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The Texarkana Court of Appeals held this month that a claimant failed to exhaust her administrative remedies at the Division of Workers’ Compensation where the allegations in her lawsuit against the carrier were not first presented to and ruled upon by the Division.
The claimant filed suit against the carrier’s third-party administrator and her employer for fraud, fraudulent inducement, gross negligence, and violations of the Deceptive Trade Practices Act and Texas Insurance Code. The gist of her allegations is that she was denied full benefits as a result of misrepresentations and mishandling of the claims process by the carrier.
In a prior related proceeding, the Austin Court of Appeals had already determined that the Division has exclusive jurisdiction over the claims in her lawsuit. The claimant subsequently entered into a benefit dispute agreement agreeing: 1) that the carrier was relieved of liability because she did not file a claim within one year of her injury, and 2) her recovery was barred under the Texas Workers’ Compensation Act because she elected to pursue a remedy and recover under the laws of another jurisdiction.
Following the agreement, the claimant filed suit again, bringing the same claims but arguing that because of the agreement she had exhausted her administrative remedies and could now proceed with her lawsuit. The issue before the Texarkana Court was whether she had, in fact, exhausted her administrative remedies.
The Texarkana Court noted that the agreement addressed only issues of compensability. It did not address the extent of the injury, preauthorization, medical necessity, or administrative violations.
The Court held that the claimant’s complaints needed to be raised with the Division and a review of the agreement shows that they were not. According to the Court, nothing in the appellate record shows that the claimant either exhausted administrative remedies under Chapter 413 or provided the Division with notice of administrative violations.
The Court’s opinion includes a detailed discussion of the Division’s exclusive jurisdiction, including the Texas Supreme Court holding that the Texas Workers’ Compensation Act “provides the exclusive procedures and remedies for claims alleging that a workers’ compensation carrier has improperly investigated, handled, or settled a claim for workers’ claim for benefits.”
Steele v. Murphy & Beane, Inc., No. 06-19-00008-CV, 2019 WL 2998278 (Tex. App.—Texarkana, July 10, 2019).
Copyright 2019,James M. Loughlin, Stone Loughlin & Swanson, LLP