Players in the Texas Workers' Comp System

Every person and office you will meet in a Texas workers' comp claim, what each one does, and whose side each one is on. Start here when an unfamiliar name or title appears in your mail.

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Why this section exists

A workers' comp claim brings a long list of strangers into your life: an adjuster, a nurse, several doctors you did not choose, a state agency, and eventually a mediator or a judge. In claims our office has handled, injured workers often treated all of them as one opponent called "the insurance company," and blamed the state for reports the state never wrote. That confusion has a cost. You cannot judge a decision until you know who made it, who pays that person, and what authority they actually have.

The pages in this section cover one player each. Three questions run through all of them: who this person works for, what they can decide, and what they cannot decide.

The insurance side

These people are paid by the insurance carrier. They are not neutral, and they are not required to be.

The Insurance Carrier. The insurance company that pays benefits on your claim. Every check, every denial, and most of the letters in your mailbox come from it.
The Adjuster. The carrier employee assigned to your file. The adjuster makes the day-to-day decisions: starting checks, stopping checks, and disputing parts of your claim.
Third-Party Administrators (TPAs). Companies hired to handle claims on a carrier's or employer's behalf. A TPA is why the name on your letters may not match the name of your employer's insurance company.
The Peer Review Doctor. A doctor paid by the carrier to review your records on paper. This doctor never examines you, yet the report can be used against your claim.
The Required Medical Exam (RME) Doctor. A doctor who examines you in person at the carrier's request, usually to challenge some part of your treating doctor's opinion.
The Nurse Case Manager. A nurse assigned by the carrier to follow your medical care, sometimes attending your appointments.
Private Investigators. People the carrier may hire to watch and record you during your claim.
The Health Care Network (HCN). The certified network of doctors your treatment may be limited to, depending on your employer's coverage.

The state

These people work for Texas, not for the carrier. Two separate agencies are involved, and the difference matters.

The Division of Workers' Compensation (DWC). The state agency that runs the comp system: it keeps the claim records, appoints designated doctors, schedules dispute proceedings, and enforces the rules.
The Benefit Review Officer (BRO). The DWC employee who runs the benefit review conference, the informal first step in most disputes. A mediator, not a judge.
The Administrative Law Judge (ALJ). The DWC judge who decides disputes at a contested case hearing and issues a binding written decision.
The Appeals Panel. The judges inside DWC who review a contested case hearing decision on the written record when either side appeals.
The Office of Injured Employee Counsel (OIEC). A separate state agency that exists to assist injured workers. It is not part of DWC and not part of any carrier.
The Ombudsman. An OIEC employee who can help you prepare for and attend dispute proceedings at no charge. An ombudsman is not a lawyer and cannot represent you.

The doctors in your claim

The Treating Doctor. The doctor you choose to direct your care. This is the most important medical role in your claim, because the treating doctor's records and opinions carry your case.
The Referred Specialist. A doctor your treating doctor sends you to for a specific problem, such as a surgeon or a pain specialist.
The designated doctor. A doctor appointed by DWC, not by either side, to answer disputed medical questions such as maximum medical improvement and your impairment rating. This role is large enough to have its own section: The Designated Doctor in Texas Workers' Compensation.

Other people in your claim

Your Employer's Role in the System. Your employer reports the injury, provides wage information, and may offer modified work, but does not decide your benefits.
Beneficiaries. The family members the system pays after a work death, and how each one proves their status.
Co-Claimants: When Someone Else Asserts a Claim in Your Case. What happens when another person asserts a claim to benefits in your case.
Vocational Experts. Specialists who evaluate what work you can still do, most often in supplemental income benefits cases.