| So you have been injured on the job, now what? Well that is a complicated question if your job injury happened in Texas. It's normal immediately after an injury to either do nothing hoping it goes away or to go to the company doctor or emergency room. You are still in pain and you've been told to go back to work but you can't work and the bills are growing, sound familiar? Sometimes, it may seem that you are the only one on your side and you may be right. Worker's compensation claims are big business. Unfortunately, let's face it the employer and company doctor's top priority is to the company. You may be the patient and employee but you are not the client, the company is the client! Ultimately the entity that is here to meet the company's needs is the insurance carrier. The insurance assigns an adjuster to your claim to decide if your claim will be accepted or disputed. This decision affects both your ability to receive healthcare benefits as well as financial benefits. The adjuster can arbitrarily decide to approve or dispute services or can send out for a pre-authorized medical opinion by a nurse or a doctor who is employed or contracted by the insurance company. If the adjuster files a dispute on a claim they can file it for a variety of reasons without needing any proof to do so. They can deny the claim in its entirety which is commonly termed relatedness or attempt to limit a claim to only a sprain/strain injury or limit by how many body parts were injured, termed extent of injury. If there is a dispute you can appeal it to a benefit review conference (BRC) and if lost either side can appeal to a Contested Case Hearing. These are heard on a first come first serve basis with most major cities in Texas backed up for several weeks. In the meantime, if the entire claim is denied then you get no checks and if the extent of injury is denied then you receive little or no treatment. Are you starting to get the picture. This is not to say that all employers or company doctors or insurance adjusters are going to go out of their way to deny your rights to medical and financial benefits. There are of course good and honest professionals who will help injured workers like yourself, at least until they are fired! Always remember there is significant pressure on all parties to make the client happy and you are not the client. On a larger scale this means that insurance political lobbyist shaped significant changes as it relates to injured workers through the development of ultra conservative treatment guidelines. The result has been to get you and all injured workers back to work as quick as possible and as cheap as possible. Notice as healthy as possible was not the main goal. Again, you as the injured worker are not the top priority. It has probably become clear by now that even if you are lucky and everything is going correctly so far on your claim, the system is not designed to be in your short term or long term benefit. Many times things will go ok for a while until the employer and /or insurance grows impatient about when you are going to return to work or how much medical and temporary benefits are being paid on a claim. Many times a claim is paid without a problem until there is notice received for a surgical consultation. Then suddenly, the insurance adjuster or their contracted "independent" doctor decide weeks or even months later that the injury should be a sprain/strain only, despite obvious medical documentation to support it and not eligible for a surgical consult or potential surgery. This effectively places the case on hold and blocks you from being able to see a surgeon because the surgeon will not be paid for their office visit. This is a common move by the insurance because if the surgeon doesn't see you and document the seriousness of your injury then there is a good chance the insurance company will win the dispute and only have to pay a small fraction of the cost of what a potential surgery may have cost. The title of this section is "Pros & Cons" for good reason. Texas is a very difficult state to receive the benefits you are entitled to without any problems. The more serious the injury... the more expensive the case... the more problems you can expect sooner or later. If this has happened to you or if you are concerned it may happen to you then contact us and we will help fight for your rights so you can focus on just getting better and recovering from your injury. |
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