional examination by a required medical examination doctor who reached the same conclusions as Dr. Debender.
Texas Mutual disputed its obligation to pay McGahey impairment income benefits based on these medical evaluations. Accordingly, a benefits review conference was held on January 31, 2011, to mediate the dispute. Because the parties were unable to reach an agreement, a contested case hearing was held on March 28, 2011, and the hearing officer found McGahey was entitled to receive sixty weeks of impairment income benefits which began on August 14, 2004 and ended on October 7, 2005. The hearing officer ordered Texas Mutual to pay the benefits. Texas Mutual appealed to the appeals panel which affirmed the hearing officer's decision without a written opinion.
Impairment income benefits are "computed at the rate of three weeks for each percentage point of impairment." TEX. LAB. CODE ANN. § 408.121 (West 2015).
Texas Mutual filed a petition in the underlying lawsuit seeking judicial review of the appeals panel's decision. In its petition, Texas Mutual named McGahey and the Division as defendants. Texas Mutual then filed a motion for summary judgment asserting, "The 401-week period of eligibility for benefits terminated by law on April 10, 2010. ... Under the plain meaning of Section 408.083, Mr. McGahey was not eligible for impairment income benefits after April 10, 2010." The Division filed a response to Texas Mutual's motion and a cross-motion for summary judgment. In its response, the Division noted Texas Mutual was contending section 408.083 contained a "type of statute of limitations, barring any action or proceeding related to the award of income benefits after 401 weeks from the date of injury." The Division asserted, however, that Texas Mutual's "reading of the statute is not supported by Texas law" and "is contrary to the Texas Supreme Court's stated policy applicable to interpretation of worker's compensation law." McGahey also filed an opposition to Texas Mutual's motion and a cross-motion for summary judgment incorporating the Division's arguments.
Before the trial court's hearing on the motions for summary judgment, Texas Mutual non-suited its claims against the Division. After a hearing on the motions, the trial court entered an order granting McGahey's motion for summary judgment and denying Texas Mutual's motion. Texas Mutual appeals.
JUDICIAL REVIEW OF APPEALS PANEL'S DECISION
A party may seek judicial review of an appeals panel's decision by filing a petition in district court. TEX. LAB. CODE ANN. § 410.252(a) (West 2015). Judicial review is governed by the substantial evidence rule under the Administrative Procedure Act ("APA"). Id. at § 410.255.
In this case, the issue presented to the trial court was an issue of statutory construction. Even in an appeal subject to the substantial evidence rule under the APA, questions of law, like statutory construction, are reviewed de novo. State v. Pub. Util. Comm'n of Tex., 344 S.W.3d 349, 356 (Tex. 2011); Cadena Commercial USA Corp. v. Tex. Alcoholic Beverage Comm'n, 449 S.W.3d 154, 161 (Tex. App.—Austin 2014, pet. filed); Enter. Leasing Co. of Houston v. Harris Cty. Toll Road Auth., 356 S.W.3d 85, 89 (Tex. App.—Houston [1st Dist.] 2011, no pet.).
SUMMARY JUDGMENT STANDARD OF REVIEW
In conducting its judicial review, the trial court reached its decision based on competing motions for summary judgment. We review a summary judgment de novo. Provident Life & Acc. Ins. Co. v. Knott, 128 S.W.3d 211, 215 (Tex. 2003). In reviewing the granting of a traditional summary judgment, we consider all of the evidence in the light most favorable to the respondent, indulging all reasonable inferences in favor of the respondent, and determine whether the movant proved that there were no genuine issues of material fact and that it was entitled to judgment as a matter of law. Nixon v. Mr. Prop. Mgmt. Co., 690 S.W.2d 546, 548-49 (Tex. 1985). "When both sides move for summary judgment and the trial court grants one motion and denies the other, we review the summary judgment evidence presented by both sides and determine all questions presented." Mann Frankfort Stein & Lipp Advisors, Inc. v. Fielding, 289 S.W.3d 844, 848 (Tex. 2009). In such a case, "we render the judgment [that] the trial court should have rendered." Id.
INCOME BENEFITS
The Texas Workers' Compensation Act authorizes four levels of income benefits for injured workers: (1) temporary income benefits; (2) impairment income benefits; (3) supplemental income benefits; and (4) lifetime benefits. Ins. Co. of State of Pa. v. Muro, 347 S.W.3d 268, 271 (Tex. 2011). For employees whose injuries result in a disability that continues longer than one week, "weekly income benefits begin to accrue on the eighth day after the date of the injury." TEX. LAB. CODE ANN. § 408.082(b).
The first level of income benefits, temporary income benefits, begins to accrue on the eighth day after the date of injury and continues "until the employee reaches maximum medical improvement." Id . at § 408.102(a). "Maximum medical improvement" is defined as the earlier of:
(A) the earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer be reasonably anticipated;Id. at § 401.011(30).
(B) the expiration of 104 weeks from the date on which income benefits begin to accrue; or
(C) the date determined as provided by Section 408.104 [for spinal surgery].
McGahey did not have spinal surgery, so subsection (C) is not applicable to him.
With regard to the second level of income benefits, "[a]n employee's entitlement to impairment income benefits begins on the day after the date the employee reaches maximum medical improvement and ends on the earlier of:
(1) the date of expiration of a period computed at the rate of three weeks for each percentage point of impairment; orId . at § 408.121(a). "The insurance carrier shall begin to pay impairment income benefits not later than the fifth day after the date on which the insurance carrier receives the doctor's report certifying maximum medical improvement." Id. at §408.121(b).
(2) the date of the employee's death."
On the expiration of the impairment income benefit period, an employee may be entitled to receive a third level of income benefits called supplemental income benefits if the employee meets certain criteria. Id. at § 408.142. McGahey did not claim to be entitled to the receipt of supplemental income benefits, so those criteria need not be further examined. McGahey also did not claim to be entitled to receive lifetime income benefits.
CERTIFICATION OF MAXIMUM MEDICAL IMPROVEMENT
As previously noted, an employee's entitlement to impairment income benefits begins on the day after the date the employee reaches maximum medical improvement. Id. at § 408.121(a). Section 408.123 of the Act describes the procedure a doctor must following in certifying that an employee has reached maximum medical improvement and in assigning an impairment rating. Id. at § 408.123. "If an employee is not certified as having reached maximum medical improvement before the expiration of 102 weeks after the date income benefits begin to accrue, the [D]ivision shall notify the treating doctor of the requirements" for certifying maximum medical improvement. Id. at § 408.123(d).
The certification is contained in a form called a report of medical evaluation. See 28 TEX. ADMIN. CODE § 130.1(d) (West 2016). --------
For injuries that do not involve spinal surgery, statutory maximum medical improvement is reached at the end of the 104th week after the date temporary income benefits began to accrue. 28 TEX. ADMIN. CODE § 130.4(a) (West 2016). If a doctor has not certified maximum medical improvement, an insurance carrier may, at any time before statutory maximum medical improvement is reached, use the procedure outlined in section 130.4 of title 28 of the Texas Administrative Code to resolve whether an employee has reached maximum medical improvement. Id. at § 130.4(b). Under this procedure, the carrier first requests the treating doctor to provide a report on the employee's medical status as it relates to maximum medical improvement. Id. at § 130.4(c). The treating doctor then has fourteen days after receiving the request to evaluate the employee's condition and must file a report within seven working days after the date of the examination. Id. at § 130.4(d). If the treating doctor fails to respond, the carrier may request a designated doctor. Id. at § 130.4(e).
If a carrier has not received a report of a medical evaluation with respect to maximum medical improvement by the date of statutory maximum medical improvement, the carrier may:
(1) suspend temporary income benefits and is not required to initiate impairment income benefits until such time as it receives a report of an impairment rating;Id. at § 130.2(e).
(2) request the appointment of a designated doctor to conduct the evaluation; and/or
(3) make a reasonable assessment of what it believes the true impairment rating should be and, if it does so, initiate impairment income benefits within five days of making the assessment.
SECTION 408.083(a)
Section 408.083(a) of the Act provides, in relevant part, "an employee's eligibility for temporary income benefits, impairment income benefits, and supplemental income benefits terminates on the expiration of 401 weeks after the date of injury." TEX. LAB. CODE ANN. § 408.083(a). Texas Mutual interprets the statute to mean that an employee cannot recover impairment income benefits after the expiration of the 401 weeks. In this case, Texas Mutual asserts McGahey cannot recover any impairment income benefits because "he did not receive a doctor's opinion that would entitle him to IIBs [impairment income benefits] until 432 weeks after his injury."
In interpreting a statute, "our primary objective is to ascertain and give effect to the Legislature's intent without unduly restricting or expanding the [statute's] scope." Greater Houston P'ship v. Paxton, 468 S.W.3d 51, 58 (Tex. 2015). We first seek that intent "in the plain meaning of the text." Id. Generally, undefined terms in a statute are given their ordinary meaning, "but if a different or more precise definition is apparent from the term's use in the context of the statute, we apply that meaning." Id. (internal citations omitted). An undefined term will not, however, be given "a meaning that is out of harmony or inconsistent with other terms in the statute." Id. "Therefore, even if an undefined term has multiple meanings, we recognize and apply only the meanings that are consistent with the statutory scheme as a whole." Id. Finally, in construing the Act, we are mindful that we liberally construe the Act in favor of the injured employees. SeaBright Ins. Co. v. Lopez, 465 S.W.3d 637, 642 (Tex. 2015).
Texas Mutual focuses on the word "eligibility" in section 408.083(a) and contends an employee cannot receive impairment income benefits after the expiration of 401 weeks from the date of his injury because the statute provides the employee is not "eligible" to receive benefits after that date. We disagree with this construction. Instead, we construe section 408.083(a) as limiting the maximum number of weeks of temporary income benefits, impairment income benefits, and supplemental income benefits an employee can receive to 401 weeks. See Ins. Co. of State of Pa., 347 S.W.3d at 271 ("A claimant's combined eligibility for temporary income benefits, impairment income benefits, and supplemental income benefits generally terminates 401 weeks after the date of injury."). This construction is consistent with the need to liberally construe the Act in favor of injured employees, the statutory requirement that the Division notify the treating doctor if the employee is not certified as having reached maximum medical improvement before the expiration of 102 weeks after the date income benefits begin to accrue, and the administrative rules adopted by the Division. See SeaBright Ins. Co., 465 S.W.3d at 642; TEX. LAB. CODE ANN. § 408.123(d); 28 TEX. ADMIN CODE §§ 130.2(e), 130.4(b).
The Act and the rules speak to the circumstances that arose in this case where a doctor failed to certify the date on which McGahey reached maximum medical improvement and assign an impairment rating. First, the Division is statutorily required to notify the treating doctor of the absence of such a certification before the expiration of 102 weeks. TEX. LAB. CODE ANN. § 408.123(d). The Legislature's decision to impose this duty on the Division prior to the expiration of 102 weeks is because, as previously noted, statutory maximum medical improvement is reached at the end of the 104th week after the date temporary income benefits began to accrue. 28 TEX. ADMIN CODE § 130.4(a)(1). Rather than deprive the injured employee of his receipt of impairment income benefits, the Legislature imposed this duty on the Division in an effort to ensure a doctor certifies the date an employee has reached maximum medical improvement prior to the date the employee would reach statutory maximum medical improvement.
Furthermore, the Division provides insurance carriers with a procedure to determine if an injured employee has reached maximum medical improvement at any time before the date of statutory maximum medical improvement. 28 TEX. ADMIN CODE § 130.4(b). Under this procedure, at any time before McGahey reached statutory maximum medical improvement, Texas Mutual could have requested that the treating doctor provide the necessary certification. Id. at § 130.4(c). And, if the treating doctor failed to provide the certification within twenty-one days, Texas Mutual could have requested the appointment of a designated doctor to perform the evaluation. Id. at 130.4(e). In this case, the record establishes the appointment of a designated doctor was not requested until October of 2010, but the record does not establish why Texas Mutual did not request such an appointment on an earlier date.
Finally, the Division has adopted rules that specifically govern the carrier's rights if the carrier has not received a report of medical evaluation by the date of statutory maximum medical improvement. See id. at § 130.2(e). As previously noted, if the carrier has not received the report of medical evaluation by that date, the carrier is not required to initiate impairment income benefits until its receipt of the report, the carrier may request the appointment of a designated doctor, and/or the carrier may make a reasonable assessment of the injured employee's impairment rating and initiate impairment income benefits based on that assessment. Id. The rule does not, however, permit the carrier to refuse to pay the impairment income benefits that the injured employee accrued once the carrier receives the report of medical evaluation certifying the injured employee's date of maximum medical improvement and assigning the impairment rating. See id.
The only case cited by Texas Mutual in support of its position is readily distinguishable. See Cruz v. Houston Gen. Ins. Co., 01-07-00225-CV, 2008 WL 5263360 (Tex. App.—Houston [1st Dist.] Dec. 18, 2008, no pet.). In Cruz, a dispute arose over a carrier's refusal to pay supplemental income benefits. 2008 WL 5263360, at *1. On judicial review, the trial court granted summary judgment in favor of the carrier, and the injured employee appealed to the Houston court. Id. One of the issues raised on appeal was that the carrier was not relieved from liability for supplemental income benefits because the injured employee failed to submit a timely application. Id. Section 408.143 of the Act, however, requires an employee to submit a quarterly statement to the carrier in order to receive supplemental income benefits, and further provides, "Failure to file a statement under this section relieves the insurance carrier of liability for supplemental income benefits for the period during which a statement is not filed." See TEX. LAB. CODE ANN. § 408.143. The Houston court did not cite section 408.143; however, the Houston court did cite a rule adopted by the Division that similarly provided, "An injured employee who does not timely file an Application for Supplemental Income Benefits with the insurance carrier shall not receive supplemental income benefits for the period of time between the beginning date of the quarter and the date on which the form was received by the insurance carrier" unless certain exceptions apply. Cruz, 2008 WL 5263360, at *4 (quoting 28 TEX. ADMIN CODE § 130.105). Although the Houston court also cited section 408.083, it appears this section was cited only in reference to the maximum time period during which supplemental income benefits could accrue. Because the Cruz decision addressed supplemental income benefits for which an injured employee is statutorily required to submit a quarterly statement in order to qualify to receive those benefits, Cruz is readily distinguishable. Section 408.142 and Division rule 130.105 do, however, show that if the Legislature or the Division intends to deprive an injured employee of income benefits based on the injured employee's failure to act, the Legislature and the Division know how to expressly provide for such a deprivation.
CONCLUSION
Reading section 408.083(a) in the context of the entire statutory scheme and the rules adopted by the Division, we hold the term "eligibility" is intended to limit the maximum number of weeks for which an employee can be paid temporary income benefits, impairment income benefits, and supplemental income benefits to 401 weeks. See Greater Houston P'ship, 468 S.W.3d at 58 (noting courts are to recognize and apply meaning to undefined terms "that are consistent with the statutory scheme as a whole"); Ins. Co. of State of Pa., 347 S.W.3d at 271 (noting an injured employees "combined eligibility for temporary income benefits, impairment income benefits, and supplemental income benefits generally terminates 401 weeks after the date of injury"). Therefore, we agree with the hearing officer's finding that McGahey is "entitled to sixty weeks of impairment income benefits based on a 20% impairment rating which began on 8/14/04 and ended on 10/7/05" and affirm the trial court's judgment.
Karen Angelini, Justice