In most ways, Chad Hennings was no different than anyone else in the working world. Every day he reported to work was another day he could have been injured on the job.

Hennings’ occupation is what set him apart, forcing Texas courts to re-evaluate a piece of the workers’ comp law that has stood since 1991.

Hennings made a living tackling quarterbacks in the National Football League. He retired in 2001 after injuring his spine. Concerned he would need ongoing medical treatment, he filed a workers’ compensation claim.

Hennings’ claim played out in court for the better part of the decade. At issue was whether the benefits provided by his football contract made him ineligible for workers’ compensation benefits. Ultimately, the 10th Court of Appeals in Waco decided that Hennings was entitled to 15 weeks of disability benefits.

Most claims are not as complicated as Hennings’. Texas Mutual evaluates each claim individually.

Generally, a claim is compensable if the injury happened during the course and scope of employment. For example, a construction worker could smash his thumb while hammering a nail.

For a definition of course and scope, see the Texas Labor Code, Sec. 401.011 (12). As with most rules, there are exceptions to the course and scope rule. Again, state law provides direction.

Under the Texas Labor Code Sec. 406.032, insurance carriers may dispute compensability in the following situations.

Intoxication

If the employee was intoxicated at the time of injury, the claim may not be compensable, even if the employee’s intoxication was not the cause of the injury.

The law assumes that the employee had the normal use of his mental and physical faculties. If the insurance carrier can provide evidence of intoxication, the burden of proof shifts to the employee to show that he was not intoxicated at the time of his injury.

That is why Texas Mutual recommends that employers send employees for drug and alcohol tests as soon as possible after an injury. Consult an attorney before you launch a drug testing program to make sure you comply with the law.

Willful intent

Willful intent injuries happen when an employee intentionally injures himself or a co-worker.

Act of a third party

Act of third party injuries happen when someone injures one of your employees for personal reasons unrelated to their employment.

Off-duty activities

If an employee is injured during an off-duty recreational, social or athletic activity, the injury is probably not compensable. The law might make an exception if the employer required the employee to participate in the activity.

Acts of God

Acts of God include tornadoes, lightning and other forces of nature. Injuries caused by acts of God are usually not compensable unless the employee’s job duties put him or her at higher risk than the general public.

Horseplay

Sometimes, employees play pranks, practical jokes or engage in other horseplay. If they get injured in the process, their claims are probably not compensable.

Disputing compensability

Texas Mutual adjusters conduct thorough accident investigations and strictly follow the law to determine whether an injury is compensable. If we decide to pay a claim and you disagree, the law allows you to dispute our decision.

Call the adjuster assigned to the claim, and explain why you think the injury is not compensable. If we disagree, you may file a dispute with the Texas Department of Insurance, Division of Workers’ Compensation (DWC).

Start by submitting DWC Form-4, Employer’s Contest of Compensability, as soon as possible. The form is available in the Employer Forms section at texasmutual.com.

From there, the dispute enters the administrative phase. You may be asked to attend a Benefit Review Conference, Contested Case Hearing or another form of mediation. It is important that you show up and present your side of the dispute.

You can visit the Employers section at texasmutual.com to learn how to respond to injuries, monitor the status of your claims, control your claim costs and help injured workers get the prescriptions they need.

Article by David Wylie, Texas Mutual Insurance Company.