Unlike most states, Texas doesn't require private employers to carry workers’ compensation insurance. But if you have a work-related injury or illness and your employer does have insurance, you may be entitled to workers' comp benefits in Texas. And if the insurance company denies your claim, you can appeal that decision. This article explains common reasons insurers deny claims and how to file an appeal with the Texas Division of Workers’ Compensation (DWC), the agency that oversees the workers’ comp system and reviews claim disputes.
Timing is everything. You could lose your right to collect benefits if you don’t notify your employer within 30 days after the injury. If you have an occupational disease (which includes repetitive stress injuries), the 30-day period starts when you learn that your condition is related to your job.
Workers' compensation in Texas only covers an injury that "arises out of and in the course and scope of employment." Essentially, that means that your were working while you were hurt, and your job duties or conditions caused your injury. This requirement is most often the focus of claim disputes. Texas law rules out workers' comp coverage in some specific situations, including when:
the injury happened during your normal commute, unless your employer provides the transportation
you were hurt because you were intoxicated or were fooling around
you hurt yourself on purpose
your injury happened because you hurt someone else illegally
someone else hurt you for reasons not related to your job, or
"an act of God” (like a natural disaster) caused the injury.
See Denied Workers Compensation Claims to learn more about common reasons insurers deny claims.
If your claim is denied, contact the insurance company and try to resolve the dispute directly with a claims adjuster. If that doesn’t work, the first thing you should do is make sure you've filed a formal claim with the DWC, if you haven't already done so. As with the reporting requirement, you could lose your right to benefits if you don't file this form within a year after your injury. (For details on the claims process, see How to File a Workers’ Compensation Claim in Texas.)
You should then contact the DWC for help resolving your dispute with the insurance company. There are several steps in the DWC dispute resolution process:
Benefit review conference. File DWC Form-045 to request a benefit review conference (BRC). Note that this step is required. You can’t participate in arbitration or a contested case hearing if you don’t first participate in a BRC. A BRC is an informal meeting where a benefit review officer will serve as a mediator and try to help you and the insurer work out an agreement. You may also use this procedure to try to resolve disputes over medical fees.
Arbitration. If you and the insurer can't resolve your dispute at the benefit review conference, you can try arbitration. Notify the DWC of this decision within 20 days after the BRC. Arbitration is a more formal proceeding where an independent arbitrator hears evidence and makes a decision about your benefits. But note that you generally can't appeal an arbitrator's decision.
Contested case hearing. If you choose not to go through arbitration, a contested case hearing is the next step after a BRC. This is a formal hearing before an administrative law judge, who will review the evidence and issue a written decision. Generally you or the insurer can’t bring up new evidence that wasn’t presented during the BRC. (Learn more about what to expect at your workers' comp hearing.)
Appeals panel. If you’re unhappy with the outcome of the hearing, you can request that the appeals panel review your case. You must make this request within 15 days after receiving the judge’s decision. A three-member panel of judges will review written statements from the parties and the facts presented during the hearing before making a decision.
Once you've gone through the entire DWC dispute resolution process, you can seek judicial review in civil court. You must file a lawsuit within 45 days after the appeals panel handed down its decision.
You don’t have to go through the appeals process alone. The Texas Office of Injured Employee Counsel has a free ombudsmen program to help injured workers with their claims. However, Texas law specifically says that ombudsmen may not provide legal representation to employees. So you may want to consider hiring hiring an experienced workers' comp attorney. If you’re on the fence about hiring an attorney, see Should I Hire a Workers’ Comp Attorney, or Can I Handle My Own Case? and How Much Does a Workers' Comp Lawyer Cost in Texas?