Disputes and the Benefit Review Conference

By Luis Julia

Upon filing a claim for a work-related injury with your employer and their insurance carrier, the carrier will conduct an investigation of the alleged injury and make a determination to accept or deny the claim. If a dispute arises about a workers’ compensation claim, the parties are required to make efforts to resolve the dispute prior to requesting a Benefit Review Conference. When the dispute cannot be resolved, a party to the dispute may request a Benefit Review Conference using DWC Form-045, Request for a Benefit Review Conference, and submit details and documentation of efforts to resolve the dispute.

The party requesting a Benefit Review Conference is required to provide pertinent information to the opposing party before requesting a Benefit Review Conference. The following categories represent most of the issues discussed at a Benefit Review Conference. Necessary information has been provided for each category as it relates to each participant in a Benefit Review Conference. Some Benefit Review Conferences may involve more than one category.

I. Compensability Issues:

Compensability is an issue when the insurance carrier denies that an injury is related to the injured employee’s employment. This dispute may be over the original injury as a whole, or whether another injury/diagnosis is a result of the original injury. The insurance carrier may also dispute whether the injury occurred while the injured employee was performing duties related to his/her employment, or whether the injured employee’s death was the result of the injury.

II. Liability Issues:

Liability is an issue when the insurance company disputes whether the injured employee was intoxicated at the time of the injury, or if the injured employee’s injury was the result of horseplay, his/her intention to injure his/herself or another person, another person intending to injure the injured employee, an off-duty (recreational/social/athletic) activity or an act of God.

III. Income Benefit Issues:

Income benefits are an issue when the insurance carrier disputes the injured employee’s entitlement to or amount of income benefits. Income benefits include temporary income benefits (TIBs), impairment income benefits (IIBs), supplemental income benefits (SIBs) and lifetime income benefits (LIBs).

IV. Average Weekly Wage (AWW) Issues:

Average weekly wage is an issue when the insurance carrier, the injured employee or their beneficiaries dispute the wages or method used to calculate an injured employee’s average weekly wage. Income and death benefits are based on an injured employee’s average weekly wage.

V. Death/Burial Benefit Issues:

An insurance carrier may dispute a beneficiary’s entitlement to receive death benefits. An issue may also arise over the reasonable cost of burial benefits and/or transportation costs incurred on behalf of the deceased employee.

If your claim has been denied in its entirety, if part of your claim has been denied or if you have a dispute concerning your right to receive medical treatment or wage benefits, you should seek the assistance of competent counsel. This is because the Benefit Review process is an adversarial process that requires hearings and supporting evidence. You can be certain that the insurance company that is denying your claim will have a team of attorneys representing its interests. You will be at a disadvantage without an attorney of your own. At Bailey & Galyen we have years of experience representing injured workers through the Benefit Review process. We can help. For more information, contact Bailey & Galyen toll-free at 1-855-747-4878. We can help you get the benefits you deserve.

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