One of the most difficult aspects of coping with a workplace injury can be dealing with the your employer’s insurance company. Most employers are required to carry workers compensation insurance so that ideally, when a worker is injured, he or she can receive payments until able to resume work. However, sometimes insurers will refuse to pay for injuries or procedures that they believe do not fall within their “scope,” which was the case with Holmes v. Zurich Insurance Company.
In Holmes, the case involved a tire lube technician, Aaron Holmes, who injured his back at work. After he applied for workers compensation, the company’s insurance carrier, Zurich, accepted that Holmes had a lower back sprain, but not any other injuries. In February 2008, Holmes and Zurich participated in a benefit review conference to resolve the dispute, but were unsuccessful. A benefit contested case hearing was then held so that it could be determined whether Zurich had to compensate for a two-millimeter disc protrusion and two other injuries. In May 2008, the Division of Workers Compensation hearing officer found that the disc protrusion was a compensable injury, but not the others.
Holmes then sought pre-authorization for spinal surgery pursuant to the Texas Workers’ Compensation Act. After being denied once and having it overturned by the Independent Review Organization, Holmes had the procedure done. However, when Zurich received the bill, it refused to pay on the grounds that the surgery repaired non-compensable injuries in addition to the disc protrusion.