If you’re injured on the job and your employer does not subscribe to workers’ compensation coverage, you can file a personal injury lawsuit against them. In limited circumstances, you may also be able to sue your employer even if they have workers comp insurance, but you can also appeal your employer’s decision to deny your workers comp claim. Keep in mind, unlike every other state in the country, Texas does not require employers to maintain workers compensation insurance coverage. Here’s a quick guide.
Can an employer deny workers compensation?
Yes, and they often do. Employers can deny a workers’ compensation claim in certain situations. According to Texas workers’ compensation law, injuries or illnesses are covered if it was sustained during the course and scope of your employment, and you file an injury report within 30 days of the incident.
You’re not required by law to prove that your employer was at fault for your injury. But if you were in some way at fault, your employer might be able to deny your workers’ comp claim. For example, your injuries will not be covered if they were incurred while you were engaging in horseplay or some sort of willful criminal act. Your claim can also be denied if you intentionally injure yourself, you were intoxicated from drugs or alcohol, or you were voluntary participating in some off-duty recreational activity. Finally, workers’ compensation also does not cover injuries caused by acts of God or a third party’s criminal act if it’s unrelated to work.
Some other reasons your employer might deny your workers comp claim include:
- You didn’t report your injury within 30 days
- Your injury doesn’t fall under the covered injuries
- You didn’t seek appropriate medical treatment
- Your injury was preexisting and did not occur at work
How do I fight a denied workers’ comp claim?
If your workers’ comp claim is denied, you can follow an administrative appeal to have the denial overturned. You’re entitled to have an attorney represent you throughout their appeals process, and it’s recommended that you do so because we know that your employer is almost always going to have an attorney handle their case.
When you receive a claim denial notice, you can request dispute resolution to the Division of Workers Compensation Insurance of the Texas Department of Insurance, which is the state agency that is responsible for managing the workers’ comp system.
There are several stages in the dispute resolution process. The first step in the process is a benefit review conference, which is an informal mediation type meeting with a representative from your employer in the Division of Workers Compensation Benefit Review Officer.
If an agreements reach during the conference, you can sign a written settlement agreement and the appeals process is over. But if you don’t reach an agreement with your employer, your dispute will progress to the next stage, which is either arbitration or contested case hearing.
The next step in the process at an arbitration or a contested case hearing is going to depend on the choice you and your employer make together. If you decide on arbitration, you and your employer will meet with an arbitrator selected by the Division of Workers’ Compensation to discuss the dispute.
The arbitration process is somewhat more formal than a benefit review conference, and the arbitrator is going to render a final non appealable decision. If you decide not to participate in arbitration, the next stage of the process is a formal contested case hearing, which is presided over by a Division of Workers’ Compensation Hearing officer. This is more like a trial.
After considering the evidence each party presents, the hearing officer is going to issue a written decision on your case.
The appeals panel. If you object to the Hearing Officers decision, you can’t appeal your case again to the Division of Workers Compensation Appeals Panel. You and your employer are going to both submit written briefs and support of your positions. The appeals panel then reviews the briefs as well as the evidence presented during the contested case hearing and issues a written decision affirming modifying or reversing the hearing officers decision.
The next step after that would be a Texas state court appeal. If you disagree with the appeals panel decision, you can take your appeal to a Texas state court. Appealing an administrative level decision to the state court is a very complicated legal proceeding. If you did not hire an attorney to assist you in the administrative appeal, it’s vital that you have legal representation when you file an appeal in state court.
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