Workers Compensation Essay
hop23
Example_Texas_WC_Dispute__Essay_UNIT_IV.docx.pdf
Running head: TEXAS WORKERS’COMPENSATION DISPUTES 1
Texas Workers’ Compensation Disputes
NAME
Columbia Southern University
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TEXAS WORKERS’COMPENSATION DISPUTES 2
Texas Workers’ Compensation Disputes
Disputes can sometimes arise in workers’ compensation cases involving
miscommunications, disagreements on ratings or benefits provided, and concerns with a lack of
support to the employee by the carrier or employer. Grabell & Berkes (2019) state, “the cutbacks
have been so drastic in some places that they virtually guarantee injured workers will plummet
into poverty”. This obviously is a driving factor as to why injured employees push for additional
support. In most events disputes could be avoided by simply taking the time to sit down with the
employee, explain their benefits, and rights and responsibilities within the workers compensation
system. In others the only way to find a resolution is to challenge a decision and depend on the
commission to play mediator. Common dispute requests might involve clarification on the extent
of injury where adverse medical effects were found after or during treatment, maximum medical
improvements challenges (MMI), an impairment rating challenges (IR) or a general claim denial
of coverage.
Extent of injury relates to an injured employee who may have had pre-existing conditions
that interfere with their injury management. An example of this is someone with previously
herniated discs in the lumbar region of their spine, that receives a strain at work by lifting a
heavy box. The carrier would except the strain as it occurred at work and would likely request
the past medical history to compare to their current findings to determine if the damages that
existed from the previous medical issues were exaggerated because of the new strain or if the
condition remained unaffected. While the employee may receive treatment for the strain, as it
was in the course and scope of their employment, the carrier would not be responsible for the
past damage to the body and could file a partial denial. Most workers feel if the injury results in
discomfort that does not subside and is new to them, everything should be done to return them to
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TEXAS WORKERS’COMPENSATION DISPUTES 3
their original state. Partial denials typically cause concern for the injured worker, in which case
they may consult with the commission and file a dispute regarding the extend of injury. While
Business Wire’s (2019), findings for similar cases in California found that 9 of out 10 cases
showed the independent medical reviews were upheld, it showed these cases involved decisions
that were modified cases involved in the study, meaning the DD’s altered their decisions and
were found accurate by another medical professional. This can benefit the employee as it forces
an impartial party review the medical findings, allowing another perspective and consideration
for facts the carrier may not have initially focused on that effects the injury to the employee’s
body. While portions of a claim may remain disputed, these conferences could also result in
opportunities for additional forms of treatment, or the full decision may be overturned.
Like with the extent of injury, it may benefit an injured worker to file a dispute pertaining
to MMI or their IR when the treating or designated doctor (DD) has closed their case
prematurely or assign a rating lower than expected for the permanent disability they sustained. In
these instances, it is almost always best to work with an ombudsmen or representation to allow
someone to help build a case to justify the concern for a low rating applied. Ratings are based on
a full body impairment. In other words, if the strain sustained to the back resulted in permanent
disability and the employee cannot longer regular functions without causing a reaggravation, the
doctors must consider how much the lost effects the full bodies functional capabilities. Being that
the back supports all our extremities, our ability to walk, stand up, lift, carry and so forth, a fair
rating must take into consideration all these things. Unfortunately, within workers’ compensation
what we value our bodies as does not translate into a substantial monetary value, but it does offer
some financial support as well as pad the medical file making it easier to receive additional
medical treatment as needed for continued care.
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TEXAS WORKERS’COMPENSATION DISPUTES 4
Denial of coverage can be a very threatening situation for an injured worker. When a
denial occurs, employees are informed that they have the right to appeal the decision within 90
days. During this time frame it allows them the opportunity to rather their medical files with any
possible evidence that would relate their injury, such as activities performed on the job. It is best
to prepare a statement that will be shared with the employee’s counsel as well as the commission
to ensure the same information is shared upon each encounter. This includes the BRC, CCH and
court stage of the dispute process should it reach that level. Denial’s may arise for many reasons,
it can be as simple as the injured party not responding to the carrier to verify injury details,
doctors providing insufficient medical evidence to support an injury, vocabulary used to describe
the injury such as soreness rather than pain, or the lack of evidence supporting a workplace
accident such as: a time, place, and incident that caused the injury. If the employee complies their
evidence and files for a BRC, they are likely to be well received and may overturn the decision
initially made by the carrier. Texas is very pro-injured worker, they workers’ compensation was
not made for the employer but to protect the employees. While this process may take time, they
are well worth the employee’s efforts.
Unlike the cases described by Hyatt & Kraji (2000), where cases with uncertainty were
more likely to receive lump sum settlements, Texas does not settle cases therefore is required to
arbitration. Upon filing a dispute in the state of Texas the first step in the dispute process is a
Benefit Review Conference. This is an informal conference lead by a DWC representative that
reviews the case file and works as a mediator to discuss actions that could be done to support a
resolution to the concerns at hand (Texas Department of Insurance, 2018). This is one of the best
ways to get all parties involved in one room; the carrier, injured worker and employer. Most
people question if a lawyer is needed to be successful in a BRC and the answer is “no”. If the
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TEXAS WORKERS’COMPENSATION DISPUTES 5
injured worker is ever unsure about the process, lacking confidence for fearful of his/her lack of
knowledge on the process, they may place a request with the commission to work with an
ombudsman for free. The ombudsmen will help walk the employee through the BRC process,
and plan with the worker what information might be needed to successfully relay their concerns
and gain the support of the parties involved.
When an agreement cannot be made within the BRC, the DWC representative then places
a request for the file to be transferred to a Contested Case Hearing (CCH). If the resolution set
forth by the CCH is found unsatisfactory to either party, a request may be placed in writing for
have an appeals panel to reconsider the CCH decision (Texas Department of Insurance, 2018). It
is uncommon for a case to be taken beyond a CCH. Most cases can be resolved; however, the
injured party may choose to go as far as having a judicial review performed. Once the courts
settle on a resolution the decision becomes final. Cases that see this level of action are typically
ones represented by an attorney. Attorneys tend to take a more aggressive and negative stance on
the workers’ compensation programs. As mentioned by Mitchell Byrd (2018), “by requiring
injured workers to fight with them for the benefits they desperately need, the insurance company
keeps the money it should pay out in its own accounts much longer”. From his perspective, with
the support of a professional on workers’ compensation law an employee is likely to be more
successful in their fight for fair benefit coverage with a timelier response. While support is
beneficial, it is difficult to understand why one would choose to hire an attorney, paying 25% of
either awarded benefits, when they could utilize the support of true professionals in workers’
compensation law whose whole purpose is to protect the people for free. While the dispute
process may appear intimidating at first, if an injured party is directed to the proper resources,
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TEXAS WORKERS’COMPENSATION DISPUTES 6
such as the TDI.gov website they may find all the support they need to successfully dispute and
resolve their workers’ compensation concerns.
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TEXAS WORKERS’COMPENSATION DISPUTES 7
Resources
Boggs, C. J. (2011). The Insurance Professional’s Practical Guide to Workers’ Comp: From
History Through Audit (2nd ed.). San Diego, CA: Wells Media Group.
Business Wire. (2019). CWCI Takes An Updated Look At California Workers’ Comp Medical
Dispute Resolution. Retrieved from
http://eds.b.ebscohost.com.libraryresources.columbiasouthern.edu/eds/detail/detail?
vid=1&sid=65351286-5828-4c49-b8b8-d68ffb2c82db
%40sessionmgr102&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d
%3d#AN=bizwire.c88762703&db=bwh
Byrd, M. (2018). The Difficult and Unfair Fight for Workers’ Compensation
Benefits. Retrieved from https://www.thecarolinalawgroup.com/2015/03/workers-
compensation-benefits-the-difficult-and-unfair-fight/
Grabell, M., and Berkes H. (2015). The Demolition of Workers’ Comp. Retrieved from
https://www.propublica.org/article/the-demolition-of-workers-compensation
Hyatt, D. and Kralj, B. (2000). The Impact of Representation and Other Factors on the Outcomes
of Employee-Initiated Workers’ Compensation Appeals. Industrial and Labor Relations
Review, 53 (4), 1-20.
Texas Department of Insurance. (2018). Dispute Resolution for Injured Employees. Retrieved
from https://www.tdi.texas.gov/wc/employee/dispute.html
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