Take a look at this link from Houston’s ABC affiliate, KTRK’s investigative report. A police officer shot in the line of duty and years later he cannot get medical care. It is sensational because it is a police officer who is fighting to get medical care approved but his experience is no different than workers in any other field. The Texas Workers Compensation system was passed by a legislature that promised lifetime medical care but as anyone who has ever dealt with workers compensation in Texas knows, lifetime medical care is a farce. The Insurance industry is simply not set up to provide lifetime medical care to claimants.
When a claim is made against an insurance company, the adjuster who is assigned the claim will investigate to determine the legitimacy of the claim and to determine the amount that the claim will cost the insurance company. That adjuster, either individually or together with a team, will set a number called the “reserves” for the claim. That is the amount that is estimated for the insurance company to keep in reserve to pay the claim. If an adjuster sets reserves appropriately, it is good for the insurance company because it allows insurance companies to properly allocate their resources and make good investments. When insurance companies make good investments, they make more profit. As a matter of public policy, we want insurance companies to make profits off of investments.
The problem though, is that there is a conflict between the need to set accurate reserves and the inability to know the future medical needs. So, an adjuster will set reserves, but getting those reserves raised can be a problem. And in some insurance companies, adjusters will tell you confidentially that raising reserves can adversely affect their employment. Also, there is frequent turnover in the job of an adjuster. What happens when an adjuster sets reserves, but then another adjuster comes along years later and needs to increase reserves?
For these reasons, and more, lifetime medical care is next to impossible to get on Texas workers comp. Routinely we have clients who are looking to get social security so that they can actually get lifetime medical care for their injuries. It isn’t right. It passes the cost of injuries that should be covered by insurance onto the general public. But it is what the injured people of Texas have to do if they truly want lifetime medical care.
And if you are employed like Mr. Bozeman in this story–you have to pay for the medical care out of your pocket. Hopefully you have insurance and only have to pay a deductible and co-pay. But if your insurance doesn’t cover pre-existing conditions you are just out of luck.