There are several reasons why an Injured Worker (IW) in Texas may not be getting treatment for an on the job injury. This entry will discuss the two most common circumstances that lead to an inability to have medical care covered by an employer’s insurance policy. First and foremost, in order for an IW to receive medical treatment through the employer’s insurance policy, the claim must be accepted by the employer’s insurance carrier (IC). Unfortunately, there are many occasions where the IC denies a claim, whether it is due to reporting issues or factual reasons. It is imperative that an IW report any injury sustained at work within 30 days. That is the easiest way to ensure that a claim will at least be considered on the merits by the IC. If a claim is denied by the IC, for whatever reason, treatment will not be covered, leaving the IW to pay for medical expenses out of pocket. In this situation, an IW will receive information from the IC on how to pursue the claim. Usually, this includes contacting the adjuster and filing a claim with the Texas Division of Workers’ Compensation (DWC).
An IW can file a dispute with the DWC individually, or with the assistance of an attorney or Ombudsman. Once a dispute is filed with the DWC, an IW enters the formal dispute resolution system enacted by the State. The initial step is to attend a mediation style meeting where the IW will meet with the IC’s representative, usually an attorney, to discuss the facts of the case. If the IC maintains it’s denial of the claim, then the dispute will move forward to an Administrative Law trial, where a Hearing Officer (HO) will determine whether or not there was an on the job injury. If the HO rules in favor of the IW, then there is a possibility that the IW will be reimbursed for past treatment by the IC and that future treatment will be covered under the employer’s insurance policy.
If a claim is deemed to be “compensable,” then usually initial treatment will be covered by the IC. However, this is no guarantee that medical treatment will continue to be approved and covered. In most situations, the IC will accept (whether initially or after a decision from a HO) a minor or less severe diagnosis. For example, if a worker injured their back at work, the IC might accept a simple back strain. What this means is that the IC will only cover treatment directly connected and necessary for that diagnosis (e.g. physical therapy, medication, and follow-up appointments). The situation gets complicated if the treating doctors believe that there is something more serious going on, and recommend more invasive treatment (e.g. injections or surgery). Taking the previous example of the back injury, an IC will not approve a surgery for a back strain, as that would be excessive for a minor injury and not medically necessary. The issue then becomes what diagnosis or diagnoses are at the root of the injury, what are the doctors treating?
This particular situation frequently frustrates IWs, as they have been receiving treatment up to a certain point, and then begin receiving denials for medical requests out of the blue. This brings up an extent of injury dispute, which often follows the same process delineated previously with the DWC. It will be up to the IW to provide sufficient medical evidence to the IC or HO to support their contention that a certain diagnosis is related to the work injury, and thus, making the IC liable for the necessary treatment. The important thing to remember is that medical treatment will only be approved and covered for injuries that the IC has “accepted.” If the injuries that are being treated by the IW’s doctors don’t line up with those accepted by the IC, then treatment will reach a screeching halt.
Although it may appear simple at the onset – you get injured at work, so your employer should take care of you – it often becomes a struggle to get the IC to cover treatment for the on the job injury. Even though the DWC offers a formal dispute resolution system, it can often be difficult for an IW to navigate without knowledge of the rules and procedures. It is recommended that an IW promptly reach out to a Workers’ Compensation attorney if any issues arise with their claim, it is better to handle matters as they occur, rather than trying to rectify an injustice years down the road.