CLAIM DENIED! THE ADVERSE BENEFIT DETERMINATION.

Why was My Texas Non-Subscriber Claim Denied and What Can I do?

• Texas Non-Subscriber Claims are Denied for Infinite Reasons.
• A claim denial does not mean that you don’t have to right to file a lawsuit.
• Figure out if you can establish that your employer’s negligence caused your injuries.
• Seek legal assistance.

Figuring out whether your work injury case is covered by workers’ compensation or whether it falls under some nonsubscriber policy can be difficult enough! Understanding the work injury process can be even more challenging. Finding out that your employer is a Texas Non-Subscriber can come as a surprise and often times, it can come too late. By then, your claim could be DENIED for not following the Rules of the Game!

Texas Non-Subscriber claims can be DENIED at various stages following the injury. Several work injury benefit plans (work injury insurance) have guidelines that enable the administrators or risk managers of the claim to reject the claims and issue an Adverse Benefit Determination, which is just a fancy way of saying that the claim has been denied. Texas non-subscriber claims can be DENIED for reasons like:

• Didn’t report within the required timeframe (Usually withing a 24-72 hour timeframe).
• Sought medical attention from a doctor that was not approved by the plan.
• Failed to timely provide a medical authorization to the insurance covering the claim.
• Failed to timely provide a recorded statement to the insurance representative.
• Failed to make your medical appointments with the approved medical providers.
• Failed to clearly report how the injury occurred.
• Failed to clearly report what parts of your body were injured.
• Failed to go back to work after you were only given restrictions by the insurance doctors.
• Failed to provide proof of a new injury.
• Failed to attend your independent medical examination (IME)(The Second Opinion).
• Etc., Etc., Etc., …

Read also: What Can You Claim in a Texas Nonsubscriber Cases that You Cannot in a Workers Comp Case?

A Claim Denial Doesn’t Mean That You Don’t Have Rights to File a Lawsuit

In these cases, if you can get beneficial treatment under your employer’s insurance, then by all means get it, get as much of it and get back to work as soon as you can! But, if what happens to you is what happens in most cases and your claim is DENIED, you have to investigate whether you have the right to file a lawsuit for your injuries. In other words, just because your claim was denied, DOES NOT MEAN THAT YOU DON’T HAVE THE RIGHT TO BE COMPENSATED FOR THE INJURIES THAT YOU SUFFERED AT WORK. When your employer’s negligent actions cause your injuries, it doesn’t matter that the insurance DENIED coverage for your claim. You could still have rights to file a lawsuit in Court (State or Federal) or Arbitration. Don’t accept a claim denial as the final word on your work injury claim. Investigate your case and find out if you have additional rights.

Failing to Know the Rules of Game!

The ERISA Plan (Plan Document and Summary Plan Description)

Texas Non-subscriber claims are perfectly set up so that the injured worker can fail. At the time that an employee first starts working for a Texas non-subscriber employer, they supposed to receive an orientation and a copy of the rule book, the Summary Plan Description (The Insurance Policy). This is a short-form explanation of the benefits that injured workers are entitled to under the employer’s work injury benefit program. Here is where you would find guidance for what you are supposed to do after you suffer an injury at work. If there are rules to follow, then you should be able to play the game, right? Wrong! Often, employees are never provided copies of the Summary Plan Description even when company policy requires that it is done. It is one of those things that is often overlooked because it’s not needed at the time of hiring. Even if you were to know that you must ask for a copy of the Plan, many times the hiring employees have not been hired to know what to look for.

Without having access to the rule book, you don’t know what the first thing is that you should do when you suffer an injury working for a Texas Non-Subscriber employer. Therefore, when you suffer an on-the-job injury, you are already playing from behind with little to no knowledge of how the work injury claim process works in non-subscriber cases.

Failing to Timely Report the Injury

One of the first ways that a work injury claim can be denied in a non-subscriber case is that the injured worker fails to report the work injury within the timeframe required by the Plan. Usually, following a work incident, you have a range of time (24 to 72 hours) to formally report an injury to a supervisor at your place of employment. This timeframe varies from employer to employer but, what you should do is assume that your employer requires that a work injury be reported immediately after the incident. This way, you don’t run the risk of having your claim denied because you did not report it. Additionally, by reporting the incident, you are making sure that you are preserving valuable information about the circumstances surrounding the incident. Often times, the adjuster working on your case will ask that you provide a medical authorization and a recorded statement as part of their investigation. If you don’t timely report the incident that caused your injuries: CLAIM DENIED!

Failing to Seek Medical Attention with a Plan Approved Doctor

After you report the incident, injured workers are typically directed to seek medical attention with a specific clinic or medical provider. The adjuster or employer representative will indicate to you that you MUST attend only plan approved medical providers. While there is no law requiring you to attend only plan approved medical providers, in order to receive treatment under your employer’s insurance, you have to see the doctors that the insurance sends you to see. There are all sorts of reasons why I don’t care much for the treatment provided under these non-subscriber plans, the point remains, if you want care and, if you want to see if your injury is serious enough that you are going to miss work but get paid under your employer’s insurance plan, you have to go to their doctors. If you are able to catch on and see that the insurance doctors really do not have your best interests in mind and you decide to go see your own doctor, your claim can be denied. If you seek treatment from your personal doctors or any other unapproved physicians or clinics: CLAIM DENIED!

Your Injury Does Not Qualify as a Covered Injury?

If the injury you reported was an aggravation of a prior injury, the adjuster handling your claim could use this basis to argue that your injury is “pre-existing” or “degenerative” and could use this as a basis to deny your claim. Simply put, injured workers could have a right to make a claim even when the incident at work resulted in an aggravation of an previous injury. If you accept the adjuster’s and the insurance doctor’s arguments that your injuries are “pre-existing” or “degenerative” CLAIM DENIED.

The IME Says Your Not Injured No Further Treatment is Necessary

In non-subscriber cases you will find that the adjusters can be pretty difficult to deal with. In fact, the process of dealing with the adjuster can really frustrating and could feel like you are being bullied for getting injured at work. In these cases, once you have received some initial treatment including some evaluations, physical therapy, x-rays, MRIs, you come to a crossroads where your treating doctor makes a recommendation. That recommendation could be for more specialized tests or, for a referral to an orthopedic specialist for further evaluation. At this point, the insurance company often refers the injured worker to “another doctor” that is not a treating physician but rather, he is a consultant on whether further treatment is necessary. Very often, …very, very often, that examination results in a report that denies that you have any injuries or need for further treatment. Again, the adjuster will still bully you into going to this exam. Again, there is no law requiring you to go but, if you don’t go: CLAIM DENIED. If you go, also: CLAIM DENIED.

If you are being sent for an IME, you know in which direction your work injury claim is going. It’s time to seek legal advice.

Can You Survive a Claim Denial?

Yes, you can! You have to proactive about figuring what the rules of the game are. If you don’t, you have a slim chance of getting the medical attention that you deserve and getting back to work. Remember that the work injury claim under your employer’s insurance is the systems used by your employer and the insurance company to make it appear that you don’t have any other rights to seek compensation for your work injuries. After a work injury, you have to consider whether or not you have rights to file a lawsuit against your employer for failing to provide you with safe work place. We focus on determining whether you have a good case against your employer and providing you with a comprehensive plan on how you can survive the injuries and get your life back!

At Sandoval Law Firm, PLLC, as your attorney, I focus on making sure you understand the process and the plan that my firm is going to implement to get your life back! If you’ve been injured at work, do your research and give us a call!