Texas Workers Compensation: Claims, Denials and Appeals

Workers compensation Texas law provides protection for workers that are injured on the job or while engaged in the performance of their duties as per their job requirements. In Texas Workers Compensation is not compulsory unless the employer is a government entity or a contractor working on a government based construction project or job. Texas is currently the only state that does not have mandatory coverage for employers, however it does provide options for self-insurance by employers to cover employees under specific conditions. Money to fund the Texas Workers Compensation program is obtained through taxation of insurance carriers as well as a 10% that is obtained by the certified self-insurers in the state, typically smaller businesses. Approximately 70% of all employers in Texas have Workers Compensation and an additional 10% are certified self-insurers.

Texas Worker Injuries

In Texas, injuries that occur on the job including any type of physical injury may be eligible for Workers Compensation fund provided you miss work for more than 7 days. This can include any physical health issue including diseases that are directly related to the work environment or conditions.

Filing a Claim for Workers Compensation

There are several different workers compensations forms that have to be completed to start the claim process. These include wage forms, employee claim forms and medical forms that need to be completed by the treating physician. Employers workers compensation forms can be obtained through the Texas Department of Insurance website and can be completed and submitted online.

Workers Compensation Claim Denials

When a work injury settlement is denied it is often due to lack of documentation, incorrect or inaccurate documentation or a lack of evidence that supports the workers claim that the injury occurred while on the job. Often additional documentation and a review can provide the opportunity to supply the required documentation to complete the claim.  

Appealing a Texas Workers Compensation Denial

Typically the first step in an appeal or benefit review conference, known as a BRC, which is managed by a dispute resolution officer, who acts as a mediator. If there is not a mutually agreeable settlement at this level, a Contested Case Hearing or CCH is then held. In this case a hearings officer can call witness and a formal decision is made. If this is not acceptable a three- judge panel reviews the transcripts if an appeal is requested within 15 days of the CCH. From there the case can go to the district court of appeals and then the Texas Supreme Court if it cannot be resolved.

Collecting Texas Workers Compensation Benefits

In Texas those receiving Temporary Income Benefits through Workers Compensation are eligible for 70% of their total income, providing they are making more than $8.50 per hour. Those making less than $8.50 per hour receive 75% of their gross income. Benefits can be paid for up to 104 weeks on Temporary benefits or until a doctor signs off on a return to work.

Since employers that have Workers Compensation cannot be sued by employees, the only recourse for injuries with companies that have Workers Compensation coverage is through the system. Workers can, however, sue employers not under Workers Compensation as well as third parties for any work related injury or disease. Hiring an attorney is essential to determine if there are any additional legal suits that may be filed to help with medical costs and compensation due to negligence.

Texas Workers Compensation Office Locations

Division of Workers Compensation
7551 Metro Center Drive, Suite 100
Austin, Texas 78744-1609

Texas Department of Insurance
Post Office Box 149104
Austin, Texas 78714-9104