If Employer Denies your Claim

In Texas, workers comp disputes are settled through an appeals process. Employees who are denied all or part of their workers compensation must request an appeal to reverse the denial. If the case cannot be settled early in the appeals process, the case may go before a civil court judicial review board. This is where IIHC can find you representation so you don’t have to face these challenges on your own. Below is the process of appealing your claim denial.

The Appeals Process
When an employee's workers' comp claim is denied, he or she has the option to first talk to an insurance adjuster to try to work out the dispute. However, if the claim remains denied, the employee may seek to appeal to the Division of Workers' Compensation. The following are steps that are part of this appeals process:

• A Benefit Review Conference may be scheduled where the employee, insurer, and a benefit review officer from the local Division of Worker’s Compensation office try to negotiate the dispute and produce a written agreement.

• If an agreement is not reached, the parties may choose to go to arbitration where a certified arbitrator will be assigned to oversee the negotiations. An arbitration decision is binding on both parties and cannot be appealed.

• An alternative to arbitration is a case hearing where evidence may be presented by both sides and witnesses may be heard by a Division Hearing Officer. The hearing officer considers the evidence and issues a decision.

• A denied employee who is unsatisfied with decisions by the insurance company and the Division has the option to take his or her case to appeal in writing. Both parties must submit written statements to an appeals panel and the statements are subsequently reviewed. After the review, the panel issues either a "reverse and remand" order sending the case back to the hearing officer, or a "reverse and render" order, which is a new decision.

• If the employee disagrees with the appeal panel's decision he or she can then request a judicial review which takes the case to a civil court of law.

There are several possible common reasons for a denial of a claim, including:

• Not filing notice of your injury with your employer within 30 days

• Not having proper medical documentation of your injury

• Not providing sufficient evidence that the claim arose directly as a result of your job.

The letter denying your benefits should include the specific reason for the denial. You can address this issue and appeal first to your employer's workers compensation insurer. If this appeal is unsuccessful, you can file another appeal to the workers comp claim with the workers compensation board in the state of Texas.

Related Topics:

• Texas Employee Rights

• Texas Laws

• Benefits (Compensation)

• If Employer Denies your Claim

• Why Contact IIHC

• FAQs