We recently attended a Benefit Contested Case Hearing regarding extent of injury, maximum medical improvement (MMI) and impairment rating (IR). These are the most common issues to be disputed over the last few years.

So, what makes this particular claim different. First of all, it was against the largest workers’ compensation insurance carrier in Texas. They were disputing some of the diagnosis in our client’s right arm.

This large network doesn’t work well in that it greatly restricts the doctors in their network. Most of the doctors are unwilling/able to provide letters of causation (which are required to establish extent of injury disputes). When we talk to them, they tell us that if they support the injured worker, they will be removed from the network.

The only option that we have in a lot of these cases is to send the injured worker to a designated doctor. That is what we did in this case.

Our client was sent to Ed Smith, MD. He is one of the doctors that frequently testifies as an expert for this exact insurance company. We were expecting the worst.

To our surprise, Dr. Smith found that our client was not at maximum medical improvement, not ready for an impairment rating and had multiple other conditions related to the compensable injury that required treatment.

Since he was one of their own doctors, we expected the insurance company to accept those findings. Much to our surprise, they requested a required medical exam with another insurance company doctor.

Surprise, this doctor agreed with all the findings of Dr. Smith. The insurance company also requested a peer review from a third doctor, who agreed with the first two doctors.

So now surely the insurance company would agree to the medical findings. NOT SO. They found a doctor who would testify in the hearing that in his medical opinion, none of the conditions were related to the accident.

In the hearing, evidence was presented that the worker was able to work a physically demanding full time job up until the accident. After the accident, he was unable to perform essential functions of his job. There was no other event discussed that would have caused physical limitations.

The testifying doctor had not examined the injured worker. I asked the doctor what other possible event could have caused these conditions. He answered that he didn’t know. He gave no other explanation other than it was not related to the compensable injury. All this in spite of every medical provider who had examined the injured worker agreeing that the conditions were related.

After all this, the judge wasn’t buying the carrier’s argument. He found that all the conditions were related to the event, and ruled in the injured worker on all issues.

The moral of this story is that even if you have a provider finding that a condition is related, don’t believe that it will be accepted by the insurance carrier.