My Texas Workers Compensation Claim Was Denied - Now What?
There are many reasons why a Texas workers compensation claim may be denied. Some of the more common reasons for denial are discussed, as well as solutions and tips for establishing the claim and overturning the insurance denial.
Defenses Raised By Insurance Companies To Deny Texas Workers Compensation ClaimsWhen a claim is denied, the insurance carrier has to send you a form stating the reasons why it denied your claim. The most common reason a Texas workers' compensation claim gets denied is when the insurance company is unsure if an actual injury was sustained in the "course and scope" of employment. Other common reasons for denial are a failure to report the injury to the employer within 30 days of the date of injury, or an allegation of intoxication at the time of injury.
Why Texas Workers Compensation Claims Get DeniedMost of the time, a denial is based on incomplete or inaccurate information, or just a made up excuse. Maybe the employer tells the insurance company that you never reported the injury to keep themselves out of trouble for failing to report the injury to the insurance company. Other times, the adjuster might state that she doesn't have any medical records to establish that the injury is work-related. And sometimes, the adjuster claims that the injury is pre-existing and didn't happen on the job. And you can't discount the fact that the insurance company makes more money if they deny the claim instead of paying the claim.
What Do I Do If My Texas Workers Compensation Claim Is Denied?If your claim is denied, you need to initiate dispute resolution. This means that you have to request a Benefit Review Conference, which is an informal mediation to try to resolve the dispute. If that doesn't work, the case will proceed to a Contested Case Hearing with a judge. A Contested Case Hearing is a formal hearing and is an administrative trial. Most likely, you will need to discuss your case with an attorney prior to the BRC so the case can be set up right.
Should I Use An Ombudsman Or An Attorney For My Texas Workers Compensation Case?While an ombudsman is free, they are not lawyers. 2013 statistics show that ombudsmen lose 73% of the cases they handle. This means that injured workers who use them are giving up 73% of their claims overall by agreeing to use them. A Texas workers comp attorney only costs 25% of benefits paid, which means you have to win before the attorney is owed anything. Attorneys have special training and skills that an ombudsman does not have. I recommend always hiring an attorney, especially when your claim has been denied. There is too much at stake!