In the Worker’s Compensation system in Texas, after you get hurt you will normally receive temporary income benefits if you are partially or wholly disabled from your regular work. These benefits will continue so long as you remain disabled and until you reach maximum medical improvement. However, when a doctor certifies you have reached maximum medical improvement, the insurance company is authorized to suspend temporary income benefits and initiate impairment income benefits for a specified period, three weeks for every percentage assigned. You may disagree with the rating you have been given, or you may think it was given prematurely and you were not at your maximum medical improvement yet. In such a situation it is necessary to obtain an alternate certification in order to challenge this benefits decision.
An alternate certification is simply a certification of maximum medical improvement and impairment rating, or certification that one has not reached maximum medical improvement, given by a doctor. Often the first certification at maximum medical improvement an impairment rating will be given by a designated doctor. That is a doctor chosen at random off a list of qualified doctors by the Texas department of insurance, division of Worker’s Compensation. That state designated doctor has presumptive weight, which is a fancy legal way of saying that the doctors opinion is binding and presumed correct unless and until it is overturned by a judge.
Is important to make sure that an alternate certification is conducted correctly. First of all, in order for the opinion of an alternate certifying doctor to be adoptable by a judge, that doctor has to be authorized by you’re treating doctor to make that report. It is not simply enough to go to a doctor that you select and have that doctor write a report. That doctor must be appropriately credentialed and authorized by your treating doctor to do this evaluation.
As if that were not enough, the doctor must be chosen carefully. Choosing the wrong doctor will mean that you might get another opinion that goes against you and makes your case even more difficult, if not impossible, to win.
Other considerations include that the certifying doctor must include all of the medical conditions that are part of the injury. If the certifying doctor gives you an impairment rating, but does not include all conditions that are part of the injury, or includes conditions that are not part of the injury, a judge will determine that certification cannot be adopted.
It is also crucial to make sure the certifying doctor has all of the relevant medical records. If the doctor does not have all of the records, that may impact the validity and foundation of the doctors opinion. If the doctor is commenting on the extent of the injury for example, then the doctors failure to comment on records that reference a prior injury may prove fatal to the doctors analysis. So it is critical to make sure that the doctor receives all relevant information.Otherwise the doctors opinion may lack foundation as an expert and be excluded from consideration by a judge.
Some of this may not apply to all alternate certification situations. For example, if you have not reached the two-year statutory maximum medical improvement date, it is valid and proper for a doctor to opine that you have not reached your maximum medical improvement. A doctor to give the opinion that you have not reached maximum medical improvement does not have to be certified to give such an opinion, and does not have to be a referral for that specific purpose. However, a doctor with that opinion does need to do a few things. The doctor needs to state the reasons and explanations as to why the patient has not reached maximum medical improvement. Simply giving the conclusion is not enough. Further, the doctor must Anticipate the approximate time frame and conditions it will take to reach maximum medical improvement. This can either take the form of a date specific or a statement that the patient will not be at maximum medical improvement until specific necessary treatment under the treatment guidelines are performed. Please note the critical nature of explaining what those procedures would be and why they are necessary under the treatment guidelines.
I will prepare an alternate certification report is literally the difference between winning and losing a case, and receiving or failing to receive months if not a year or more of benefits.
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