HOW TO DISPUTE THE INSURANCE CARRIER S DECISION IN A TEXAS WORKERS COMP CASE?

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1 HOW TO DISPUTE THE INSURANCE CARRIER S DECISION IN A TEXAS WORKERS COMP CASE? An injured worker is entitled to apply for workers compensation benefits in the state of Texas if the workers employer is a participant in the workers comp benefits program.

2 An injured worker is entitled to apply for workers compensation benefits in the state of Texas if the workers employer is a participant in the workers comp benefits program. Workers compensation is a state-regulated insurance program, which means that there are strict rules regarding worker rights. There are also rules regarding the benefits available to an employee who has suffered a work injury or become sick due to work tasks. When an employee is not happy with the decision made by the workers comp insurance carrier, there is an appeals process that can be followed. Employees may get help resolving any type of dispute related to workers compensation benefits. The Texas Department of Insurance Division of Workers Compensation helps to facilitate dispute resolution. Therefore, if an injured worker is not happy with decisions made by the insurance carrier, it is 2

3 possible to seek relief by going through the dispute resolution process of the Division of Workers Compensation. An experienced Houston, TX workers compensation lawyer can assist with every phase of the appeals process in order to help workers get the benefits that they need and deserve. If the insurance carrier has denied workers compensation benefits to which you are entitled, contact an experienced attorney today. WHAT TO DO IF YOU ARE NOT SATISFIED WITH THE INITIAL DETERMINATION OF YOUR WORKERS COMP CASE There are actually several different stages of review that are part of the dispute resolution process when you and the employer s insurer disagree 3

4 about either your eligibility for workers comp benefits or about the types of benefits that you should be receiving. For example, when a dispute arises, you can ask for a benefit review conference (BRC). A BRC is held at a Division of Workers Compensation Office and the conference is presided over by a Benefit Review Officer who works for the Texas Department of Insurance. The meeting is an informal one attended by you and the insurance company to give you an opportunity to come to a resolution of a disagreement. A BRC can resolve a wide variety of different issues, including disputes over medical fees. After this BRC, if disagreements about benefits remain, you can choose to resolve the ongoing disagreements by having your case heard at a Contested Case Hearing (CCH) is held after a BRC. This is a more formal hearing than the BRC. A Hearing Officer from the Division of Workers Compensation presides over the hearing and is asked to make a decision on any disputed issues not resolved at the BRC. You are notified of the decision later in writing after the Contested Case Hearing. 4

5 If you are dissatisfied with the decision that was made by the hearing officer, the next step is to ask the appeals panel to review the prior decisions that were made. You do not have to attend another hearing before the appeals panel, which is still a part of the Division of Workers Compensation. Instead, written arguments are submitted explaining your position about why the prior decisions were wrong. The Appeals Panel will review the written arguments, the record from the Contested Case Hearing, and the written decision made by the hearing officer. If it determines that there were errors made in the handling of your case and the decision made on the disputed issues, then you may get a different outcome to your case than what the hearing officer had chosen. A written decision will be issued by the Appeals panel explaining the outcome of your 5

6 appeal. This is the last phase of appeals that is handled internally by the Division of Workers Compensation. If you are still not satisfied with what the workers comp board has done, you can request judicial review. This takes the case out of the purview of the Division of Workers Compensation for the first time and it puts it before a judge. The judge does not just substitute his or her own opinions about the case- the judge will look at what was done before and will consider whether any errors were made that had an adverse impact on the outcome of your case. It is important to have legal representation throughout the appeals process, as it can be very complicated to get decisions by the workers comp board overturned. An experienced attorney can help you throughout the process so you can protect your rights. 6

7 About Abbott & Clay, LLP Abbott, Clay & Reed, LLP, is a Plaintiff Personal Injury Law Firm in Houston, Texas with 7 attorneys committed to protecting the rights of the injured. They do not represent companies or insurance carriers. The primary focus is on Workers Compensation claims and maritime injuries. They represent injured works before every field office in the state of Texas and have handled more Workers Compensation claims than any other plaintiff Firm in the state. The partners of the Firm, Bill Abbott, Fyodor Clay, Bianca Reed, and Leslie Levingston, have spent over 45 years combined fighting for the rights of injured workers. The remaining lawyers of the Firm have all been actively fighting for injured workers for the Firm for at least 2 years. Abbott, Clay & Reed, LLP, is a continuation of the Ogletree, Abbott, Clay & Reed Law Firm, formerly Ogletree Abbott, LLP, and Bill Ogletree P.C. Bill Ogletree, who spent his entire career fighting for the rights of workers, retired in He began assisting workers before the Division of Workers Comp, or the Texas Workers Compensation Commission, were even created. He was joined by Bill Abbott in 1999, and the two attorneys teamed up to create a Firm that handles the largest volume of Workers Compensation claims for injured workers in the state. Abbott, Clay & Reed L.L.P N Featherwood Drive Suite 200, Houston, TX Houston: Dallas: Austin: San Antonio: Toll Free: COMP 7