Disputes vs. Complaints | Your Guide to Workers’ CompOn February 6, 2020 by Raul Dinwiddie
Hi, my name is Kelly and I’m with the Texas Department of Insurance, Division of Workers’ Compensation. There are differences between disputes and complaints in the Texas workers’ compensation system. Disputes are a disagreement between two parties. A complaint is a claim that someone violated the law. An example of a dispute would be an insurance company who denied your claim, or is not paying you benefits for the weeks that you were not able to work because of your injury. Another kind of dispute might come up if you do not agree with the date your benefits are ending, or maybe you disagree with a doctor’s opinion about the damage that the injury did to your body. A dispute could happen if the insurance company denies your medical benefits because they think the treatment wasn’t necessary, or
maybe they only paid part of a doctor’s bill. If you file a dispute you could get a ruling
that the insurance company has to pay you certain benefits. Again, disputes are a disagreement between two parties. Complaints within the workers’ compensation system are a written notice to the Division alleging that someone in the system did not follow the Texas Workers’ Compensation Act or rules. In our rules and laws it states how a party
is supposed to handle certain issues. If someone isn’t following rules or laws,
that could be a complaint. A complaint might be if a health care provider bills you directly for treatment for your injury. You might file a complaint if the insurance
company has not provided medical records, or if they haven’t mailed you your benefit
checks on time. If you file a complaint the insurance company could be punished for not doing something they were supposed to do. On the other hand, an insurance company might file a complaint when you don’t go to a required doctor’s exam or proceeding. Sometimes one issue can result in a dispute and a complaint. To get more information about complaints and disputes within the Texas workers’ compensation system, go tdi.texas.gov/wc/employee, or call our customer service number for more information at 800-252-7031, option 1.