Tex. Dep't of Ins.—Division of Workers' Comp. v. Mensch
| Decision Date | 14 January 2015 |
| Docket Number | No. 04–14–00449–CV,04–14–00449–CV |
| Citation | 457 S.W.3d 163 |
| Parties | Texas Department of Insurance—Division of Workers' Compensation, Appellant v. Ronald Mensch, Appellee |
| Court | Texas Court of Appeals |
Dennis M. McKinney, Austin, TX, for Appellant.
Mark Anthony Cevallos, Odessa, TX, for Appellee.
Sitting: Sandee Bryan Marion, Chief Justice, Karen Angelini, Justice, Luz Elena D. Chapa, Justice
The Texas Department of Insurance, Division of Workers' Compensation (“the Division”) appeals from the trial court's denial of its plea to the jurisdiction in which it alleged the trial court lacked jurisdiction over the lawsuit filed by Ronald Mensch because Mensch failed to exhaust his administrative remedies. We reverse and render a dismissal in favor of the Division.
Mensch was injured on June 9, 1980, in a work-related accident when a tire rim struck him in the face. State Farm Insurance, the workers' compensation insurance carrier, paid for medical expenses related to Mensch's teeth until 2008, at which time State Farm refused to pay any additional medical benefits for his teeth. Mensch filed suit, State Farm filed a plea to the jurisdiction, and the lawsuit was abated for a pre-hearing conference before the Division. On October 19, 2011, the Division rendered a final judgment that Mensch's injury was in the course and scope of his employment and he was entitled to lifetime medical benefits for those injuries. Mensch's lawsuit against State Farm was then reinstated.
Thereafter, Mensch approached State Farm for pre-approval of additional dental work costing in the range of $50,000 to $75,000. State Farm denied the request for pre-approval on the grounds that, under governing law, those medical services had to first be rendered to the employee before being presented to the carrier. A second pre-hearing conference before the Division was held on February 11, 2014, at which Mensch requested preauthorization for additional dental work and he presented an affidavit from his doctor stating he needed another dental procedure to treat his compensable injury. On May 7, 2014, the Division sent a letter to Mensch's attorney stating the initial award issued on October 19, 2011 had become final; therefore, the Division's authority to act on further medical benefits was limited to the procedures set forth in Article 8307, section 5, of the Texas Civil Statutes in effect at the time of his injury. The Division further stated that its continuing jurisdiction to render successive awards was limited to costs or expenses of items actually furnished to and received by Mensch; therefore, the Division had “no authority to preauthorize the dental procedure.” The letter ended by stating “[u]ntil incurred and itemized bills are presented to the carrier, the [Division] has no jurisdiction to act on the carrier's liability to furnish medical benefits, and the [Division would] take no further action on the claim.” Mensch then amended his lawsuit to add the Division seeking a declaration that the Division has jurisdiction to determine whether he is entitled to the additional dental work and that he had exhausted his administrative remedies and was entitled to seek medical benefits from State Farm.
The Division and State Farm each filed pleas to the jurisdiction, which were both denied. State Farm filed a petition for writ of mandamus, which is pending before this court in appellate cause number 14–14–00519–CV. The Division filed this underlying interlocutory accelerated appeal. On appeal, the Division argues the “old” workers' compensation law requires Mensch to first receive medical treatment and pay for that treatment before he can present his claim to the Division for adjudication. The Division asserts that because Mensch has not yet received and paid for his medical care, the Division has no authority to “adjudicate” or “pre-approve” his claim and, thus, the trial court lacks jurisdiction to consider Mensch's complaint against the Division.
There is no dispute that Mensch's claim is governed by the Workers' Compensation Act in effect at the time of his injury in 1980—Article 8306, section 7, and Article 8307, section 5. See Act of Mar. 28, 1917, 35th Leg., R.S., ch. 103, 1917 Tex. Gen. Laws 269, 269 (repealed 1989) (current version of Texas Workers' Compensation Act at Tex. Labor Code Ann. ch. 408 (West 2006 & Supp.2014)); see also City of Houston v. Rhule, 417 S.W.3d 440, 442 (Tex.2013) ().1
On appeal, the Division relies on section 5 of Article 8307, which, in pertinent part, provided as follows: “Notwithstanding any other provision of this law ... no award of the Board, and no judgment of the court ... shall include in such Award or Judgment any cost or expense of any such items not actually furnished to and received by the employee prior to the date of said award or judgment. ” Tex. Rev. C iv. Stat. Ann. . art. 8307, § 5 (emphasis added). The Division argues that under section 5, the additional dental work has not yet been furnished to and received by Mensch; therefore, Mensch cannot present his claim to the Division for adjudication, nor can he seek a judgment in court. The Division argues Mensch must first receive and pay for the additional dental work, and then exhaust his administrative remedies by submitting the claim to the Division for a determination of whether the treatment is related to his compensable injury and whether the cost of the treatment is reasonable and necessary. The Division concludes that because Mensch did not exhaust his administrative remedies, the trial court lacks jurisdiction over his claims.
Mensch, on the other hand, relies on section 7 of Article 8306, which, in pertinent part, provided as follows: “The employee shall have the sole right to select or choose the persons or facilities to furnish medical aid, chiropractic services, hospital services, and nursing and the association shall be obligated for same or, alternatively, at the employee's option, the association shall furnishsuch medical aid, hospital services, nursing, chiropractic services, and medicines as may reasonably be required at the time of the injury and at any time thereafter to cure and relieve from the effects naturally resulting from the injury .” Tex. Rev. Civ. Stat. Ann. . art. 8306, § 7, repealed by Acts 1989, 71st Leg., 2nd C.S., ch. 1, § 16.01(7) to (9), eff. Jan. 1, 1991 (West Supp.1994). Mensch argues section 7 (1) provides him with medical services for life, (2) requires State Farm to “furnish” his medical care, (3) does not require him to bear the cost of his treatment and then seek reimbursement, and (4) at most, State Farm could only contend the charges were not reasonable and necessary.2
To resolve the issue on appeal, we turn to the interplay between Article 8306, section 7, and Article 8307, section 5.3 Before 1957, Article 8306, section 7, provided, generally, that the insurer should furnish reasonable medical and hospital services for an injured worker during the first four weeks following injury and, on proper weekly certificates, should furnish additional medical services for a total period not exceeding ninety-one days and additional hospital services for a total period not exceeding 180 days. See Tex. Cas. Ins. Co. v. Beasley, 391 S.W.2d 33, 39 (Tex.1965) (op. on reh'g). In 1957, section 7 was amended to remove the time limitation on the insurer's liability for medical and hospital services and the need for weekly certificates. Id. The Act of 1957 also added a new paragraph to Article 8307, section 5, which stated:
Notwithstanding any other provision of this law, as amended, no award of the Board, and no judgment of the court, having jurisdiction of a claim against the association for the cost or expense of items of medical aid, hospital services, nursing, chiropractic services, medicines or prosthetic appliances furnished to an employee under circumstances creating a liability therefor on the part of the association under the provisions of the law, shall include in such Award or Judgment any cost or expense of any such items not actually furnished to and received by the employee prior to the date of said award or judgment. The first such final Award or Judgment rendered on such claim shall be res judicata of the liability of the association for all such cost or expense which could have been claimed up to the date of said award or judgment and of the issue that the injury of said employee is subject to the provisions of this law with respect to such items, but shall not be res judicata of the obligation of the association to furnish or pay for any such items after the date of said Award or Judgment. After the first such final award or judgment, the Board shall have continuing jurisdiction in the same case to render successive awards to determine the liability of the association for the cost or expense of any such items actually furnished to and received by said employee not more than six (6) months prior to the date of each such successive award, until the association shall have fully discharged its obligation under this law to furnish all such medical aid, hospital services, nursing, chiropractic services, medicines or prosthetic appliances to which said employee may be entitled; provided, each such successive award of the Board shall be subject to a suit to set aside said award by a court of competent jurisdiction in the same manner as provided in the case of other awards under this law.
Tex. Rev. Civ. Stat. Ann. . art. 8307, § 5.
“[T]hese 1957 amendments require the insurer to furnish all medical services as may reasonably be required to cure and relieve the employee from the effects naturally resulting from his injury, but ... Section 5, Art. 8307, prohibits the rendition of an award of judgment for future medical expenses in a workmen's compensation case.” Employers...
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...by the Workers' Compensation Act in effect at the time of his injury.”); see also Tex. Dep't of Ins.-Div. of Workers' Comp. v. Mensch, 457 S.W.3d 163, 164 (Tex.App.–San Antonio 2015, pet. denied) (workers' compensation act in effect at time of 1980 injury governed benefits claim). We must d......