A Denial Is Not the End of Your Claim
Few things are more stressful than getting hurt at work, except opening a letter from the insurance carrier telling you your workers' compensation claim has been denied. Suddenly, the medical care and wage-replacement benefits you were counting on are in question, and the bills keep arriving.
Here is what every injured worker in San Antonio should know: a denial from the insurance carrier is not the final word. Texas has a structured dispute resolution process through the Texas Department of Insurance, Division of Workers' Compensation (DWC), and many denied claims are ultimately overturned when the injured worker presents the right evidence at the right stage.
At Espinoza & Brock, our workers' compensation team is led by Amanda J. Spencer, who is Board Certified in Workers' Compensation Law by the Texas Board of Legal Specialization, a distinction held by only a handful of claimant's attorneys in the entire state. We know this system inside and out, and we know how carriers build denials.
Why Insurance Carriers Deny Workers' Comp Claims in Texas
Insurance companies are for-profit businesses focused on limiting costs. Some of the most common reasons carriers give for denying claims include:
- Claiming the injury is not work-related or did not occur in the course and scope of employment
- Arguing the injury is due to a pre-existing condition rather than the workplace accident
- Disputing the extent of the injury, such as accepting a sprain or strain while denying more serious diagnoses
- Asserting the injury was not reported to the employer within 30 days
- Alleging the formal claim was not filed with the DWC within one year
- Disputing your disability status or ability to work
- Challenging your impairment rating after you reach maximum medical improvement
Some of these disputes involve the entire claim, while others involve only certain body parts, benefits, or treatments. Either way, each dispute can be challenged.
The Texas Workers' Comp Dispute Process, Step by Step
Disputed claims in Texas move through the administrative process established under Chapter 410 of the Texas Labor Code. Here's how it generally works:
Step 1: Benefit Review Conference (BRC)
A benefit review conference is an informal mediation session with a DWC benefit review officer. You and your attorney, if you have one, meet with the insurance carrier's representative to try to resolve the disputed issues. Many disputes are narrowed or resolved at this stage, especially when the injured worker arrives with organized medical evidence rather than hoping the carrier will change its mind.
Step 2: Contested Case Hearing (CCH)
If the BRC does not resolve the dispute, the case proceeds to a contested case hearing before a DWC administrative law judge. This is a formal proceeding, much like a trial. Evidence is admitted, witnesses testify, and the judge issues a written decision on the disputed issues. The medical records, expert opinions, and testimony presented here are critical. This is where most claims are won or lost.
Step 3: Appeals Panel
Either side can appeal the judge's decision to the DWC Appeals Panel, which reviews the written record for errors. Strict deadlines apply, and the arguments must be made in writing.
Step 4: Judicial Review
If the administrative process does not resolve the dispute, the final step is seeking judicial review in court. At this stage, having a firm with real litigation experience matters enormously.
You can read more about the state's dispute resolution process directly from the Texas Department of Insurance, Division of Workers' Compensation.
Deadlines That Can Make or Break Your Claim
Texas workers' compensation claims are governed by strict deadlines, including:
- 30 days to report your injury to your employer
- One year to file a formal claim with the DWC
- Short windows, often measured in days, to request a BRC, appeal a CCH decision, or respond to the Appeals Panel
Missing a deadline can forfeit benefits entirely, even in an otherwise strong claim. If your claim has been denied, do not wait to get guidance.
How a Workers' Compensation Lawyer in San Antonio Helps After a Denial
Injured workers who go through the dispute process alone face experienced adjusters and carrier attorneys who handle these hearings every day. An experienced workers' compensation lawyer in San Antonio can:
- Identify exactly what the carrier is disputing and what evidence will defeat the denial
- Gather medical records and work with your doctors to document the compensable injury
- Challenge unfair extent of injury positions and improper impairment ratings
- Prepare and present your case at the BRC, contested case hearing, and on appeal
- Protect you from missing the deadlines that end claims prematurely
If your employer fired you or punished you for pursuing your claim, you may also have a separate workers' compensation retaliation claim under Texas Labor Code § 451.
What Is the Takeaway?
A denied workers' compensation claim in Texas is a serious problem, but it is also a fixable one in many cases. The DWC dispute process gives injured workers the chance to challenge the carrier's decision through a benefit review conference, a contested case hearing, an appeals panel review, and ultimately the courts. Success depends on evidence, preparation, and meeting every deadline along the way.
Amanda J. Spencer, the only Board Certified workers' compensation claimant's attorney in the Greater San Antonio Area, and the team at Espinoza & Brock have brought thousands of workers' compensation cases to successful resolution. If your claim was denied or your benefits were cut off, contact our office today to schedule a no-risk consultation and learn how we can fight the denial.
