If you and the insurance adjuster can't agree on what should be paid, you can request a hearing through the dispute resolution process.
What are the steps in that process?
There are several stages. The first is you are required to document efforts to try to work it out with the insurance before you can request a hearing.
If that fails, you can request a benefit review conference (BRC) on a form DWC-45.
It will take about a month for that first hearing to take place. It is an informal meeting with an employee of the TDI-DWC (Benefit Review Officer) who mediates the dispute between you (with your attorney present) and an attorney from the insurance company. There is no record taken and no testimony under oath. The issues and evidence are discussed and a plan for moving the case forward should be the goal.
If you and the insurance representative can agree, the agreement on benefits is reduced to writing, sometimes there on the spot, and signed to finalize what the insurance must do and what you are giving up, if anything, in exchange. This agreement is binding in most circumstances and requires careful advice and consideration.
If you cannot reach an agreement, the case may be reset for another BRC or set for a final contested case hearing before a workers' compensation , an attorney trained by the TDI-DWC to hear workers' compensation disputes.
A contested case hearing takes place approximately two months later. This is a formal hearing with a record made (sometimes by a court reporter, otherwise by audio recording). An interpreter can be requested in case of a language barrier for a party or witness.
Not later than 15 days from the date of the hearing, any evidence and witness information must be exchanged to the other party. The administrative law judge may exclude evidence not timely exchanged.
Not later than 10 days prior to the hearing, a subpoena for the appearance of any witness must be requested. A subpoena duces tecum for the production of records carries the same deadline.
The administrative law judge may permit witnesses to appear by telephone. This should be requested well in advance to ensure proper acommodation.
Documentary evidence (such as witness statements, claim documents, and medical records) must be prepared and catalogued for easy and comprehensible review by the in order to make sure that all relevant evidence is brought to the 's full attention.
Applicable decisions from the Texas Supreme Court, courts of appeals, TDI-DWC Workers' Compensation Appeals Panel should be cited at the hearing to ensure that the decision conforms with relevant precedent. Statutory provisions from the Labor Code and rules from the Administrative Code will also be helpful. Often it is advisable to prepare copies of legal precedent for review by the and opposing attorney.
By law, the judge is supposed to issue a decision within 7 days of the hearing. That decision will order or deny benefits sought in whole or in part. Not every judge is consistent in getting the decision out in that time frame, and occasionally the judge will either leave the record open or re-open the record to correct an error in the record or obtain additional information to fully develop the record of the case.
The insurance carrier must pay benefits pursuant to the judge's decision and order pending Appeals Panel review. If an employee receives benefits under order from the judge, and the Appeals Panel reverses this decision, the employee does not have to pay back those benefits. The insurance carrier may seek reimbursement from the State of Texas Subsequent Injury Fund
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