GQ Corner

Q. How would you word a denial if there is no coverage for the employer at issue?

A. Any time you have a case in which you think there is no coverage for a particular employer, you probably want to deny not only coverage but compensability. As for coverage, you should include, at a minimum, language specifying that the carrier at issue did not have workers’ compensation insurance coverage for the employer at issue. Be sure to name the carrier and employer specifically. You may want to add additional details, such as whether the carrier previously had coverage prior to the date of injury or subsequently provided coverage after the date of injury, in which cases you would include comments as to the dates of coverage. 

Q. I have a claimant who is approaching statutory MMI. When he does so, what are my options concerning indemnity benefits?

A. When the claimant reaches statutory MMI and you have not received a DWC-69 Report of Medical Evaluation in connection with the claim, you should suspend temporary income benefits. You are permitted to make a reasonable assessment of impairment, request a designated doctor, do both, or do neither. See Rule 130.2(e).

Q. The claimant sustained injuries when she fell down some stairs at work. The injury occurred on the employer’s premises during normal work hours. However, our investigation indicates that the claimant fell because she was looking down at her phone and not paying attention to what she was doing at that time. Does this fact furnish a basis for denial?

A. Unfortunately, this fact alone would not furnish a basis for denial since the Texas workers’ compensation system is a no-fault scheme.