Tex. Dep’t of Ins. v. Ins. Council of Tex.

2008 Tex. App. LEXIS 2024 (Tex. App. Austin Mar. 21, 2008)

On behalf of Texas Property and Casualty Insurance Guaranty Association, we helped obtain a declaratory judgment invalidating rule 133.309 of the Texas Department of Insurance, Division of Workers’ Compensation, which was intended to create a less expensive alternative review procedure for low-dollar medical necessity disputes. The rule was challenged on the grounds it made the case review doctor’s determination the final decision of the Division, and thereby denied the parties the right to an administrative hearing or judicial review of an administrative decision and because it provided that the employee is never liable for the case review fee. The Austin Court of Appeals concluded that the rule is invalid because it is inconsistent with the Division’s enabling legislation for medical disputes which provide for judicial review of medical necessity disputes.