When Upper School math teacher Karen Sanchez tripped and fell while teaching her E-Period precalculus class on March 8, she assumed she would use her personal insurance to seek medical help from a trusted hospital. She was wrong.

Instead, she was informed by the school nurses that her only option for receiving full financial treatment coverage for her injury was to use the Texas Workers’ Compensation Insurance, a service which provides wage replacement and medical benefits to employees injured while working, but only under certain conditions.

Although she obtained all appropriate financial and medical benefits, Sanchez’s experience with this system was far from perfect.

To receive workers’ compensation, the affected employee is required to waive his or her right to sue the employer for negligence. In Sanchez’s case, this condition was not a problem due to the fact that she fell in her classroom and expressed no desire to sue the school. In addition, the worker’s compensation insurance dictates which doctors the patient can see and the treatments methods the patient should receive.

“I went to the nurse after I fell and they said if you’re going to go to the doctor we have a protocol you have to follow, so you can’t just go to any doctor,” Sanchez said.

Director of Health Services Erika Herridge was one of the nurses that guided Sanchez in the right direction.

“If [an injury] happens here at school while you are on the job, we want to make sure you get taken care of and get what care you need,” Herridge said.

Sanchez was given a list of acceptable doctors which are organized by workers’ compensation insurance carriers. Sanchez chose to go to Concentra Urgent Care, where she got an X-ray and the incorrect diagnosis of a broken arm.

“I could tell that the doctor there was a little uncomfortable with dealing with a broken arm and when I went to my choice of ER, they did their own X-rays and told me that my elbow was broken, and not my arm,” Sanchez said.

In addition to the initial mis-diagnosis, the workers’ compensation paperwork was incorrectly completed and a staff member at Concentra filed her claim as a contusion (a bruise). This misclassification caused Sanchez to fill out extra paperwork on top of the preexisting forms.

“[Workers’ compensation] is a long, drawn out process,” Sanchez said. “The protocol was annoying.”

For Sanchez, the problems with the Worker’s Compensation were minor grievances–she was able to return to work promptly, avoiding the fight for wage replacement and all of her medical expenses were covered. She acknowledged that the Hockaday community ensured that she was properly cared for and well-rested.

Sanchez said that she could have paid for her medical care but made the choice to use the workers’ compensation insurance to avoid paying out-of-pocket for the expenses.But many workers across Texas do not have this option.

Workers’ compensation lawyer Jacob Ginsberg said that many workers who live from paycheck-to-paycheck do not have the luxury of choosing between workers’ compensation and their personal savings.

“For a lot of people, if they have a broken arm, their constant worry is ‘How am I going to pay the bills?’ so they need workers’ compensation to pay for the medical expenses and their time off from work,” Ginsberg said.

Ginsberg fights for claimants (people who have suffered an injury) who have been wronged by the workers’ compensation system. Ginsberg said that the problems with workers’ compensation extend well beyond those that Sanchez faced. He has noticed some common themes in his cases and come up with two major deficits with this statewide insurance: insurance-controlled doctors and unreasonable legal definitions of extent of injury.

In Sanchez’s case, she would have preferred care from her private healthcare physician because she noticed that her doctor at Concentra Emergency Care seemed inexperienced and unequipped to deal with her injury. This is a problem that Ginsberg said is very common in the workers’ compensation industry because the doctors are controlled by division networks set up by major insurance carriers that tend to be more worried about saving money than protecting the claimants.

“You’re letting the insurance be in control of the medical attention that the claimants receive, and the companies need to approve every medical procedure so it can be a long process,” Ginsberg said.

Using a broken back as an example, Ginsberg explained the differences between using private healthcare and the state system. He said that while in private healthcare a slipped disk in the back would translate into immediate surgery, the workers’ compensation system would result in a much longer process.

“The worker’s compensation people will say the procedure is necessary and medically reasonable, but they might say it may not be a part of extent of injury,” Ginsberg said.

The “extent of injury” controls how many medical expenses the workers’ compensation would actually cover. In the case of the slipped disk, Ginsberg said that insurance carriers would go through a systematic process in order to ensure no money is lost paying for unnecessary procedures.

First, the claimant would go through physical therapy, followed by a series of muscle injections, and then surgery would be considered. At this point, the insurance carrier could even claim a lower extent of injury. While the claimant suffered a slipped disk, the workers’ compensation adjuster has the power to only offer benefits to cover a mere muscle strain.

“If an adjuster wronged a claimant in this way, it starts a whole process of benefit review conferences and claim hearings that could take up to eight months,” Ginsberg said. “After that long of a waiting period, an injured back could have all sorts of nerve problems and it can get really serious from that point.”

Ginsberg said that workers’ compensation lowers benefits given to claimants by having a strict definition for extent of injury. Unlike in a personal injury case, in order to receive benefits for a work injury, a doctor needs to testify in court and explain the extent of injury with correct legal terminology and details.

Although these problems exist, workers’ compensation lawyer John Fundis who, unlike Ginsberg, works for the insurance carriers, argues that the system’s benefits outweigh its obstacles.

“I don’t know that I see disadvantages for the workers because it’s a no fault system. If you’re a teacher and you fall even though someone doesn’t cause you to fall, you still receive a continuation of your weekly income and medical benefits,” Fundis said.

While he acknowledged that the system could be trying at times, he stated that the injured workers still receive full benefits from the insurance carriers. In addition, Fundis said that, although rare, there are people who attempt to cheat the insurance system and receive pay when they are not actually injured from a work-related incident.

“We need to make sure that we can keep costs in control, but certainly provide benefits where it’s deserved,” Fundis said.

Workers’ compensation insurance protects many employees, such as Sanchez, from having to pay for their injuries sustained during their job, but Ginsberg, Fundis and Sanchez all agree that there is room for improvement for this nationwide system.