Claimant suffered injury, entitled to Temporary Income Benefits; MO-18287315-01
Feb 15, 2019
OUTCOME: Claimant suffered a compensable injury and entitled to Temporary Income Benefits
Carrier denied claim as three witnesses stated Claimant was "loafing," all day and they never saw him do any work. Carrier took several recorded statements, and had safety personnel appear to testify.... Claimant was able to successfully demonstrate the inconsistencies in recorded statements, written statements, and live testimony clearly contradicted one another and made all evidence irrelevant at trial. Claimant further was able to argue his medical records consistently demonstrated he suffered a back injury and not a kidney infection as Carrier argued. As a result, Claimant prevailed on issues of compensability and eight months of back-due benefits to be paid immediately.
Workers compensation
Claimant shows Carrier dispute of extent, MMI, and IR; Claimant awarded SIBs-15100533-01
May 18, 2018
OUTCOME: Claimant retained his extent of injury, MMI date, IR, Carrier waived all disputes, and Claimant entitled to Supplemental Income Benefits
Claimant was in his second quarter of Supplemental Income Benefits; carrier had paid the first. Carrier sought to dispute the Claimant's Maximum Medical Improvement date, Impairment Rating, Extent of ...Injury and entitlement to Supplemental Income Benefits. Parties proceeded to a Benefit Review Conference in which Claimant's Attorney added issues of waiver based on payment of first quarter of Supplemental Income Benefits as well as the 90-day provision, and waiver of the right to dispute the extent of injury as a matter of law. At trial it was found the Carrier had never disputed the Impairment Rating or the date of Maximum Medical Improvement until the date of the Benefit Review Conference, despite the existence of the same for over a year. Likewise, it was found the Impairment Rating was provided based on diagnoses which far exceeded the diagnoses which were being accepted by the Insurance Carrier at the Contested Case Hearing. Moreover, Claimant's Attorney was able to demonstrate the Carrier accepted and paid the first quarter of Supplemental Income Benefits without having ever disputed the Maximum Medical Improvement and/or Impairment Rating. As such, Administrative Law Judge determined; 1) compensable injury extended to and included a herniated nucleus pulposus of the cervical spine as well as cervical radiculopathy/radiculitis, 2) the Claimant's MMI and IR were correct, 3) Carrier waived their right to dispute MMI and IR as they did not dispute prior to the 90-day time frame, 4) Carrier waived their right to dispute MMI and IR as they did not dispute the same prior to the expiration of the first quarter of Supplemental Income Benefits, 5) Carrier waived their right to dispute the extent of injury as the Impairment Rating had become final and rated those diagnoses, and 6) Claimant was entitled to Supplemental Income Benefits for all disputed quarters.
Workers compensation
Death Benefits payable to spouse and grandson; 17274083-01
Jan 03, 2018
OUTCOME: Grandson entitled to Death Benefits as a dependent and wife of Decedent entitled to Death Benefits as spouse.
Carrier argued spouse of decedent had abandoned her husband and therefore was not entitled to Death Benefits. Decedent fell from the roof of a gymnasium and suffered injuries directly leading to death.... Decedent also had a dependent grandson who lived with him at the time of his death. Beneficiaries were both represented by attorney. Attorney successfully demonstrated decedent provided for the health and welfare of the grandson; and, more importantly, the father of the grandson was not providing any ongoing support of his son. Moreover, through written statements, documentary evidence and testimony of relatives, Attorney demonstrated spouse of the decedent had not voluntarily abandoned decedent for more than one year prior to his death.
Workers compensation
TDI-DWC Docket No. 13-126938-01
Oct 03, 2013
OUTCOME: Beneficiary is entitled to the Death Benefits
Security Guard for Dallas apartment complex was killed while on duty. Deceased worker had no children or siblings as beneficiary, leaving only a mother entitled to Death Benefits for two years. Carri...er recieved notice of the claim and did not dispute the same timely, instead filing a notice saying there were no known beneficiaries. Mother filed claim for death benefits which Carrier began paying. Carrier then obtain autopsy which had been completed several months prior. Based upon the autopsy drug test and a peer review report, Carrier then denied Death Benefit payment to mother.
Claimant hired Mr. Rodriguez who pursued the matter to Contested Case Hearing on the theory the deceased employee was not intoxicated at the time and the Carrier had waived their abilty to dispute the Death Benefits as they had not filed a Plain Language Notice disputing the claim within 60 days of having received notice of the death.
Hearing Officer found, Claimant (who had died as a result of a gunshot wound to the back of the head) sustained a compensable injury. The Carrier recieved notice of the injury on October 16, 2012 and notice of the death benefits claim on January 5, 2013. Carrier did not dispute the compensability until March 21, 2013 when they did so claiming there was newly discovered evidence (autopsy report).
Despite the autopsy report, Mr. Rodriguez was able to demonstrate, through use of letters from family members who took deceased employee to work on the date of the accident, the deceased employee did possess the normal use of his faculties at the time of the injury (deceased employee worked alone and there were no other witnesses); therefore he was not in a state of intoxication. Moreover, Attorney demonstrated, the Carrier did not contest compensability in a timely manner as the Insurance Carrier could have discovered the evidence at an earlier date.
OUTCOME: Hearing Officer found the compensable injury was not a cause of the death; however, the Carrier had waived their right to dispute the Death benefits and thusly the spouse and the decedent's dependent child were entitled to Death benefits.
Injured Employee died one year post injury, spouse filed claim for Death benefits. Carrier failed to file a denial of the Death benefits claim within 60-days, although they had denied the injury previ...ously. At the time of the death there was no issue regarding compensability of the original injury. Insurance Carrier argued they were not required to dispute the Death benefits claim as they had originally denied the compensable injury a year previous. Additionally, Carrier argued the spouse could not demonstrate the compensable injury was a cause of the injured employee's death. Claimant argued, the Texas Labor Code and Texas Administrative Code has separate and distinct requirements for disputing a Death benefits claim and as the Carrier did not dispute the Death benefits claim in a timely manner, they had waived their right to do so. Oddly, this seems to have been a case of first impression.
