What if Workers' Comp disputes my claim?
Disputes between the Insurance Company (Carrier) and Claimant occur frequently. The areas of disputes can be complicated and complex. Many times, the Carrier relies on the opinion of the network doctor as to the extent of your Injury, MMI and Impairment Rating which limits medical treatment and income benefits.
In most cases the individual claimant does not have the training or knowledge to properly address these denials. You have a much better chance of prevailing if you hire an attorney. Be aware that attorneys do not take all cases, especially if a significant time has lapsed since the date of injury.
Disputes arise in many areas, including, but not limited to:
Disputed cases can be resolved through an administrative structure. The first step in this administrative structure is the Benefit Review Conference (BRC). At a BRC a Benefit Review Officer (BRO) will preside and see if the parties can come to an agreement. It is also used to identify the issues.
It is not necessary for the BRO to be a lawyer.
Currently a party is eligible to have not more than two (2) BRCs before the case goes to a Contested Case Hearing (CCH). A CCH is an administrative trial of the disputed issues. An administrative law judge (ALJ) presides and is the sole judge of the evidence and will make a decision.
It is not advisable for an injured worker to attempt to go to a CH without an attorney. Statistics show that most decisions favor the Insurance Company. A party not satisfied with the decision at the CCH, can file an appeal with the Appeals Panel. There are strict rules that are applied both at the CCH and Appeals Panel.
Currently, the Appeals Panel reviews very few of the cases filed. A party not satisfied with the Appeal result may file a lawsuit in District Court. It will be difficult finding an attorney in Texas to handle these cases.
The best advice is for a claimant to be aware that the Workers’ Compensation process is lengthy and there should be a solid and factual basis to pursue this Dispute resolution process.
In most cases the individual claimant does not have the training or knowledge to properly address these denials. You have a much better chance of prevailing if you hire an attorney. Be aware that attorneys do not take all cases, especially if a significant time has lapsed since the date of injury.
Disputes arise in many areas, including, but not limited to:
- Compensability
- Extent of Injury
- Maximum Medical Improvement (MMI)
- Impairment Rating
- Disability
- Average Weekly Wage
- Bona Fide Offer of Employment
- Ability to Return to Work
- Proper Beneficiary in Death Cases
- Entitlement to Lifetime Benefits
Disputed cases can be resolved through an administrative structure. The first step in this administrative structure is the Benefit Review Conference (BRC). At a BRC a Benefit Review Officer (BRO) will preside and see if the parties can come to an agreement. It is also used to identify the issues.
It is not necessary for the BRO to be a lawyer.
Currently a party is eligible to have not more than two (2) BRCs before the case goes to a Contested Case Hearing (CCH). A CCH is an administrative trial of the disputed issues. An administrative law judge (ALJ) presides and is the sole judge of the evidence and will make a decision.
It is not advisable for an injured worker to attempt to go to a CH without an attorney. Statistics show that most decisions favor the Insurance Company. A party not satisfied with the decision at the CCH, can file an appeal with the Appeals Panel. There are strict rules that are applied both at the CCH and Appeals Panel.
Currently, the Appeals Panel reviews very few of the cases filed. A party not satisfied with the Appeal result may file a lawsuit in District Court. It will be difficult finding an attorney in Texas to handle these cases.
The best advice is for a claimant to be aware that the Workers’ Compensation process is lengthy and there should be a solid and factual basis to pursue this Dispute resolution process.
If you still have any questions, feel free to contact us. We are happy to assist you by phone, text, or email.
