Adrian Tijerina v. Texas Property Casualty Insurance Guaranty Association as Receiver for SIR Lloyd's Insurance Company and the Texas Department of Insurance, Division of Workers' Compensation, 03-13-00300-CV

Background

Ronald Mensch suffered a compensable work injury in 1980; State Farm paid medical/dental benefits until 2008 and then refused further payment.
The Division of Workers' Compensation (the Division) issued a 2011 final award recognizing Mensch's injury and entitlement to lifetime medical benefits under the "old" workers' compensation law (Articles 8306/8307).
Mensch sought preauthorization from State Farm for extensive additional dental work; the carrier denied preapproval because, under the applicable law, medical services must be furnished before being presented for payment.
The Division informed Mensch it had no authority to preauthorize the dental procedure and would take no further action until bills were incurred and presented to the carrier.
Mensch sued, adding the Division as a defendant and asking the court to declare the Division has jurisdiction to preapprove the proposed dental work; the trial court denied the Division's plea to the jurisdiction.
The Fourth Court of Appeals reversed, holding under the pre-1991 statutory scheme that the Division (and courts) lack jurisdiction to adjudicate or preauthorize medical expenses that have not yet been incurred — the claimant must first obtain the services and exhaust administrative remedies.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether the Division/court may adjudicate or preauthorize future medical expenses not yet incurred	Mensch: Article 8306 §7 grants lifelong medical benefits; insurer must furnish services and preauthorization is permissible	Division: Article 8307 §5 prohibits awards/judgments for items not actually furnished and received; claimant must incur expenses then exhaust administrative remedies	Held: Division and courts lack jurisdiction to adjudicate/preauthorize unincurred medical expenses; claimant must obtain treatment, present bills, and exhaust administrative remedies
Whether the first final award is res judicata as to past expenses and bars relief for future unincurred expenses	Mensch: argues insurer obligated to furnish care without claimant fronting costs	Division: first final award is res judicata only for expenses incurred up to that date; future expenses require successive awards after services are furnished	Held: First award is res judicata for expenses through its date; it is not res judicata for future expenses, which require successive awards after services are actually furnished
Whether administrative exhaustion requirement applies after insurer's liability has been established	Mensch: seeks court relief despite prior award	Division: claimant must still pursue agency remedies for subsequent medical services	Held: Administrative exhaustion still required for disputes about continuing medical services; failure to exhaust deprives the trial court of jurisdiction
Effect of Article 8307 §5 on trial-court jurisdiction over future medical expenses	Mensch: contends section 7 controls and allows continuing entitlement	Division: section 5 limits awards/judgments to items actually furnished and received before award/judgment	Held: Section 5 controls jurisdictional scope; it prevents trial courts from deciding claims for unincurred future medical expenses

Key Cases Cited

Employers Mut. Cas. Co. v. Poorman, 428 S.W.2d 698 (Tex. App.—San Antonio 1968) (section 5 bars awards/judgments for future medical expenses not yet furnished)
Pearce v. Tex. Employers Ins. Ass'n, 403 S.W.2d 493 (Tex. Civ. App.—Dallas 1966) (successive awards and res judicata limitations under section 5)
Paradissis v. Royal Indem. Co., 507 S.W.2d 526 (Tex. 1974) (administrative exhaustion required for continuing medical services after insurer liability is established)
City of Houston v. Rhule, 417 S.W.3d 440 (Tex. 2013) (statute in effect at time of injury governs entitlement)