Workers’ compensation is the only means for workers to be able to support their families monetarily during the time of injury, which sometimes may be for a few months to a few years.

Many workers across America have had a negative, perhaps even slightly hostile, experience with workers’ compensation and have had the need to dispute certain aspects such as compensation, medical bill payment, and level of disability rating among other issues.

For this assignment, write an essay describing the benefit of the dispute process for the state that you live and/or work in.

Think about these questions when writing your essay:

Why is the dispute process even needed?

What are common causes of injured workers disputing the level of benefits or compensation?

What are the workers’ rights and responsibilities when dealing with disputes? · What is the root cause of disputes?

Is it a basic viewpoint of the accident situation in general, or is it a lack of communication, or inaccurate communication

between many different groups?

How does the dispute process fit into the claims management process?

Your essay should be a minimum of five pages. At a minimum, the resources you identified in your Unit IV annotated bibliography should be used in your paper. The annotated bibliography itself will not be included as a part of the assignment, just the resources you identified. All sources used, including your textbook, must be cited and referenced following APA

guidelines, and your essay should be formatted in APA style to include a title page and reference page.

NOTE: Much of the dispute process may be reviewed on your state’s web page. Remember, the assignment is to show the

perceived benefits of the dispute process, not the actual description or purpose of the process.

Information about accessing the grading rubric for this assignment is provided below.

The state to be used is Texas

https://www.tdi.texas.gov/wc/index.html

Annotated Bibliography

Occupational Injury and Illness Surveillance: Conceptual Filters Explain Underreporting

This article written in 2002 address’ how occupational health surveillance data are key to effective intervention yet the he US Bureau of Labor Statistics survey significantly underestimates the incidence of work-related injuries and illnesses. (Azaroff, Levenstein, & Wegman, 2002). The researchers concluded that the US Bureau of Labor Statistics survey does not have a comprehensive national surveillance system for occupational injuries and illnesses and lacking this system, major sources of US occupational health data include the Bureau of Labor Statistics (BLS) annual survey of occupational injuries and illnesses, workers’ compensation records, and physician reporting systems. produced by these systems have been described as fragmentary, unreliable, and inconsistent. Moreover, they have been shown to underestimate the incidence of work related injuries, illnesses, and even fatalities by as much as several hundred percent. (Azaroff, Levenstein, & Wegman, 2002) The researchers applied the filter model of Webb et al. to underreporting by the Bureau of Labor Statistics, workers’ compensation wage-replacement documents, physician reporting systems, and medical records of treatment charged to workers’ compensation. (Azaroff, Levenstein, & Wegman, 2002) They discovered that better methods to track the cases were needed as some were just lost during the process and that most workers typically risk negative consequences in order to get their claims actually filed. It was also found that due to the loss of claims and negative consequences that there were no actual steps to assist workers in filing of their claims and for the ones that do exist they weren’t helpful or barely existed at all.

Compensating Workers for Permanent Partial Disabilities

This article address the major differences in different states and their workers’ compensation programs. Although workers’ compensation is the nation’s oldest social insurance program, it is less well understood than others. Perhaps the greatest variability is in how the jurisdictions compensate workers for permanent disability, particularly permanent partial disability. (Barth, 2004) A contributing factor is that the laws and administration of these programs vary by state. Even practitioners, who may be familiar with the application of the law within their own states, often have little knowledge about the workings of the laws in other jurisdictions (Barth, 2004). With the exception of Texas all states require that employers provide coverage for their employees in accordance with the state’s laws. Employers obtain coverage in one of three ways; purchasing insuracne from private carriers or competitive state based companies, self insure, or from the state operated insurance company which exists in four states. The basic approaches used by the states can be classified into four groupings; impairment-Based Approach, Loss-of-Earning-Capacity Approach, Wage-Loss Approach Bifurcated Approach. Although important differences exist within each group depending on the approach used, workers with similar injuries can receive substantially different amounts of benefits. Because compensating permanent partial disabilities frequently involves contention, the matters in dispute will depend on the approach used to determine benefits. The one issue all states agree on is that medical bills be aid for by the employer when an injury occurs on the job but there is tpically a 3-7 day waiting period for that to occur. The continuation of such differences in approach suggests that the states have not found a single “best practice” for determining what such benefits should be. (Barth, 2004)

TXANS tackle workers’ compensation

This article was written in order to discuss the organization TXANS, a nonprofit organization consisting of approximately 1,200 employers that have opted out of the state’s workers’ compensation system to provide a different option. Started in 1990, TXANS’ primary goals are to work with the state legislature to keep the system elective and to encourage members to develop effective employee injury benefit programs. (Christine, 1994) Those employers who are listed as “nonsubscriber” to the Texas workers’ compensation system, typically experience large cost savings. However, concurrent with this benefit is a significant risk: Nonsubscribing firms lose the statutory protections afforded by workers’ compensation, leaving them vulnerable to many types of negligence suits. (Christine, 1994) Those who choose to become nonsubscribers must provide insurance benefits to their employees but must also maintain the safety standards as set forth by OSHA. TXANS requires that its’ members develop benefits that are equal to or greater than the benefits that state based workers comp programs provide. A survey conducted by Abilene Christian University demonstrates that TXANS members have been successful in creating their own programs. For example, although workers’ COMpensation coverage in Texas begins seven days after an injury, 91 percent of TXANS members begin paying benefits immediately. Also, nonsubscribing employers require a safety program compared to only 52 percent of subscribers. This emphasis on safety has reduced injuries and associated costs by 54 percent. And these savings can be accomplished at coverage rates that are 69 percent lower than the cost of workers’ compensation insurance. (Christine, 1994)

New Texas ‘Two-Step’ Program Aims to Simplify Workers’ Comp Disputes.

This article was written to address The Texas Division of Workers’ Compensation is taking a promising pilot program statewide to help simplify and speed resolution of some disputes. (Jones, 2020) No claim is the same so the program will have to take into account the difeerences that each individual case will undergo. The pilot program was started in 2015 and splits up related claim issues so that a hearing officer can decide the most far-reaching issue first. This can clear the way for secondary issues to be resolved sooner. So far, about half of the disputes accepted for the program have had a hearing, and a third of those have resulted in full agreement to resolve the dispute. (Jones, 2020) The Texas Workers Compensation Commissioner is hopeful about the program and its inception and ability to help the current system. When an injured employee has a dispute about a claim, it often involves three issues: extent of the injury, the date that the employee reached maximum medical improvement, and the impairment rating for the injury. Deputy Commissioner for Hearings Kerry Sullivan said even though extent of injury is a “threshold issue” that can affect the other issues, it was addressed at the same time as the other issues in the dispute process. (Jones, 2020). Although a voluntary program the option to participate in the program provides benefits to both the employee and employer. The option for this program is only used if both parties agree to use it and an agreement on the ratings can be reached.

Texas lawmakers pass workers comp reforms

This artcle written in 2001, address’ how employers that opt out of the state workers compensation system will no longer be able to ask workers to waive their rights to sue for injury benefits under a measure passed in the final days of the state’s legislative session. This article also addresses how the a new piece of legislation would which would make the state’s workers comp fund a mutual insurer which means that it would be both a market of last resort and a competitive fund (Bradford, 2001). Since Texas, unlike all other states doesn’t require an employer to have workers’ compensation coverage this leaves an employer open to personal liability suits and a way to avoid this was to get employees to sign away their rights. H.B. 2600, sponsored by Sen. Robert Duncan, R-Lubbock, nullifies a recent Texas Supreme Court decision that upheld the right of employers that opt out of the state’s workers comp system to ask workers to sign the waivers. Non-subscribing employers typically have in place plans that provide benefits to injured workers, and some employers have sought to have workers waive their rights to additional benefits. (Bradford, 2001) This bill is important because although benefits should be given to those who actually protect their emloyees by providing some type of workers comp the state doesn’t want employers to use intimidation or other methods to convince employees to waive their rights. This could be especially important because Texas has a lot of immigrants and for employers that lean towards employing imigrants they could coherse them to work with no benefits if they don’t provide the translation.

Trends in worker’ compensation

This article was written to address the issues within the workers’ compensation system and how corporations and the insuracne industry are rallying together to change laws to benefit thmeselves while hurting their employees and leaving them to end up on well fare after completion of benefits or resorting to violence. This article initially talks about employees who either murdered their boss and other employees and themselves after being told that they would no longer receive benefits from workers’ compensation even though they still needed the benefits and had received no compensation to sustain themselves or their families. The common issue with these employees was compensation laws have been passed denying injured workers the minimum financial sustenance they need to get healthy and go back to work. The laws are part of a nationwide attempt by the insurance industry and big business to gut individual state workers’ compensation systems. (McDonald & McDonald, 1997) While the “reform” has been disastrous for injured workers, employers and insurers have benefited. Changes in state workers’ compensation systems from 1991 to 1996 reaped $3.6 billion in savings nationwide, according to the National Council on Compensation Insurance, Inc. (McDonald & McDonald, 1997). The American Insurance Association (AIA) is already lobbying for additional “reforms” in several other states and these “reforms” will benefit the insurance companies as well as the businesses. These so called reforms would limit what could be claimed Limiting or abolishing claims for nonscheduled soft-tissue-type injuries, repetitive motion injuries, and stress-related injuries, eliminating benefits for injuries related to preexisting conditions, pushing for the mandatory use of the American Medical Association (AMA) Guides, pushing for ironclad exclusive remedy provisions, Legislating attorneys out of the system to eliminate litigation costs in favor of alternative dispute resolution (McDonald & McDonald, 1997).

Bibliography
Barth, P. S. (2004, March). Compensating workers for permanent partial disabilities. Retrieved from Pro Quest Public Health Databse: https://search-proquest-com.libraryresources.waldorf.edu/publichealth/docview/227782154/5D3E993779A84E75PQ/1?accountid=40957
Bradford, M. (2001, June 4). Texas Lawmarkers pass workers comp reforms. Retrieved from Business Insurance Vol 35: https://go-gale-com.libraryresources.waldorf.edu/ps/retrieve.do?tabID=T003&resultListType=RESULT_LIST&searchResultsType=SingleTab&hitCount=13588&searchType=BasicSearchForm&currentPosition=63&docId=GALE%7CA75405484&docType=Brief+article&sort=Relevance&cont
Christine, B. (1994, April). TXANS tackle workers’ compensation. Retrieved from Gale OneFirle: https://go-gale-com.libraryresources.waldorf.edu/ps/i.do?p=PPIL&u=waldorfcoll&id=GALE|A15192957&v=2.1&it=r&sid=PPIL&asid=a1b63ac6
Jones, S. K. (2020, March 19). New Texas ‘Two-Step’ Program Aims to Simplify Workers’ Comp Disputes. Retrieved from Gale OneFile: https://go-gale-com.libraryresources.waldorf.edu/ps/retrieve.do?tabID=T003&resultListType=RESULT_LIST&searchResultsType=SingleTab&hitCount=1&searchType=BasicSearchForm&currentPosition=1&docId=GALE%7CA543099847&docType=Article&sort=Relevance&contentSegment
McDonald, G. R., & McDonald, L. A. (1997, October). Trends in worker’s compensation. Retrieved from GALE ONEFILE Criminal Justice: https://go-gale-com.libraryresources.waldorf.edu/ps/retrieve.do?tabID=T002&resultListType=RESULT_LIST&searchResultsType=SingleTab&hitCount=2737&searchType=BasicSearchForm&currentPosition=11&docId=GALE%7CA20018005&docType=Article&sort=Relevance&contentSegm

Running head: TEXAS WORKERS’COMPENSATION DISPUTES 1

Texas Workers’ Co

m

pensation Disputes

NAME

Columbia Southern University

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TEXAS WORKERS’COMPENSATION DISPUTES 2

Texas Workers’ Compensation Disputes

Disputes can sometimes arise in workers’ compensation cases involving

miscommunications, disagreements on ratings or benefits provided, and concerns with a lack of

support to the employee by the carrier or employer. Grabell & Berkes (2019) state, “the cutbacks

have been so drastic in some places that they virtually guarantee injured workers will plummet

into poverty”. This obviously is a driving factor as to why injured employees push for additional

support. In most events disputes could be avoided by simply taking the time to sit down with the

employee, explain their benefits, and rights and responsibilities within the workers compensation

system. In others the only way to find a resolution is to challenge a decision and depend on the

commission to play mediator. Common dispute requests might involve clarification on the extent

of injury where adverse medical effects were found after or during treatment, maximum medical

improvements challenges (MMI), an impairment rating challenges (IR) or a general claim denial

of coverage.

Extent of injury relates to an injured employee who may have had pre-existing conditions

that interfere with their injury management. An example of this is someone with previously

herniated discs in the lumbar region of their spine, that receives a strain at work by lifting a

heavy box. The carrier would except the strain as it occurred at work and would likely request

the past medical history to compare to their current findings to determine if the damages that

existed from the previous medical issues were exaggerated because of the new strain or if the

condition remained unaffected. While the employee may receive treatment for the strain, as it

was in the course and scope of their employment, the carrier would not be responsible for the

past damage to the body and could file a partial denial. Most workers feel if the injury results in

discomfort that does not subside and is new to them, everything should be done to return them to

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TEXAS WORKERS’COMPENSATION DISPUTES 3

their original state. Partial denials typically cause concern for the injured worker, in which case

they may consult with the commission and file a dispute regarding the extend of injury. While

Business Wire’s (2019), findings for similar cases in California found that 9 of out 10 cases

showed the independent medical reviews were upheld, it showed these cases involved decisions

that were modified cases involved in the study, meaning the DD’s altered their decisions and

were found accurate by another medical professional. This can benefit the employee as it forces

an impartial party review the medical findings, allowing another perspective and consideration

for facts the carrier may not have initially focused on that effects the injury to the employee’s

body. While portions of a claim may remain disputed, these conferences could also result in

opportunities for additional forms of treatment, or the full decision may be overturned.

Like with the extent of injury, it may benefit an injured worker to file a dispute pertaining

to MMI or their IR when the treating or designated doctor (DD) has closed their case

prematurely or assign a rating lower than expected for the permanent disability they sustained. In

these instances, it is almost always best to work with an ombudsmen or representation to allow

someone to help build a case to justify the concern for a low rating applied. Ratings are based on

a full body impairment. In other words, if the strain sustained to the back resulted in permanent

disability and the employee cannot longer regular functions without causing a reaggravation, the

doctors must consider how much the lost effects the full bodies functional capabilities. Being that

the back supports all our extremities, our ability to walk, stand up, lift, carry and so forth, a fair

rating must take into consideration all these things. Unfortunately, within workers’ compensation

what we value our bodies as does not translate into a substantial monetary value, but it does offer

some financial support as well as pad the medical file making it easier to receive additional

medical treatment as needed for continued care.

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TEXAS WORKERS’COMPENSATION DISPUTES 4

Denial of coverage can be a very threatening situation for an injured worker. When a

denial occurs, employees are informed that they have the right to appeal the decision within 90

days. During this time frame it allows them the opportunity to rather their medical files with any

possible evidence that would relate their injury, such as activities performed on the job. It is best

to prepare a statement that will be shared with the employee’s counsel as well as the commission

to ensure the same information is shared upon each encounter. This includes the BRC, CCH and

court stage of the dispute process should it reach that level. Denial’s may arise for many reasons,

it can be as simple as the injured party not responding to the carrier to verify injury details,

doctors providing insufficient medical evidence to support an injury, vocabulary used to describe

the injury such as soreness rather than pain, or the lack of evidence supporting a workplace

accident such as: a time, place, and incident that caused the injury. If the employee complies their

evidence and files for a BRC, they are likely to be well received and may overturn the decision

initially made by the carrier. Texas is very pro-injured worker, they workers’ compensation was

not made for the employer but to protect the employees. While this process may take time, they

are well worth the employee’s efforts.

Unlike the cases described by Hyatt & Kraji (2000), where cases with uncertainty were

more likely to receive lump sum settlements, Texas does not settle cases therefore is required to

arbitration. Upon filing a dispute in the state of Texas the first step in the dispute process is a

Benefit Review Conference. This is an informal conference lead by a DWC representative that

reviews the case file and works as a mediator to discuss actions that could be done to support a

resolution to the concerns at hand (Texas Department of Insurance, 2018). This is one of the best

ways to get all parties involved in one room; the carrier, injured worker and employer. Most

people question if a lawyer is needed to be successful in a BRC and the answer is “no”. If the

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TEXAS WORKERS’COMPENSATION DISPUTES 5

injured worker is ever unsure about the process, lacking confidence for fearful of his/her lack of

knowledge on the process, they may place a request with the commission to work with an

ombudsman for free. The ombudsmen will help walk the employee through the BRC process,

and plan with the worker what information might be needed to successfully relay their concerns

and gain the support of the parties involved.

When an agreement cannot be made within the BRC, the DWC representative then places

a request for the file to be transferred to a Contested Case Hearing (CCH). If the resolution set

forth by the CCH is found unsatisfactory to either party, a request may be placed in writing for

have an appeals panel to reconsider the CCH decision (Texas Department of Insurance, 2018). It

is uncommon for a case to be taken beyond a CCH. Most cases can be resolved; however, the

injured party may choose to go as far as having a judicial review performed. Once the courts

settle on a resolution the decision becomes final. Cases that see this level of action are typically

ones represented by an attorney. Attorneys tend to take a more aggressive and negative stance on

the workers’ compensation programs. As mentioned by Mitchell Byrd (2018), “by requiring

injured workers to fight with them for the benefits they desperately need, the insurance company

keeps the money it should pay out in its own accounts much longer”. From his perspective, with

the support of a professional on workers’ compensation law an employee is likely to be more

successful in their fight for fair benefit coverage with a timelier response. While support is

beneficial, it is difficult to understand why one would choose to hire an attorney, paying 25% of

either awarded benefits, when they could utilize the support of true professionals in workers’

compensation law whose whole purpose is to protect the people for free. While the dispute

process may appear intimidating at first, if an injured party is directed to the proper resources,

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TEXAS WORKERS’COMPENSATION DISPUTES 6

such as the TDI.gov website they may find all the support they need to successfully dispute and

resolve their workers’ compensation concerns.

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TEXAS WORKERS’COMPENSATION DISPUTES 7

Resources

Boggs, C. J. (2011). The Insurance Professional’s Practical Guide to Workers’ Comp: From

History Through Audit (2nd ed.). San Diego, CA: Wells Media Group.

Business Wire. (2019). CWCI Takes An Updated Look At California Workers’ Comp Medical

Dispute Resolution. Retrieved from

http://eds.b.ebscohost.com.libraryresources.columbiasouthern.edu/eds/detail/detail?

vid=1&sid=65351286-5828-4c49-b8b8-d68ffb2c82db

%40sessionmgr102&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d

%3d#AN=bizwire.c88762703&db=bwh

Byrd, M. (2018). The Difficult and Unfair Fight for Workers’ Compensation

Benefits. Retrieved from https://www.thecarolinalawgroup.com/2015/03/workers-

compensation-benefits-the-difficult-and-unfair-fight/

Grabell, M., and Berkes H. (2015). The Demolition of Workers’ Comp. Retrieved from

https://www.propublica.org/article/the-demolition-of-workers-compensation

Hyatt, D. and Kralj, B. (2000). The Impact of Representation and Other Factors on the Outcomes

of Employee-Initiated Workers’ Compensation Appeals. Industrial and Labor Relations

Review, 53 (4), 1-20.

Texas Department of Insurance. (2018). Dispute Resolution for Injured Employees. Retrieved

from https://www.tdi.texas.gov/wc/employee/dispute.html

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