STATE OFFICE OF RISK MANAGEMENT v. MARY LAWTON (Majority)

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State: Texas

Court: Supreme Court

Docket No: 08-0363

Case Date: 08/28/2009

Judge: Wallace B. Jefferson

Plaintiff: STATE OFFICE OF RISK MANAGEMENT

Defendant: MARY LAWTON (Majority)

Preview:STATE OFFICE OF RISK MANAGEMENT v. MARY
LAWTON (Majority)
IN THE SUPREME COURT OF TEXAS
No. 08-0363
State Office of Risk Management, Petitioner,
v.
Mary Lawton, Respondent
On Petition for Review from the
Court of Appeals for the Tenth District of Texas
Argued March 11, 2009
Chief Justice Jefferson delivered the opinion of the Court.
In an effort to streamline workers compensation claim processing, the Legislature established time limits applicable to
compensability disputes. See Act of Dec. 11, 1989, 71st Leg., 2nd C.S., ch. 1, 5.21(a), 1989 Tex. Gen. Laws 1, 51.
These limits furthered the legislative goal of providing employees with either prompt payment or notice of denial of
benefits. Cont l Cas. Co. v. Downs, 81 S.W.3d 803, 806 (Tex. 2002), overruled on other grounds by Sw. Bell Tel. Co.
v. Mitchell, 276 S.W.3d 443, 448 (Tex. 2008). Today we must decide whether the sixty-day period for challenging
compensability of an injury also applies to a dispute over the extent of injury, if the basis for that dispute could have
been discovered by a reasonable investigation within the waiver period. We hold it does not and therefore reverse the
court of appeals judgment.
I
Factual and Procedural Background
On July 5, 2005, Mary Lawton, a Texas Department of Criminal Justice employee, hit her left knee on a steel monitor
while at work. A physician diagnosed her with a left knee contusion and strain. The State Office of Risk Management
(SORM), which is responsible for administering the state employees workers compensation insurance program,1
received written notice of the injury the next day and commenced paying benefits. On July 25, 2005, Lawton
underwent an MRI, and the reviewing physician diagnosed severe chondromalacia, an irritation of the cartilage on the
undersurface of the patella. In October, Lawton saw an orthopedic surgeon, who recommended surgery. SORM
ordered a peer review of this recommendation. On November 29, 2005, the peer review physician reported that the
medical conditions for which surgery was sought [were] related to [Lawton s] known degenerative changes of the knee
and [were] not the result of the contusion she realized from her reported compensable injury. He concluded that [the]
proposed surgery would not be reasonable or necessary as related to the left knee contusion. Eight days later, SORM
disputed the extent of Lawton s compensable injury and refused to pay benefits for any pre-existing degenerative joint
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disease.
Following a contested case hearing, the hearing officer concluded that SORM waived the right to contest responsibility
for the degenerative joint disease because SORM waited too long after it received notice of Lawton s knee contusion
to dispute the extent of injury. The officer found that SORM could have discovered the extent of Lawton s claimed
injury if it had conducted a reasonable investigation within the sixty-day time period established by Texas Labor Code
section 409.021(c), and SORM s failure to dispute the claim within that deadline waived its right to do so. An appeals
panel affirmed the officer s decision, and SORM sought judicial review. On competing motions for summary
judgment, the trial court affirmed the decision and awarded Lawton attorney s fees. See Tex. Lab. Code 408.221(c). A
divided court of appeals affirmed. 256 S.W.3d 436, 441. We granted SORM s petition for review, 52 Tex. Sup. Ct. J.
333 (Feb. 13, 2009), and now reverse.
II
Discussion
This appeal concerns the interpretation of both a statutory provision and an administrative rule. Texas Labor Code
subsection 409.021(c) provides, in pertinent part:
If an insurance carrier does not contest the compensability of an injury on or before the 60th day after the date on
which the insurance carrier is notified of the injury, the insurance carrier waives its right to contest compensability.
Tex. Lab. Code 409.021(c).
The administrative rule states:
Texas Labor Code, 409.021 and subsection (a) of this section do not apply to disputes of extent of injury. If a carrier
receives a medical bill that involves treatment(s) or service(s) that the carrier believes is not related to the compensable
injury, the carrier shall file a notice of dispute of extent of injury (notice of dispute). The notice of dispute shall be
filed . . . not later than the earlier of:
(1) the date the carrier denied the medical bill; or
(2) the due date for the carrier to pay or deny the medical bill as provided in Chapter 133 of this title (relating to
General Medical Provisions).
28 Tex. Admin. Code 124.3(e) ( Rule 124.3(e) ).
The court of appeals reviewed both of these provisions and determined that SORM s contest did not pertain to
compensability: SORM s dispute is not a denial of Lawton s entitlement to benefits in general or a dispute as to the
overall injury, . . . [rather the] complaint falls within the scope of an extent of injury dispute. 256 S.W.3d at 440. We
agree.
The court then examined a Texas Workers Compensation Commission2 appeals panel decision that stated:
[T]he injury that becomes compensable by virtue of waiver is not necessarily limited by the information listed on the
first written notice of injury. Rather the nature of the injury will be defined by that information that could have been
reasonably discovered in the carrier s investigation prior to the expiration of the waiver period.
Appeals Panel No. 041738-s, 2004 WL 2347601, at *2 (Tex. Workers Comp. Comm n Sept. 8, 2004), cited in 256
S.W.3d at 440-41. The court noted that SORM received the MRI report within the initial sixty-day period, and the
report put SORM on notice that Lawton was seeking benefits for something more than a contusion and placed SORM
in a position to dispute the extent of Lawton's injury. 256 S.W.3d at 441. Accordingly, the court concluded that SORM
waived its right to contest the extent of Lawton s injury because SORM s first challenge to extent was presented
outside the initial sixty-day period. Id. SORM argues that this holding is unsupported by the text of Section 409.021,
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and conflicts with Rule 124.3(e) and the [Division] s intent in adopting the rule. We agree.
Section 409.021(c) s sixty-day deadline applies only to compensability. Rule 124.3(e), which has the force and effect
of a statute and must be construed accordingly,3 provides that section 409.021 does not apply to disputes regarding
extent of injury, and the rule sets deadlines for disputing those types of claims. 28 Tex. Admin. Code 124.3(e). This is
consistent with the Division s reasoned justification for the Rule as reflected in the Texas Register. See Rodriguez v.
Serv. Lloyds Ins. Co., 997 S.W.2d 248, 254 (Tex. 1999) (noting that our primary objective is to give effect to the
[Division s] intent, and [o]ur best source of the [Division s] intent is the Texas Register ). In relation to Rule 124.3, the
Texas Register provides:
Texas Labor Code, 409.021, is intended to apply to the compensability of the injury itself or the carrier's liability for
the claim as a whole, not individual aspects of the claim. When a carrier disputes the extent of an injury, it is not
denying the compensability of the claim as a whole, it is disputing an aspect of the claim. . . . [A] dispute involving
extent of injury is a dispute over the amount or type of benefits, specifically, medical benefits, to which the employee
is entitled (i.e. what body areas/systems, injuries, conditions, or symptoms for which the employee is entitled to
treatment); it is not a denial of the employee's entitlement to benefits in general.
25 Tex. Reg. 2096, 2097 (2000) (noting that, as required by statute, the [Division] s reasoned justification for this rule
is set out in this order ). The Texas Register also notes that [t]he timeframes for a denial of a claim in its entirety such
as those addressed in subsection (a) are statutorily driven by Texas Labor Code, 409.021 and are tied to notice of the
injury. Extent of injury disputes are not so governed. Id. at 2100. Nowhere in the text of the rule, the statute, or the
Texas Register is there a suggestion that a carrier waives the right to challenge the extent of an injury if the extent of
that claim was reasonably discoverable within the period for determining compensability.
Moreover, implying such a requirement would eliminate the distinction between compensability and extent: a dispute
about any injury reasonably discoverable within sixty days of the initial notice would be governed by the deadlines for
compensability, while information obtained outside that time frame would fall under the deadlines for disputing extent.
Not only does this contravene the statute and the rule, it would create an unworkable situation. A carrier who received
medical information within the sixty-day period even on the fifty-ninth day would have to determine immediately
whether to contest the injury s extent (or its discoverability)4 or waive its right to do so. This would lead to an
investigation of all conditions that may be reasonably discoverable, resulting in increased costs and premature or
unnecessary disputes (as a worker may never seek benefits for those conditions). Although the sixty-day period
governs only compensability, not extent, the Legislature and the Division have ensured that workers enjoy certain
protections during extent-related disputes including, in certain cases, expedited proceedings, benefits during appeal,
interlocutory orders requiring medical and income benefits, and examinations by designated doctors. See Tex. Lab.
Code 408.0041(a)(3), 410.025(d), 410.169, 413.055(a); 28 Tex. Admin. Code 126.7(a), (c)(3), 133.306(b).
Here, SORM agreed that Lawton s injury was compensable. When it later disputed the extent of that injury, it was
governed by the deadline applicable to such disputes, not the sixty-day deadline governing compensability. A carrier
has up to forty-five days from the date it receives a complete medical bill to dispute whether that treatment was
necessary. See 28 Tex. Admin. Code 124.3(e); 133.240(a). That is the time frame applicable here. [T]he [Division]
could have easily formulated exceptions in the language of a general rule. Rodriguez, 997 S.W.2d at 255. Because the
Division has not done so, the court of appeals reliance on an appeals panel decision to the contrary was improper. Id.
at 254-55 (holding that, while courts defer to the [Division s] interpretation of its own regulation, they cannot do so if
that interpretation is plainly erroneous or inconsistent with the regulation (quoting Public Util. Comm n of Tex. v. Gulf
States Util. Co., 809 S.W.2d 201, 207 (Tex. 1991))). To the extent some cases have held differently, we disapprove of
them. See, e.g., Fed. Ins. Co. v. Ruiz, 281 S.W.3d 177, 183-84 (Tex. App. Dallas 2009, no pet.); Sanders v. Am. Prot.
Ins. Co., 260 S.W.3d 682, 685 (Tex. App. Dallas 2008, no pet.).
Accordingly, we reverse the court of appeals judgment, render judgment that SORM did not waive the right to contest
the extent of Lawton s knee injury by not disputing the extent of that injury within the initial sixty-day period, and
remand this case to the trial court for further proceedings consistent with this opinion. Tex. R. App. P. 60.2(c),(d).
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Wallace B. Jefferson
Chief Justice
Opinion Delivered: August 28, 2009
1 SORM administers insurance services obtained by state agencies, including the government employees workers
compensation insurance program . . .. Tex. Lab. Code 412.011(a). SORM is treated as an insurer for purposes of
applying chapter 409 of the Labor Code. Id. 501.002(c).
2 The Commission is now known as the Division of Workers Compensation, a division of the Texas Department of
Insurance. See Act of May 29, 2005, 79th Leg., R.S., ch. 265, 1.003, 2005 Tex. Gen. Laws 469, 470.
3 Rodriguez v. Serv. Lloyds Ins. Co., 997 S.W.2d 248, 254 (Tex. 1999).
4 Amicus curiae Office of Injured Employee Counsel cites two appeals panel decisions holding that injuries not
diagnosed until the fifty-eighth and fifty-seventh days, respectively, of the sixty-day period were not discoverable by
reasonable investigation during that period. See Appeals Panel No. 070181, 2007 WL 1034970, at *2 (Tex. Workers
Comp. Comm n Mar. 19, 2007); Appeals Panel No. 062601-s, 2007 WL 747440, at *3-*4 (Tex. Workers Comp.
Comm n Feb. 21, 2007);.
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