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The insurer must reimburse the health center an additional $ 20,000 for treatment



An insurer for workers' compensation failed to show that an administrative law judge erred in claiming that it bore the burden of proof in a compensation dispute with a health center.

Patients Medical Center v. Facility Insurance Corp. ., The Texas Supreme Court on Friday overturned an appeal decision after ruling that the insurer did not show that a medical provider was not entitled to an additional $ 20,000 in compensation for the treatment. of an injured worker.

In 2009, Patients Medical Center in Pasadena, Texas, requested prior approval from Austin, Texas-based workers and insurers Facility Insurance Corp. to perform operations on a covered worker. The insurer issued a letter of approval and after the operation was performed, the patients invoiced the insurer $ 94,640. was guilty. The insurer also denied the patients' request for reconsideration.

The Drug Center submitted a request to the Texas Division of Workers Compensation for review, claiming that the insurer did not pay the proper compensation for the services it provided. The department ordered the insurer to pay patients an additional $ 20,000 and the Facility appealed the decision to the Texas State Office of Administrative Hearings.

A judge in the administrative court upheld the department's decision, claiming that the insurer 'did not bear its burden of proof. that Patients Medical Center was not entitled ”to further compensation. The insurer appealed again, claiming that the judge in the administrative court erred in placing the burden of proof on the insurer during the hearing, and an appellate court agreed and restored the case.

The Supreme Court of Texas, which agreed to hear the case, overturned the appellant's decision and argued that the administrative judge correctly applied the rules of the Department of Compensation to the burden of proof.

The Court held that, since the insurer had requested the hearing to challenge the department's original decision, it bore the burden of proof and reversed and reinstated the case.

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