LIFE, HEALTH & LICENSING 2007 Workers’ Compensation Health Care Network Workshop Texas Department of Insurance What Has Not Changed In Workers’ Compensation? Amy Lee Workers’ Compensation Research and Evaluation Group (REG)
Injury Notification and Claim Filing Requirements
How does the process work? (Workers’ responsibilities)
Within 30 days from the date of the injury or 30 days from the date the worker should have known an occupational disease was work-related, the worker must report the injury to the employer.
Within one year, the injured worker must also file a claim for compensation with the DWC.
If the worker does not report the injury to the employer or file a claim with the DWC in a timely fashion, then the worker may lose eligibility to benefits.
How does the process work? (Employers’ responsibilities)
Employers must report any work-related injury that results in more than one-day of lost time, or any occupational disease claim, to the insurance carrier.
Employers must report any work-related injury or occupational disease within 8 days from the date the injured worker began to lose time away from work or within 8 days from the date that the employer received notice that the worker contracted an occupational disease.
The employer must provide a copy of the injury report to the injured worker along with a copy of the employee’s rights and responsibilities under the Act.
Determinations of Compensability/ Extent of Injury
Regardless of whether a claim is part of a network or not, insurance carriers still have a responsibility to review whether the injury is “work-related” or compensable under the WC Act;
Insurance carriers, by statute, may investigate and contest the compensability of an injury within 60 days from the date the carrier received notice of the injury;
Additionally, insurance carriers may contest the “extent” of the compensable injury (e.g., whether a worker’s new shoulder injury is related to the worker’s compensable neck injury) at any point during the claim;
***Note: In accordance with Section 1305.153(e), network doctors receive written notice when an insurance carrier contests the compensability of a network claim (doctors treating non-network claims are not required to receive such a notice). Payment for services rendered prior to this notice cannot be denied based on compensability; however, they may be denied based on medical necessity.
If an insurance carrier successfully contests compensability of a network claim, the carrier’s liability for payment of medical care is capped at $7,000
Treating Doctor Exam to Define the Compensable Injury
Carriers may request that the worker’s treating doctor perform an examination to define the compensable injury (see DWC Rule 126.14);
Once an examination is performed by the treating doctor, the insurance carrier will review the results and either “accept” or “deny” the injury or diagnoses documented in the doctor’s report;
If the carrier denies all or part of the injury documented in the doctor’s report, then any care related to the specific injury or diagnosis denied, must be preauthorized by the carrier until the compensability or extent of injury dispute can be resolved through dispute resolution or mutual agreement of the parties
Income benefits are paid by insurance carrier directly to injured employee
Temporary Income Benefits (TIBS)
Impairment Income Benefits (IIBS)
Supplemental Income Benefits (SIBS)
Lifetime Income Benefits (LIBS)
Death & Burial Benefits
How are Income Benefit Disputes Resolved in Texas?
Benefit Review Conference (BRC) – an informal mediation between the parties and a DWC benefit review officer;
Contested Case Hearing (CCH) – a formal hearing between the parties that is presided over by a Contested Case Hearing officer; a formal decision is typically rendered at this level.
Appeals Panel review (AP) – a paper review of the CCH decision by a panel of three administrative law judges at DWC; the AP may agree, reverse or remand the CCH decision (this is the end of DWC’s administrative dispute process).
Judicial review of DWC decision – if a party is still not satisfied with the AP decision, then a party may appeal the decision to a district court.