"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.
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 third category of disputes involves the denial by the insurance company to pay for treatment that has been provided on your compensable claim.
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. | Contact FormContact Form |
Thomson Law Firm
Principal Office: 2461 Forest Park Blvd., Ste. 103, Fort Worth, Texas 76110