Common Claim Denials
Most Texas workers' comp denials use one of a small set of recognized defenses. This section explains each one: what the carrier is claiming, what the law actually requires, and how injured workers answer it.
A denied claim is not the end, it's the beginning.
When a Texas workers' comp claim is denied, that does not mean a judge has ruled against you. It means the carrier, the insurance company responsible for paying benefits under your employer's workers' compensation coverage, has decided that it does not believe some or all of those benefits are owed. Texas law gives workers a dispute process through the Division of Workers' Compensation (DWC) to challenge that decision.
Most denials are based on a specific legal or factual defense. The carrier may dispute whether the injury happened in the course and scope of employment, whether a medical condition was caused by the accident, whether the worker has disability, or whether a deadline was met. These defenses tend to follow familiar patterns, and each raises different questions about the facts and evidence. The pages in this section break down the most common denial defenses, what they mean, and where they can be challenged.
Why was my workers' comp claim denied?
Your denial letter must state a specific reason, and that reason is where your dispute begins. DWC rules do not allow carriers to deny with vague phrases such as "liability in question" or "under investigation" standing alone. If your letter contains only a phrase like that, the denial itself may be defective.
Nearly every stated reason belongs to one of a few families. The carrier may claim you were not working when you were hurt, called a course and scope defense. It may point to a defense written directly into the statute, such as intoxication. It may accept that you were hurt but blame something other than your job, such as a preexisting condition. It may argue you missed a reporting or filing deadline. It may accept the injury but refuse a particular treatment, or accept one body part and deny others. Each family has its own page below, and each page explains what the carrier must actually prove.
What do I do after my claim is denied?
Read the letter carefully, identify exactly what was denied, and start the dispute process. A denial does not end your claim. It moves your claim into a dispute, and workers win disputes all the time.
Take these steps in order.
1. Identify which letter you received. A PLN-01 denies the whole claim. A PLN-11 disputes only part of it, which means medical care for the accepted parts must continue. The PLN-01 Full Denial: When the Carrier Denies Everything and the PLN-11 explainer page cover each letter line by line. 2. Find the stated reason and match it to its page in this section, so you know what the carrier must prove and what evidence answers it. 3. Confirm your own deadlines are protected. A denial does not pause the one-year deadline to file your claim with the state. If you have not filed a DWC041, do it now. The One-Year Deadline to File Your DWC Claim explains why this matters even on a denied claim. 4. Request a benefit review conference, an informal meeting with a DWC officer, using form DWC045. Dispute Resolution walks through every stage that follows. 5. Get help. The Office of Injured Employee Counsel provides free ombudsmen, and an attorney costs nothing up front in the Texas comp system.
Do not stop treating, and do not go silent. Gaps in treatment and long silences become the carrier's next arguments.
Common reasons carriers deny claims
Two other pages on this website cover the most common practical fights: Disputing Low Impairment Ratings in Texas Workers' Compensation Cases explains what to do when the rating that sets your permanent-injury money comes in too low, and How to Handle Medical Denials in Texas Workers' Compensation Claims explains the path when the carrier refuses treatment your doctor ordered.
Where and when you were hurt. Course and Scope Defenses covers the carrier's claim that you were not working when the injury happened: commutes, personal errands, travel, company parties, and disputes rooted in personal matters.
Defenses written into the statute. Statutory Defenses covers the defenses the Labor Code names directly, including the intoxication defense, willful injury, acts of third persons for personal reasons, and benefits during incarceration.
What caused the injury. Medical Causation Defenses covers claims that something other than work caused your condition: preexisting conditions, natural progression of old injuries, injuries with no identifiable cause, and heart attacks, strokes, and heat illness.
Occupational disease. Occupational Disease Defenses covers the arguments raised against illness claims, including ordinary disease of life and exposure outside employment.
Whether you lost wages. Disability Defenses covers the carrier's arguments that your injury is not costing you income: returning at the same wages, termination for cause, resignation, retirement, and refusing a job offer.
Whether you followed the rules. Procedural Defenses covers late reporting, late filing, missed exams, and missed dispute deadlines. These denials are about missed dates, not about the injury itself.
Whether a treatment is owed. Medical Treatment Defenses covers denials of specific care, including medical necessity denials and Extent-of-Injury Denials: When the Carrier Accepts Only Part of Your Injury, the dispute behind more stalled claims than any other.
Whether you were an employee at all. Employment Relationship Defenses covers independent contractor labels, non-subscriber employers, borrowed servants, volunteers, and exempt job categories.
Mental injuries. Mental Injury Defenses covers the special rules carriers use against PTSD and other mental injury claims.
The pages in this section
01 Section overview Disputing Low Impairment Ratings in Texas Workers’ Compensation Cases ▸
02 Section overview How to Handle Medical Denials in Texas Workers’ Compensation Claims ▸
03 6 pages Course and Scope Defenses ▸
04 3 pages Statutory Defenses ▸
05 1 page Act of a Third Person for Personal Reasons ▸
06 4 pages Medical Causation Defenses ▸
07 3 pages Occupational Disease Defenses ▸
08 8 pages Disability Defenses ▸
09 7 pages Procedural Defenses ▸
10 8 pages Medical Treatment Defenses ▸
11 7 pages Employment Relationship Defenses ▸
Attorney notes regarding carrier defenses
An insurance carrier’s denial is not the final word on your workers’ compensation claim. Carriers have many legal defenses available to them, but whether a defense actually applies depends on the facts, the medical evidence, and Texas law.
Take a closer look when the carrier claims:
- Your injury did not happen at work: Details about where you were, what you were doing, and why you were doing it may be important.
- A medical condition is not part of your injury: Medical records, testing, and expert opinions may tell a different story.
- A prior injury or condition is to blame: Having a medical history does not automatically mean your current condition was not caused by a work injury.
- You are able to work: Your medical restrictions, actual job duties, and ability to earn your pre-injury wages can matter.
- You missed a deadline: Some deadlines have exceptions, and the carrier may not have the complete story.
At Abbott, Clay & Bedoy, we examine the carrier’s defense, compare it with the evidence, and determine where its position can be challenged.
A denial letter tells you the carrier’s position. It does not tell you whether the carrier can prove it. Let us take a look at what they are claiming and what can be done about it.
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