The Answer is Yes!
A Denial of Medical and Wage Benefits for Your Work Injury Does Not Mean That You Do Not Have A Case or a Right to Sue Your Employer!
The claim for medical and wage benefits is separate from your right to file a lawsuit for employer negligence. Remember that Texas law does not require employers to carry traditional workers’ compensation coverage. Several large companies are Texas Non-subscribers to the Workers’ Compensation insurance program, which means that they could have an insurance plan (ERISA) that covers injuries to employees. The main goal of these insurance plans is to manage work injury claims, like yours, so that they:
- Limit exposure to lawsuits and
- Limit expense to the employer
Therefore, they do not have an injured workers’ best interests in mind when determining whether the insurance should pay medical and wage benefits. The insurance administrator, (Third Party Administrator or “TPA”), will usually find every way possible to keep from approving any major medical procedure like MRIs or surgery, even when the worker has a serious injury. That is because they are working to limit exposure to lawsuits and to limit the amount of money spent on your claim.
Do not assume that just because your claim for medical and wage benefits is denied that you do not have a negligence case! The very purpose behind denying your claim could be to convince you that you do not have any kind of case. This is just another tactic used by big companies to make injured workers think that they do not have any rights!
What does it mean to Receive an Adverse Benefit Determination?
An adverse benefit determination is a denial of your work injury claim. Just because your claim for medical and wage benefits is denied does not mean that you do not have a right to sue your employer for negligence. There are a number of reasons that your employer’s insurance could use to deny your claim. Your claim could be denied early in the process or even later, when the insurance administrator is having to make a decision on paying for more serious treatment. Remember, they insurance is always looking for ways to deny your claim so that they won’t have to pay you any medical or wage benefits. Here are just some reasons that the insurance could use to deny your claim:
- You didn’t report the claim immediately or within 24 hours;
- You do not have an injury that is covered;
- You did not go to medical provider within the plan;
- Your injury is pre-existing and,
- You have no injury.
At some point, you may have been told that “The Plan” requires you to go only to medical providers that are approved by the plan or, they won’t pay for it. What they don’t tell you is that it is not “illegal” for you to go to your own doctor. In fact, you have every right to go see a physician outside of the plan but, obviously, you will have to pay for those visits. At first examination, you may think that your best option is to stick to the doctors under the plan. Unfortunately, that is exactly what they want you to believe. This is how they will retain control of your treatment and, most often, this is the way that they ruin your negligence case against your employer. Do not settle for treatment under “The Plan”.
Over the years, we have represented injured Texans working for the following Texas Non-Subscribers:
If Your Worker’s Compensation Claim is Denied, You Could Still Sue Your Employer for Negligence!
Now that you know that the work injury claim for benefits is different from a negligence claim, you need to focus on the specific facts of your case to determine if you could sue your employer. If your injury resulted from your employer’s failure to provide a safe workplace because of the lack of training, equipment, manpower, or, because they adopted an unsafe work practice, you could have a good negligence case against your employer.
Knowing what to do even when your claim for benefits is denied is crucial to making sure that you protect your rights as an injured worker. Neither your employer, their insurance, nor their doctors are going to do anything to protect your rights! You will need to act promptly.
Even after understanding the difference between a claim for benefits and a negligence case, you will need to be sure you consult with a Texas non-subscriber attorney that can provide with the best way to approach your case.