Appealing a denied workers’ compensation claim in Texas involves attending reviews and hearings to defend your need for benefits. No matter how many work injuries a person is recovering from, their employer’s insurer can send them a letter saying it denied their workers’ compensation claim. Fortunately, a denied claim is not the final say in many cases.
Texas allows workers to appeal a denied workers’ compensation claim. If you are in this situation, you don’t have to handle this process by yourself. A Waxahachie workers’ compensation lawyer can manage your appeal and fight for your rightful compensation. They can explain your rights, protect your interests, and work to achieve a fair outcome.
The Stages of Challenging a Denied Workers’ Compensation in Texas
If you receive a notice of denial, it should tell you why your employer’s insurer denied your workers’ compensation claim. It should also tell you how to appeal the decision, the documents you will need to challenge it, and the deadline for filing it. If you don’t understand why your initial benefits application was denied, you can consult an attorney and ask them to review it.
Below are the stages of the workers’ compensation appeal process in Texas:
Attend a Benefit Review Conference
The first step to appealing a denied workers’ compensation claim in Texas is to request a benefit review conference (BRC). During this informal meeting, you and your attorney (if you have one) will discuss the disputed claim with an insurance representative and a Division Workers’ Compensation (DWC) benefit review officer. You could resolve the matter at this stage. But if you don’t, you will move on to a formal meeting called a contested case hearing.
Attend a Contested Case Hearing (CCH)
If you are in this phase, you will attend a formal hearing conducted by a DWC administration law judge (ALJ), who will review the disputed claim. The judge will hear from you and issue a decision, which you can appeal. You could also go to arbitration. During this proceeding, both parties can present evidence about the issues and explain their position. They will also testify under oath. After everyone has had a say, the arbitrator will decide. From that point, neither side can appeal the decision.
Request an Appeals Panel Review
If you appeal the ALJ’s decision made during the contested case hearing, you can ask the Appeals Panel to examine the decision. You have 15 days from the day you learn of the decision and submit this request in writing. Your request must explain why you want to appeal the decision. The opposing side will also submit a written statement. The panel will review both statements along with the ALJ’s decision during a 45-day period and issue a decision in writing. The panel could change the ALJ’s decision or leave it as is. After that, either side has 45 days to appeal the panel’s decision.
Request a Judicial Review
If you reach this stage, you are at the final step in the DWC’s dispute resolution process. However, as the Texas Department of Insurance (TDI) explains, a decision can be appealed to the proper court at this stage.
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A Lawyer Can Manage Your Denied Workers’ Compensation Claim Case in Texas
This brief overview of the steps of appealing a denied workers’ compensation claim is just a glimpse of what injured workers in Texas face if they take that path. They must consider many laws, rules, and regulations in addition to proceedings that can take months to complete.
If you are in this position, you can hire an attorney to represent you. Even if you voluntarily resolve your claim during the benefits review conference stage, an attorney who knows the law can defend your claim. They can also:
- Explain your rights and responsibilities under Texas workers’ compensation law
- Investigate the work-related injury and accident
- Gather evidence to support your work injury claim (e.g., your medical records, employment records, witness testimony, pay stubs, photos, video footage)
- Identify all liable parties that could owe you compensation (A personal injury lawyer could file a personal injury lawsuit for damages against a third party that injured you.)
- Lead negotiation talks with the insurance carrier for a fair outcome
- Explain each stage of the appeals process
- Review proposed insurance offers to determine if they meet your needs
- Represent you in all hearings, meetings, and at trial if necessary
- Prepare you for any testimony you may be required to give on your own
- Answer your questions and concerns
- Update you regularly on all case developments and outcomes
A workers’ compensation lawyer working on your behalf will take care of your entire case while you focus on recovering from your injuries. Hiring a legal professional to handle your legal matter can save you time and ensure you avoid mistakes that could further delay your case.
Reasons Why Insurance Companies Deny Texas Workers’ Compensation Claims
Before you appeal a denied work injury benefits claim, you should ensure you understand the reason for the denial. Common reasons include:
- The application contained inaccurate or incomplete information.
- The application missed the filing deadline and, therefore, was late.
- The injury did not happen at work or during a work-related activity.
- The applicant did not notify the employer of the injury or illness promptly.
- The injury happened in an uncovered incident, such as substance use on the job or horseplay on the job.
- The injury already existed before the incident that occurred in the workplace.
- The applicant’s status is ineligible for benefits. Contractors, agriculture workers, and freelancers cannot receive workers’ compensation benefits in Texas.
You may be able to fix small errors on an application and send it back to the insurer. In other cases, an attorney can review your situation and determine how to prove you are due benefits.
Call Clay Jenkins & Associates for Help With a Worker’s Compensation Claim Dispute
If you want to challenge a claim denial for workers’ compensation benefits, our attorneys can lead your case while you focus on improving your health and well-being. Our law firm has been fighting for Texans’ recovery since 1948, and we care about their ability to move forward with the medical and income benefits they deserve after getting hurt on the job.
Call us today for a free consultation. We can review your options and tell you the next steps to take in your case.