Texas Workers Compensation Denial and Dispute Guide


"I have been told that the insurance company has disputed my claim.  What does this mean?"

If you have been told that the insurance company has disputed your claim or denied your claim, that means the insurance company is not going to pay benefits based on that dispute or denial unless they work out an agreement with you regarding the dispute or are ordered to pay the disputed benefits.  There are several different kinds of disputes.  The action to resolve the disputes depends upon the type of dispute that is filed.

The first category of disputes involves compensability or liability of the workers compensation insurance company to pay benefits on the claim.

  • The dispute may be a complete claim denial.  The insurance company may be stating that it is refusing to pay benefits because your claim is not compensable, such as that you were not injured at work, or that the injury was not reported timely.  
  • The dispute may be a partial denial, stating that you have a compensable claim but that the benefits are limited in some way.  For example, the insurance company may attempt to limit your injury to a simple strain or sprain of a part of your body.  The dispute shows that the insurance company refuses to accept any injury to underlying structures of your body that are more seriously injured.
  • The dispute may be a dispute refusing to pay certain benefits.  These include income benefits such as temporary income benefits, impairment income benefits, supplemental income benefits, lifetime income benefits, death benefits, or medical benefits due to compensability of those medical conditions being denied.  These include disputes concerning your date of maximum medical improvement and disputes regarding your impairment rating.
You usually receive this type of dispute filed on a PLN-11 form.  Texas workers compensation insurance companies are required to file the PLN-11 form to notify the Texas Division of Workers Compensation and you that the insurance company is refusing to pay benefits in some way.  The form is supposed to be a plain language notice to you.  It should state plainly the reasons for the denial of benefits on the form.  The insurance company is limited to the reasons for denial that it places on the forms it sends to you.  A generic statement that simply states the insurance company's position with phrases such as "employee returned to work," "adjusted for light duty," "liability is in question," "compensability in dispute," "under investigation," or other similar phrases with no further description of the factual basis for the action taken does not satisfy the requirements of the law.  In these cases, there have been rulings that the insurance company filed such a vague denial that it amounted to no denial at all and that the insurance company is responsible to pay the benefits.  There are also rulings that hold that the insurance company does not have the right to use certain defenses because they were not stated on the denial.  

You may receive this type of dispute over the phone in a conversation with the adjuster and not receive any paperwork in the mail.  While insurance companies are required to file the PLN-11 form, sometimes the insurance company does not file the form and there is no record of the dispute, even though you are not receiving benefits.

You should talk with an attorney regarding the insurance company's denials.  Your attorney will be able to apply the law to your specific fact situation and discuss the next steps to handle your case and resolve the situation.

The second category of disputes involves the denial by the insurance company to provide treatment for your compensable claim.
  • The dispute may be a medical necessity dispute on your claim.  This is a dispute concerning whether or not specific medical treatments or services are medically necessary.  These denials may include office visits with your treating doctor or prescriptions.
  • These disputes also include preauthorization denials for certain treatments that are required to be preauthorized by the doctor before the service is provided to you.  These disputes will affect the type of treatment you can receive on your claim and can slow down or stop you from obtaining medical treatment for your injuries.  This will in turn affect your ability to reach maximum medical improvement before your statutory date of maximum medical improvement. You should talk with an attorney about the problems that you are having trying to obtain treatment.

The third category of disputes involves the denial by the insurance company to pay for treatment that has been provided on your compensable claim. 

  • The dispute may be a medical fee dispute on your claim.  This denial comes as an Explanation of Benefits sent by the insurance company to your treating doctor with a copy sent to you.  This dispute is concerning the amount charged by your doctor for the medical services that you received.  These charges are governed by the Medical Fee Guidelines adopted by the Texas Division of Workers Compensation.  The medical fee dispute is a denial or reduction of reimbursement for compensable and medically necessary health care already provided to you.  
  • These disputes arise when your insurance company does not have a network of doctors or you are allowed to treat with a non-network health care provider.  
  • You are not responsible for the difference between the amount paid by the insurance company and the amount charged by your doctor.  Your doctor should not be asking you to pay this difference, and your bill should not be sent to any credit reporting agencies or medical collection agencies.  This includes radiology providers or hospitals that may send you bills.  If you are having a problem with this, you should consult an attorney.

The Division of Workers Compensation processes requests for dispute resolution.  It generally defines these disputes it processes as the disagreements between system participants involving the entitlement to workers’ compensation benefits and the amount to be paid. How the dispute is filed and processed depends upon the type of dispute as listed above.  The dispute is handled by different departments within the Texas Division of Workers Compensation.  Each department handles only that type of dispute.  The resolution of one type of dispute may be delayed because another type of dispute will need to be processed first by another department within the agency.  An attorney can help you with how the processes interplay and what needs to be done as the next step in your case to help you obtain your workers compensation benefits.

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