Texas Department of Insurance Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 512-804-4000 512-804-4001 fax Austin, Texas 78744-1609 www.tdi.state.tx.us
BENEFIT REVIEW CONFERENCE (BRC) INFORMATION FOR BENEFICIARIES IN A DEATH CLAIM
COMPENSABILITY ISSUES: When the insurance carrier challenges whether an injury or resulting death is related to the injured worker’s employment. The burden is on the injured worker’s beneficiaries to show that the decedent had an injury on the job which resulted in his/her death. This dispute may involve the original injury as a whole, or whether another injury/diagnosis is a result of the death of the decedent. The carrier may also dispute whether the injury occurred while the injured worker was performing duties related to his/her employment. A party should be prepared to discuss the following information at a BRC on a compensability dispute.
Definition of Terms
“Injury” means damage or harm to the body, including infections from the injury. See §401.011(26). “Compensable Injury” means an injury in the course and scope of employment. See §401.011(10). “Course and Scope of Employment” means an activity performed by the injured worker originating in the work of the employer. See §401.011(12). An “Autopsy” is necessary in a claim for death benefits based on an occupational disease. See §408.187. “Occupational Disease” means a disease or repetitious trauma arising from the injured worker’s employment. See §401.011(34). “Repetitive Trauma Injury” means damage to the body from repetitious activities related to the injured worker’s employment. See §401.011(36). “Mental Trauma” may be compensable if it is traceable to a traumatic event in the injured worker’s employment. See §408.006. “Heart Attack” may be compensable if it occurred at a definite time and place in the course and scope of employment. See §408.008. “Required Medical Exam” is an exam required by the Division to address the appropriateness of health care or other similar issues. See §408.004.
Division Forms DWC-41, “Supplement A - Beneficiary's Claim for Compensation (Rev. 10/04),” filed by family members of the deceased injured worker if the injury resulted in injured worker’s death. DWC-45, “Request for a Benefit Review Conference Interim” (unrepresented injured workers may request a conference by contacting the Division in any manner). DWC-150, “Notice of Representation or Withdrawal of Representation,” if the injured worker is represented by an attorney. Medical Records Emergency room reports. An autopsy report will be necessary in claims for death benefits resulting from an occupational disease. Medical narratives from a doctor to establish the relationship between the original claimed injury (or disease) and the injured worker’s employment. A list of doctor’s names that treated the injured worker, if more than one. Doctor’s narrative resulting from a required medical examination, if any. For an occupational disease, there must be medical information that establishes the relationship between the disease and the injured worker’s employment. For a repetitive trauma injury, there must be information that shows the duration, frequency, and nature of the activities alleged to be traumatic and medical to show the relationship between the injury and the employment. For a mental trauma injury, there must be information to show that the mental trauma is traceable to a definite time, place and cause. For a heart attack, there must be medical information to show that the work rather than the natural progression of a preexisting heart condition or disease was a substantial contributing factor of the heart attack. Additional Information Witness Statements – while not all injuries are witnessed, it is beneficial to present the names and/or statement of any co-workers who might have seen or heard the incident. Death Certificate, if applicable – required when a work related injury results in the injured worker’s death. Autopsy Report – if injured worker’s death resulted from an occupational disease. Any information that will show that the injured worker timely reported the injury to the employer. Exchange of Information Must be exchanged with DWC and other parties per Rule 141.4. Must be exchanged no later than 14 days prior to a BRC (5 days if BRC was expedited). Bring information that is obtained after the exchange deadline to the conference in sufficient copies for filing and exchanging at the conference.