A subclaimant may be a party to a proceeding when the insurance carrier refuses a request for reimbursement from the subclaimant. A subclaimant may also request a proceeding not currently before the Texas Department of Insurance, Division of Workers' Compensation (DWC) to address the insurance carrier's liability when an insurance carrier denies a subclaimant's request for reimbursement. A party should be prepared to discuss the following information at a BRC on a compensability dispute.
- DWC Form-001, Employer's First Report of Injury or Illness (paper copy if filed electronically).
- Plain Language Notice (PLN) 1, Notice of Denial of Compensability/Liability and Refusal to Pay Benefits, or PLN 11, Notice of Disputed Issue(s) and Refusal to Pay Benefits.
- DWC Form-045, Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC).
Parties to a dispute are also required to provide pertinent information to DWC not later than 14 days before the scheduled benefit review conference, but should NOT attach this information to the Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) (DWC Form-045).
Pertinent information includes:
- Medical Records:
- Emergency room reports;
- Medical narratives from a doctor to establish the relationship between the original claimed injury (or disease) and the injured employee's employment;
- For an occupational disease, there must be medical information that establishes the relationship between the disease and the injured employee's employment;
- For a repetitive trauma injury, there must be information that shows the duration, frequency, and nature of the activities alleged to be traumatic and medical to show the relationship between the injury and the employment;
- For a mental trauma injury, there must be information to show that the mental trauma is traceable to a definite time, place and cause;
- For a heart attack, there must be medical information to show that the work rather than the natural progression of a preexisting heart condition or disease was a substantial contributing factor of the heart attack;
- Requests for a designated doctor exam:
- letters of clarification to a designated doctor and responses from the designated doctor, and
- treating doctor's response to a designated doctor's opinion;
- Witness Statements - while not all injuries are witnessed, it is beneficial to present the names and/or statement of any coworkers who might have seen or heard the incident;
- Death Certificate, if applicable - required when a work-related injury results in the injured employee's death;
- Autopsy Report - if the injured employee's death resulted from an occupational disease;
- Any information that will show that the injured employee timely reported the injury to the employer; and
- Written notice to the DWC from a health care provider identifying themselves as a Subclaimant.
Exchange of Information
Pertinent information must be exchanged in accordance with Texas Administrative Code §141.4.
- Disputing party must exchange all documents in their possession with the other party before requesting a BRC.
- Opposing party must exchange documents within 10 working days after receiving the request for a BRC (DWC Form-045).
- Any additional documents that come into a party's possession after the initial timeframes must be exchanged no later than 14 days before the BRC (5 days if the BRC is expedited).
- All documents must be submitted to the DWC no later than 14 days before the BRC (5 days if the BRC is expedited).
- Any documents obtained after the exchange deadline should be brought to the BRC with sufficient copies for both the other party and the DWC.
"Injury" means damage or harm to the body, including infections from the injury. See Texas Labor Code §401.011(26).
"Compensable Injury" means an injury in the course and scope of employment. See Texas Labor Code §401.011(10).
"Course and Scope of Employment" means an activity performed by the injured employee originating in the work of the employer. See §401.011(12).
"Occupational Disease" means a disease or repetitious trauma arising from the injured employee's employment. See Texas Labor Code §401.011(34).
"Repetitive Trauma Injury" means damage to the body from repetitious activities related to the injured employee's employment. See Texas Labor Code §401.011(36).
"Mental Trauma" may be compensable if it is traceable to a traumatic event in the injured employee's employment. See Texas Labor Code §408.006.
"Heart Attack" may be compensable if it occurred at a definite time and place in the course and scope of employment. See Texas Labor Code §408.008.
"Subclaimant" means any person who has been denied reimbursement from an insurance carrier for compensation or health care provided to an injured employee or their beneficiary. See Texas Labor Code §409.009.