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HOW TO DISPUTE THE INSURANCE CARRIER’S DECISION IN A TEXAS

WORKERS’ COMP CASE? “An injured worker is entitled to apply for workers’ compensation benefits in the state of Texas if the workers’ employer is a participant in the workers’ comp benefits program.”

How to Dispute the Insurance Carrier’s Decision in a Texas Workers’ Comp Case? www.workerscomp.com 2

An injured worker is entitled to apply for workers’ compensation benefits in

the state of Texas if the workers’ employer is a participant in the workers’

comp benefits program. Workers’ compensation is a state-regulated

insurance program, which means that there are strict rules regarding worker

rights. There are also rules regarding the benefits available to an employee

who has suffered a work injury or become sick due to work tasks.

When an employee is not happy with the decision made by the workers’ comp

insurance carrier, there is an appeals process that can be followed. Employees

may get help resolving any type of dispute related to workers’ compensation

benefits. The Texas Department of Insurance Division of Workers’

Compensation helps to facilitate dispute resolution. Therefore, if an injured

worker is not happy with decisions made by the insurance carrier, it is

How to Dispute the Insurance Carrier’s Decision in a Texas Workers’ Comp Case? www.workerscomp.com 3

possible to seek relief by going through the dispute resolution process of the

Division of Workers’ Compensation.

An experienced Houston, TX workers’ compensation lawyer can assist with

every phase of the appeals process in order to help workers get the benefits

that they need and deserve. If the insurance carrier has denied workers’

compensation benefits to which you are entitled, contact an experienced

attorney today.

WHAT TO DO IF YOU ARE NOT SATISFIED WITH THE INITIAL

DETERMINATION OF YOUR WORKERS’ COMP CASE

There are actually several different stages of review that are part of the

dispute resolution process when you and the employer’s insurer disagree

How to Dispute the Insurance Carrier’s Decision in a Texas Workers’ Comp Case? www.workerscomp.com 4

about either your eligibility for workers’ comp benefits or about the types of

benefits that you should be receiving.

For example, when a dispute arises, you can ask for a benefit review

conference (BRC). A BRC is held at a Division of Workers’ Compensation Office

and the conference is presided over by a Benefit Review Officer who works for

the Texas Department of Insurance. The meeting is an informal one attended

by you and the insurance company to give you an opportunity to come to a

resolution of a

disagreement. A BRC can

resolve a wide variety of

different issues, including

disputes over medical

fees.

After this BRC, if

disagreements about

benefits remain, you can

choose to resolve the ongoing disagreements by having your case heard at a

Contested Case Hearing (CCH) is held after a BRC. This is a more formal

hearing than the BRC. A Hearing Officer from the Division of Workers’

Compensation presides over the hearing and is asked to make a decision on

any disputed issues not resolved at the BRC. You are notified of the decision

later in writing after the Contested Case Hearing.

How to Dispute the Insurance Carrier’s Decision in a Texas Workers’ Comp Case? www.workerscomp.com 5

If you are dissatisfied with the decision that was made by the hearing officer,

the next step is to ask the appeals panel to review the prior decisions that

were made. You do not have to attend another hearing before the appeals

panel, which is still a part of the Division of Workers’ Compensation. Instead,

written arguments are submitted explaining your position about why the

prior decisions were wrong.

The Appeals Panel will review the written arguments, the record from the

Contested Case Hearing, and the written decision made by the hearing officer.

If it determines that there were errors made in the handling of your case and

the decision made on the disputed issues, then you may get a different

outcome to your case than what the hearing officer had chosen. A written

decision will be issued by the Appeals panel explaining the outcome of your

How to Dispute the Insurance Carrier’s Decision in a Texas Workers’ Comp Case? www.workerscomp.com 6

appeal. This is the last phase of appeals that is handled internally by the

Division of Workers’ Compensation.

If you are still not satisfied with what the workers’ comp board has done, you

can request judicial review. This takes the case out of the purview of the

Division of Workers’ Compensation for the first time and it puts it before a

judge. The judge does not just substitute his or her own opinions about the

case- the judge will look at

what was done before and

will consider whether any

errors were made that had

an adverse impact on the

outcome of your case.

It is important to have legal

representation throughout

the appeals process, as it can be very complicated to get decisions by the

workers’ comp board overturned. An experienced attorney can help you

throughout the process so you can protect your rights.

How to Dispute the Insurance Carrier’s Decision in a Texas Workers’ Comp Case? www.workerscomp.com 7

About Abbott & Clay, LLP

Abbott, Clay & Reed, LLP, is a Plaintiff Personal Injury Law Firm in Houston, Texas with 7 attorneys committed to protecting the rights of the injured.

They do not represent companies or insurance carriers. The primary focus is on Workers’ Compensation claims and maritime injuries. They represent injured works

before every field office in the state of Texas and have handled more Workers’ Compensation claims than any other plaintiff Firm in the state.

The partners of the Firm, Bill Abbott, Fyodor Clay, Bianca Reed, and Leslie

Levingston, have spent over 45 years combined fighting for the rights of injured workers. The remaining lawyers of the Firm have all been actively fighting for injured

workers for the Firm for at least 2 years. Abbott, Clay & Reed, LLP, is a continuation of the Ogletree, Abbott, Clay & Reed Law Firm, formerly Ogletree Abbott, LLP, and

Bill Ogletree P.C. Bill Ogletree, who spent his entire career fighting for the rights of workers, retired in 2012. He began assisting workers before the Division of Workers’

Comp, or the Texas Workers’ Compensation Commission, were even created. He was

joined by Bill Abbott in 1999, and the two attorneys teamed up to create a Firm that handles the largest volume of Workers Compensation claims for injured workers in the

state.

Abbott, Clay & Reed L.L.P. - 12600 N Featherwood Drive Suite 200, Houston, TX 77034

Houston:713-223-1234 • Dallas:214-347-4395 • Austin:512-487-7426 • San Antonio:210-807-4302 • Toll Free:888-434-COMP