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If you have found this page, you have to be wondering if workers’ comp is cheating you out of your medical treatment and benefits. After all, it’s an insurance program, and everyone knows that insurance companies exist to collect premiums and minimize the cost of paying a claim. The Texas workers’ compensation system is no different. Our legislature has allowed insurance companies to run all over injured workers. That’s why you have to know what your rights are, what workers’ compensation benefits to expect, and how insurance companies take it all away.

SE HABLA ESPAÑOL – MLF Legal, PLLC

Red Flags Indicate Insurance Company Manipulation In Your Case

These are the most common things a workers’ compensation insurance company will do to cheat you out of your benefits:

  1. Limit or deny medical treatment
  2. Deny your prescriptions
  3. Termination from your job
  4. Refuse to pay you when you are unable to work
  5. Get you sent out for an impairment rating

The absolute best way to know whether or not an insurance company is manipulating your case is to look at who your doctor is. If you are treating at a company doctor or a doctor you were sent to by the adjuster, then your case is being manipulated. It was being manipulated before you ever even showed up. That’s what the law allows them to do.

How Workers’ Compensation Insurance Companies Limit Medical Treatment

Insurance companies are smart. And they spend a lot of money lobbying lawmakers to make laws that help them, and hurt you. The one thing they did that gave them so much power over your claim was to get the legislature to create medical networks for workers’ compensation medical treatment. It works like your health insurance. In the real world, if you have Blue Cross/Blue Shield insurance, you have to get treatment from a doctor who has a contract with Blue Cross/Blue Shield to provide treatment. In workers’ comp, if you have a claim with Texas Mutual, you have to get treatment in the network set up by Texas Mutual.

The main problem with getting treatment from a doctor in a network, is that the insurance company controls the network. The insurance company gets to decide which doctors can be in the network and which ones cannot be in the network. That’s why almost every doctor in the network you are stuck in is at Concentra, CareNow, PrimaCare, or Texas MedClinic or some other urgent care center. Really? These places are for head colds and the flu, or for people who don’t have a family doctor or can’t get an appointment for today. And they are supposed to be your long-term treating doctor for your work injury? Half the time you don’t even see the same doctor you saw last time.

So, these are the docs they want you to treat with. By the way, most of them only have a one year contract. Know why? So they can cut them if they don’t follow orders. They proved too many serious injuries? Cut them. They wrote a causation letter? Cut them. They referred out to a specialist more than they were allowed? Cut them. It keeps the insurance company in control – not just of that doctor, but of all the claims…YOUR claim.

While the insurance company is in control, we do know a few doctors here and there who participate in the network and do their best to help the patient. One of the advantages of a workers’ compensation lawyer is gaining access to the wide swath of people they know who can help you in whatever situation you are facing. It’s important to know how to maneuver within the network framework.

Workers’ Compensation Prescriptions

Prescriptions are a natural extension from your medical treatment. Some require preauthorization and some don’t. That’s the least of your worries. The bigger problem is how prescriptions get denied. Sometimes they are denied outright. Other times the denial is manipulated in a way where its hard to figure out what’s going on. For instance, you may go to the pharmacy to get your meds and you are told they can’t fill them because they haven’t heard from the adjuster to “approve” them. They don’t need approval, but the pharmacy wants a guarantee of payment so they hold things up and blame the adjuster. The adjuster knows that’s why they are calling so the call is not returned. You get stuck in limbo.

Another fun game they play is when a middleman company gets involved. This happens in almost every case. Pharmacies usually have a company that buys their claims from them. A middleman. The middleman gives the pharmacy less than full value for the billing that came out of your prescription and then collects the claim from the adjuster. They make money on the difference. The pharmacy gets the value of having money right now and the middleman gets a cut of the money in exchange for “lending” the money up front. The game is, the middleman doesn’t get paid and refuses to buy your claim from the pharmacy again so the pharmacy tells you that the insurance company didn’t pay your bill. That’s the excuse for not giving you your meds. Whatever the reason, it’s hard to function when your medication gets denied or refused.

Termination From Your Job

I’ve never understood why so many employers terminate employees who get hurt on the job. It’s most often an accident, not your fault. You didn’t do anything to warrant getting fired, but they often terminate an injured worker anyway. This creates chaos with workers’ compensation benefits. It doesn’t help that insurance companies treat all injured workers like they are criminals trying to steal money from insurance. That person is pretty rare though. Insurance companies just want to create that stigma so they look good and injured workers look bad. But employers believe this stuff.

This particular game usually works in your favor, at least with respect to benefits. It doesn’t save your job, but termination often makes getting workers’ compensation benefits a lot easier. If you get terminated, then your employer will not be willing to work you on light duty when you get restrictions. Therefore, you may be entitled to benefits longer than other injured workers.

Insurance Companies Will Refuse To Pay Benefits

When you are unable to work because of your injuries, the insurance company is supposed to pay benefits. Very often, they just refuse to do so. This is one of the most cruel games they play. It’s obvious that you got hurt at work and they just refuse to take care of you. This happens because they think you will go away. The odds are in their favor on this one. So many people just give up that it’s worth the risk for the insurance company to deny benefits. There used to be a law against treating people like this, but our courts and our legislature have declared that an insurance company can do anything they want to an injured worker with almost no consequences. They took away your right to sue them for denying you benefits that should obviously be paid. There are ways to deal with this, though.

Early Impairment Ratings

This is one of the oldest tricks in the book. The insurance company will get the company doctor to give you an impairment rating and dismiss you from care. Why is an impairment rating a bad thing? When you get an impairment rating you are no longer able to get paid lost wages, and quite often, the insurance company denies additional medical treatment from that point forward. Try asking a company doctor or a network doctor to help you fight an impairment rating and see how far that gets you. It’ll get you nowhere. This is how they shut down claims and kick you to the curb.

Secrets The Insurance Company Doesn’t Want You To Know About Texas Workers’ Compensation Benefits

As dirty as insurance companies play, there are ways to fight back. You don’t have to be at the mercy of a workers’ compensation insurance company. The law gives you some rights to deal with the games that insurance companies play. You don’t have to give up, or get trampled on. You can push back.

Secret #1: You Get To Choose Your Workers’ Compensation Doctor

Whether or not you are stuck in a network, you still get to choose your doctor. If you have an out of network claim, then you can treat with any doctor willing to take on a Texas workers’ compensation patient. There’s no restriction at all.

If you are dealing with a network claim, then you still get to choose your doctor, but you have to choose a doctor on the network list. This can be tricky. Most people don’t know which doctors on the list typically work for insurance companies and which ones are willing to go the extra mile to help out an injured worker. This is one reason why injured workers need an attorney. It’s all about who you know.

One of our jobs is to help people find the best possible doctor for treatment. This decision has to take into account the type of injury you have, where you live, the network you are dealing with, and the doctor’s willingness to make the proper referrals and provide the right documentation for your case. Most of the time it’s not too hard to find a good doctor. Sometimes it’s impossible. That depends on the network mostly. Some networks have gotten rid of every doctor who ever tried to bend over backwards for an injured worker. In those situations, we do our best to work around the doctor and still get the documentation you need to prove your case. Choosing the right doctor can have a big impact on your workers’ compensation benefits.

Secret #2: You Get To Choose Your Pharmacy

One trick insurance company adjusters play on injured workers is telling them what pharmacy they have to use. They might say, “that’s our preferred pharmacy,” or “that’s our network pharmacy.” The truth is, there is no such thing as a network pharmacy. The insurance company might have a “preferred” pharmacy, but why do you think they want you to use that pharmacy? So they can play games and keep you from getting the medications you need for recovery and return to work.

So, you get to pick your pharmacy. That’s your right. You might want to pick your local pharmacy at a big retail store, at the grocery store, or the name brands that have a store on every street corner. That’s not the right choice though. It might be convenient the first time you go in, but the insurance company is hoping you pick those pharmacies. Those pharmacies have middlemen that get in the way of you getting your medications. We talked about that earlier. This is how your meds get bogged down in red tape and delays.

This pharmacy problem is so big of an issue with our clients, that we made it a priority to find a better solution. We were getting so many phone calls – every day – from clients who couldn’t get their prescriptions filled, that we had to search for a better way. We were not interested in just another pharmacy who would cave to the pressures put on them by an insurance company. We needed a pharmacy who could deliver the goods, and do it in a timely manner. We needed a pharmacy who could do that in the most convenient way for our clients. A pharmacy without a middleman to shut it all down. We needed our clients to get their medication as fast as possible, every time, as prescribed, no matter what the insurance company does to try to stop it. We found that pharmacy, and made them our partner in helping injured workers in Texas.

We partnered up with Customedico Pharmacy & Wellness who rolled out the First Choice Program for our clients and injured workers all over Texas. This program is designed to deliver your medication to your door with next day shipping. You don’t have to go anywhere to get your meds…they come to you. Your doctor can send in your prescription just like she would do for any other pharmacy, and it gets delivered straight to you. It doesn’t matter that the insurance company doesn’t want to pay for it – it gets delivered. It doesn’t matter what the insurance company disputes – it gets delivered. It doesn’t matter what the adjuster calls and threatens to do – it gets delivered. And there’s nothing they can do about it.

Take advantage of this program today. Call the pharmacy customer support line at 888-520-0252 and sign up today – it’s free.

Secret #3: You Can Dispute Insurance Company Decisions

Insurance companies deny things all the time. They deny medical treatment. They deny prescriptions. They deny responsibility for certain injuries. They deny paying benefits they owe. They deny, they deny, they deny. Currently, they deny more and more every day. We used to be able to sue them for denying things that they had no business denying. But all of that got taken away because it hurt the profits of insurance companies.

Fortunately, the law still allows injured workers to make a stand. You can dispute insurance company decisions any time they deny something. We do this through a request for a benefit review conference. That starts the litigation process at the Division of Workers’ Compensation. This also gets the insurance company’s lawyers involved.

A benefit review conference is a mediation. It’s an opportunity for you and the insurance company to work out a deal. If the dispute can’t get resolved with this face to face meeting, an administrative trial is scheduled. That is called a contested case hearing. At a CCH, evidence and testimony is presented to a judge for a ruling on the dispute. The insurance company sends its lawyer to argue the case. You will have your lawyer argue the case. Then the judge will issue a ruling.

Secret #4: If Your Company Doesn’t Honor Your Work Restrictions, Then You Have Disability Under Texas Workers’ Compensation Law

You are entitled to Texas workers’ compensation benefits if you are not able to work at your regular job position in most cases. These benefits are called temporary income benefits, and they are wage replacement benefits. If you can’t work, you are supposed to get paid by your employer’s insurance company.

Getting paid is trickier when you have work restrictions. Technically, you can’t perform your regular job in that situation. If your employer won’t let you work light duty, then you have workers’ compensation disability under the law and the insurance company has to pay you temporary income benefits. It’s that simple. Sometimes, your employer will allow you to work light duty. In that situation, you get to work light duty for the time and wages offered, and then get temporary income benefits for any remaining lost wages.

You are entitled to temporary income benefits until the doctor releases you to return to work at full duty, or you reach maximum medical improvement (which means you have recovered from your injury as much as can be expected).

Secret #5: They Probably Owe You More Money

The truth is, many injured workers are owed more money. Insurance companies do whatever they can to pay you less than you are owed. Instead of figuring out what they owe you, they will claim that you haven’t proven what you are owed. And it’s not your obligation. It’s mostly between the insurance company and your employer.

The first thing they do to underpay your benefits is to guess at how much they owe you. The adjuster will just estimate your earnings based on your hourly wage. They have a relationship with your employer, but instead of getting your actual wages they just guess. This doesn’t take into account your overtime pay, bonuses, your health insurance, or any other perks you had on the job.

Your workers’ compensation benefits are supposed to be calculated based on your total earnings during the thirteen weeks prior to your injury. Those earnings are added up and divided by thirteen. We call this your average weekly wage. It is supposed to include wages, bonuses, per diem, housing provided by the employer, and any other perk or benefit provided by your employer.

Most of time, they don’t get a full thirteen weeks of pay when the adjuster makes this calculation. We’ve seen them get only twelve weeks of pay and still divide by thirteen. That’s a sure-fire way to get paid less than you are owed.

I am always surprised at how often injured workers get paid less than their full benefit amount. Don’t let that happen to you. We review this for injured workers daily.

Secret #6: You May Have Multiple Claims

The typical workers’ compensation case includes one injured worker and one employer, and nobody else. But, it is common for their to be other parties involved in a claim. For instance, an oil rig has many companies providing services on that jobsite. Some provide services, some provide equipment, different companies drive vehicles on and off the jobsite all day long. An injury that includes a worker or product from another company can give you a different claim. We call these third party claims.

An example of a third party claim is an A/C repairman who is traveling to his next customer’s home when a car runs a red light and collides with his work vehicle. That repairman has a workers’ compensation claim with his employer, as well as a third party claim against the driver of the other vehicle.

When you have a third party claim involving workers’ compensation, it is very important to hire a lawyer who can handle both claims at the same time. When you hire one lawyer for the workers’ comp case and a different lawyer for the third party claim, you will often get less overall. Knowing how to integrate the two claims and understanding how one claim affects the other as you negotiate the two recoveries is vital to maximizing your return.


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