Insult to Injury: Texas Workers’ Comp System Denies, Delays Medical Help – from the ABA

This is an amazing look at the Workers’ Comp system in Texas and it’s penchant for repeat delays and denials. The article, from the ABA, details decades of changes in the state system that made it almost impossible for claimants to receive representation.

It’s a long story but well worth the read.

As Deputy Sheriff Ed Martin sat by his squad car in a fast-growing pool of his own blood, he called his wife and woke her at 3:30 a.m. He knew he might die from the point-blank shotgun blast that greeted him moments earlier when he knocked on a door for a 911 call in a tiny east Texas town called China.

“It’s pretty bad and I don’t know how it’s gonna turn out,” Martin told his wife as he awaited a helicopter medical evacuation. “Get the kids and meet me at the hospital.”

When they arrived, Martin was on a gurney and covered with a white sheet splotched red. His wife clutched their sleepy 2-year-old daughter to her chest as their sons, 6 and 10, stood at her side.

“I know it was tough for them,” Martin says, retelling the story of that night in June 2006 in the flat monotone of cop-speak. “But I wasn’t sure if I’d make it through surgery and I wanted to at least tell them ‘Hello’ and ‘I love you.’ ”

Doctors say Martin’s life was saved by his ballistic vest and the swift trip to the hospital in Beaumont, near the Gulf Coast and the Louisiana border. But the blast vaporized the skin of his inner arm down to bare muscle and tendons, and tore out the main artery.

A couple of weeks later, Martin got a phone call from an insurance adjuster handling his workers’ compensation claim. He was told the $7,300 helicopter ride was “not medically necessary” and likely would not be covered.

“Not medically necessary,” Martin says, repeating the phrase twice in succession five years after the shooting. “That was my first introduction to those words. And I’ve heard them a lot since then.”

While cops can’t be sure what lurks behind a door on an emergency call, they know the hazards. But Martin could not have foreseen the traps and trauma in store for him as he entered a state workers’ compensation system that was radically overhauled 20 years ago expressly to drive out lawyers representing injured workers, and that has grown ever friendlier to the insurance industry.

Martin, 45, has undergone 11 surgeries to repair his various injuries. He was away from work for two years. Such treatment is built in progressive stages, many of which—like his helicopter evacuation—were initially denied by the insurer and only later approved.

The chain of repeated denials of treatment not only kept him from recovering sooner but also left him with deep, nerve-enveloping scars that today cause sharp tingles he says feel like ants constantly biting his hand.

As a law enforcement officer, Martin knows it’s best to have backup. But he never had a lawyer to help him through the adversarial, multilevel administrative maze that is the Texas Department of Insurance’s Division of Workers’ Compensation. He never had an administrative hearing. His case played out in an endless stream of letters and phone calls between his doctor, an insurance adjuster and various division officials.


Read the rest here at the ABAJOURNAL