About compensability disputes

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Insurance carriers will pay benefits only for a compensable work injury, illness, or death. 

If there is a dispute about your claim, it may be resolved through DWC's dispute resolution process.

What is a compensable injury?

You have a compensable injury if the insurance carrier accepted liability for the injury or DWC determined the injury is compensable during the dispute resolution process. 

Why your claim may be disputed:

An insurance carrier may dispute a claim if it believes you were not injured in the course and scope of employment or if there are exceptions that allow the insurance carrier to not pay benefits.

What is an injury in the course and scope of employment?

An injury in the course and scope of employment means at the time of the injury you were:

• doing activities related to the business of your employer, and
• furthering the interests of your employer.

An insurance carrier may dispute a claim if it believes there is not enough information to show that your work activities caused an injury, illness, or medical condition.

Learn about the definitions of compensability, course and scope, and other workers’ compensation terms in Texas Labor Code §401.011.

What are the exceptions?

If a work injury is not reported or filed on time, it may not be compensable.

• You must report your injury to your employer within 30 days from the date of injury.
• You must file your claim with DWC within one year from the date of injury.

Learn more about reporting requirements in Chapter 409 of the Labor Code.

The events leading up to your injury could give the insurance carrier legal reasons (exceptions to liability) to dispute your claim. For example:

• You were intoxicated when you were hurt.
• When your injury happened, you meant to hurt yourself or another person.
• When your injury happened, another person meant to hurt you for non-work-related reasons.
• You were hurt during an off-duty (recreational, social, or athletic) activity.
• Your injury was caused by an act of God (such as lightning), and you were at no greater risk than the general public of getting hurt.
• You were hurt during horseplay.

Learn more about exceptions to liability in Labor Code §406.032.

If there is a dispute, what do I do next?

If there is a dispute about your claim, you must prove why it should be paid. Gather information related to your dispute. This may include witness statements, reports, medical records about your injury, and any other information that shows:

• You were hurt because of work activities.
• Your disputed condition was caused by your compensable injury.
• You reported your injury to your employer or filed your claim with DWC on time.
• The insurance carrier’s reasons for denying your benefits do not apply. 

Learn more about:

• when and what kind of information to share
• how to send information
• Appeals Panel decisions about compensability, exceptions to liability, and timely reporting and filing
• disputes about death benefits