Appealing a Texas Workers Compensation Denial

Understand what steps should be taken when appealing a workers compensation denial in the state of Texas.

If you are injured on the job in Texas, you may have a workers’ compensation claim under Texas state law. (To learn about making a claim, see Workers Compensation Claims in Texas). If your employer, or your employer’s workers’ compensation insurance carrier denies your claim, you have the right to appeal. Here is how the appeals process works in Texas.

Benefit Review Conference

As soon as you receive notice of a claim denial, you should contact your employer or its insurance company to try to resolve the problem. Division of Workers’ Compensation Insurance of the Texas Department of Insurance. This is the state agency responsible for administering the workers’ compensation system. You should request dispute resolution.

The first stage of dispute resolution before the Division of Workers’ Compensation is a Benefit Review Conference. This is an informal meeting in which you and a representative of your employer will meet with a Division of Workers’ Compensation Benefit Review Officer. The process is much like mediation – the parties meet and discuss the dispute in an effort to reach an agreement. This may result in a settlement offer to you.

If you and your employer or its insurance company come to an agreement, you may be asked to sign a written settlement agreement. However, if you cannot agree, you may agree to proceed to arbitration or you can go directly to a contested case hearing.

Arbitration

Arbitration is a slightly more formal process than a Benefit Review Conference. At arbitration, you will meet again with a representative from your employer. An arbitrator chosen by the Division of Workers’ Compensation will discuss the dispute with all parties.

The arbitrator will render a decision. This decision is final, and cannot be appealed. Arbitration typically takes less time and costs less than a full contested case hearing. However, you waive your right to a contested case hearing in front of a hearing officer and you wave all future your appeal rights if you choose to participate in arbitration.

Contested Case Hearing

If the parties did not choose to participate in arbitration, the next step will be a contested case hearing. This hearing is a formal, legal process. A Division of Workers’ Compensation Hearing Officer presides over the hearing.

The Hearing Officer will consider evidence submitted by all parties. You will need to present medical evidence to support existence of your workers’ compensation claim. You will also need to present evidence from any individuals that witnessed your industrial injury.

After the hearing, the Hearing Officer will issue a written decision adjudicating the issues involved in the contested case hearing.

Appeals Panel

If you disagree with the Hearing Officer’s decision, you may appeal to the Division of Workers’ Compensation Appeals Panel. You and your employer or its insurance company will submit written briefs arguing your respective positions. The Appeals Panel will review the briefs and the record from the contested case hearing. No new evidence may be presented to the Appeals Panel.

The Appeals Panel will then issue a written decision. This decision may affirm, modify, or reverse the Hearing Officer’s decision.

Texas State Courts

If you are unsatisfied with the Appeals Panel decision, you can appeal to the Texas State Courts. Making an appeal from the administrative level to the state courts is a complex legal process. You should strongly consider hiring an attorney to assist with this portion of the appeal, if you have not hired an attorney already.

Attorney Assistance & Office of Injured Employee Counsel

You are entitled to have an attorney represent you throughout your workers’ compensation claim, and should strongly consider hiring an attorney if your injuries are severe or you have significant pre-existing conditions. The dispute resolution processes, especially beginning with the contested case hearing, require knowledge of sophisticated legal rules, and the judge will require you follow these rules.

The Office of Injured Employee Counsel (OIEC) can also help you with your disputed workers’ compensation claim, free of charge. You can contact OIEC at (866) 393-6432.

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