The process to appeal a workers’ compensation claim denial

| Nov 2, 2016 | workers' compensation

Not all workers’ compensation claims in Texas are processed to the satisfaction of the claimant. This might be a complete denial of the claim, or it might be an insufficient amount. According to the Texas Department of Insurance, dispute resolution might go through one or more of the following steps:

  • Judicial review
  • Benefit review conference
  • Arbitration
  • Contested case hearing
  • Appeals panel

The first step after receiving a disputed resolution to a workers’ compensation claim is to take it up with the insurance adjuster directly to see if there is a way to come to a resolution. When this comes to an unsatisfactory conclusion, an individual begins the official dispute resolution process through the Texas Department of Insurance, Division of Workers’ Compensation.

The final decision that is unable to be appealed is handed down during a judicial review. This occurs in a court of law after an appeals panel is unable to come to a satisfactory conclusion for the injured employee. During an appeals panel, which takes place after an unsatisfactory decision at a contested case hearing, a written review of the situation is submitted to the panel. The panel also reviews the decision of the contested case hearing to inform their decision.

Another way that a final decision is made is through arbitration, which occurs after an unsatisfactory decision during a benefit review conference. This is the official start of the claim denial process when a representative of the insurance company and the individual informally meet with an officer. An injured employee also can choose to go to a contested case hearing, which is a formal hearing in front of an officer, after an unsatisfactory finding in the benefit review conference.

According to the Office of Injured Employee Counsel, an appeal can be done on the entire decision or just a part of it. It is up to the dissatisfied party to clearly and concisely demonstrate the areas of disagreement, along with why there is a problem. The injured employee only has 15 business days to submit an appeal after a contested case hearing, and the opposing party might also request a hearing.

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