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On April 23, 2024, TDI-DWC’s General Counsel, Kara Mace, issued
a memorandum to system participants regarding preventative treatment claims
handling. In it, Ms. Mace stated that the Division “would like to remind
insurance carriers of the rules associated with preventative treatment related
to a physical injury and workers’ compensation claims handling.”
The memo notes that preventative treatment “may include medications such as
rabies vaccines, tetanus shots, and post-exposure prophylaxis that are prescribed
by a health care provider.” It also states that “an insurance carrier must
follow treatment guidelines and pay for specified pharmaceutical services
sufficient for the first seven days following the date of injury, regardless of
issues of liability for or compensability of the injury,” citing Texas Labor
Code §413.011 and DWC rules 134.501 and 137.100.
Rule 134.501, titled Initial Pharmaceutical Coverage, provides in part that:
The insurance carrier . . . shall pay for specified
pharmaceutical services sufficient for the first seven days following the date
of injury, regardless of issues of liability for or compensability of the
injury that the carrier may have, if, prior to providing the pharmaceutical
services, the health care provider . . . obtains both a verification of
insurance coverage, and an oral or written confirmation that an injury has been
reported.
. . . Specified pharmaceutical services are prescription drugs and over-the-counter
medications prescribed by a doctor that cure or relieve the effects naturally
resulting from the compensable injury, promote recovery, or enhance the ability
of the employee to return to or retain employment.
Ms. Mace ends the memo by noting that “failure to properly
handle preventative treatment claims under these rules and other applicable
laws may result in the assessment of administrative penalties not to exceed
$25,000 per day per occurrence.”
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