Just because your workers’ compensation claim was initially denied, doesn’t mean you should give up. Fortunately, you have the right to fight the decision by contacting the Division of Workers’ Compensation Insurance of the Texas Department of Insurance.
As soon as you receive your denial letter, first try to resolve the issues with your employer or its insurance company. If a resolution cannot be reached, you should request dispute resolution from the Division of Workers’ Compensation Insurance of the Texas Department of Insurance.
Benefit Review Conference
The “Benefit Review Conference" is the first stage of the appeal process. This is an informal meeting where you and your employer's representative discuss your denial with a Division of Workers’ Compensation Benefit Review Officer. Similar to mediation, the goal is to obtain a fair agreement, such as a settlement offer along with a written statement.
Arbitration & Contested Case Hearing
On the other hand, if the parties are not able to reach an agreement, the next step can be either arbitration or a contested hearing.
At Arbitration, you will once again meet with a representative of your employer. An arbitrator will attempt to make a decision on the matter at hand. In the end, the arbitrator will come to a decision that is conclusive. Although arbitration often doesn' take a long period of time and is less expensive compared to a contested case hearing, if you choose to participate in this process, you lose the ability to seek a contested case hearing.
By contrast, you and your employer decide not to undergo arbitration, a contested case hearing will be scheduled. Rather than an arbitrator, a hearing officer from the Division of Workers’ Compensation oversee the case. The officer will assess all of the evidence submitted, such as medical records and witness accounts. In the end, the officer will make a decision.
If you do not agree with the decision in the contested case hearing, you may appeal to the Division of Workers’ Compensation Appeals Panel. Written briefs that argue you and your employers positions must be submitted. Briefs and the record from the contested hearing will be reviewd by the panel, not any new evidence. The panel will either affirm, modify, or reverse the decision in the contested case hearing.
Texas State Courts
If you disagree with the Appeals Panel decision, you can appeal to the Texas State Courts. Due to the complexities of the legal process, it is wise to hire an attorney to address the state courts, if you haven’t hired one already.