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Workers' Compensation in Texas


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A primer on the basics of Texas Workers’ Comp and the rights of employees.

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Workers' Compensation in Texas

  1. 1. WORKERS’ COMPENSATION IN TEXAS A primer on the basics of Texas Workers’ Comp and the rights of employees
  2. 2. What is Workers’ Compensation? Workers' compensation is liability insurance which provides medical benefits and limited wage replacement to employees who are injured at work or become ill as a result of their work-related duties. It is essentially “no fault” insurance for both parties. With the exception of federal employees and some small groups of private-sector employees who are covered by federal law, private-sector employers purchase commercial liability insurance in order to provide workers’ comp benefits to their employees. The plan is governed and administered by the State of Texas. FOR A FREE CONSULT CALL US AT (800) 444-5000
  3. 3. FOR A FREE CONSULT CALL US AT (800) 444-5000 How Does it Benefit Employees & Employers? Injured employees can quickly have their medical bills paid; their families receive survivor benefits in case of fatal work accidents; and workers are compensated for most of their lost wages without unnecessary delays or having to pay the legal costs associated with a civil trial. Employers are at virtually no risk of a large legal judgment against them in a lawsuit brought by the injured employee, because the employee gives up the right to sue.
  4. 4. FOR A FREE CONSULT CALL US AT (800) 444-5000 How are Covered Employers Protected? In Texas, employers are not required to carry traditional workers’ compensation insurance. However, private employers with six or more employees must either carry workers’ comp coverage or post a bond (approved by the Texas Department of Insurance’s Division of Workers’ Compensation) to reimburse injured employees. If your employer has workers’ comp coverage, you must go through that specific administrative process to be compensated for your injury.
  5. 5. FOR A FREE CONSULT CALL US AT (800) 444-5000 Does your company have WC insurance? • If no, this is considered a non-subscriber case that operates like any other civil case. • If yes, then the case operates very differently. • Step one is to file a claim with the WC insurance (your company should do this automatically, but they do not always, so this is something an attorney can do for you, or you can go to the Division of Workers’ Compensation to file it yourself).
  6. 6. FOR A FREE CONSULT CALL US AT (800) 444-5000 Filing the Claim • Once a claim is filed, the insurance company has 15 days to make a determination on your claim. • If at the 15th day they have not decided to accept or deny your case, they must start paying until they make a decision. • If by the 60th day the insurance company has not made a decision, they have waived their right to dispute the claim.
  7. 7. FOR A FREE CONSULT CALL US AT (800) 444-5000 Once a claim is set up, what next? • Case accepted: This means that they agree you had an injury on the job, but it does not necessarily mean that the extent of your injury has been accepted, or that they will start paying you. • Once your case is accepted, you need to be sure that the diagnosis given by your doctor is the diagnosis accepted by the insurance company. • You also have the right to change treating doctors once on your claim, so if you do not feel the doctor has your best interests at heart, exercise this right! • If your diagnoses are not accepted, you will need to go through the dispute resolution process (see subsequent slides).
  8. 8. FOR A FREE CONSULT CALL US AT (800) 444-5000 Workers’ Compensation Denials Another issue that often arises is that your case will be accepted but the insurance company will deny payment. If this has happened, you will need to go through the dispute resolution process. The various reasons an insurance company could deny benefits are: • The doctor has released you for full duty (you are entitled to income benefits only if you are restricted from work and that prevents you from earning your pre-injury wages). • The doctor has released you for full duty but the company has given you an offer of employment (also known as a Bonafide Offer of Employment or “BFOE”). • “BFOEs” often do not comply with the Rules, and while the Carrier will dispute paying you because a light duty job is available, it does not mean that is right. Exercise your right to dispute! • The doctor has released you for light duty, but the employer has terminated you for cause. This is one of the top disputes that arises for disability and it is often WRONG. Granted, decisions are made on a case by case basis, depending on the reason for the termination, but it is always good to consult with an attorney about your rights.
  9. 9. FOR A FREE CONSULT CALL US AT (800) 444-5000 Temporary Income Benefits It is important to note that the type of benefits we are referring to are called “temporary income benefits,” and they are paid weekly while you are considered off work or on light duty (without work available) by the doctor. Once you are released to full duty, the benefits stop. Another way your benefits can stop is based on a designated doctor report.
  10. 10. FOR A FREE CONSULT CALL US AT (800) 444-5000 Designated Doctors These are doctors assigned by the state to review various aspects of your claim. You could be set to be examined every 60 days, but often it only happens a few times, perhaps only once, per claim. It is important to note that the designated doctor’s report holds more weight than those of all other doctors. Either you or the insurance company can request for this appointment to happen for the following reasons: • Extent of injury: whether your entire injury was caused by the on-the-job accident • Return to work: how able you are to return to work, if at all • Disability: whether your ability to return to work is related to the on-the-job injury. • Maximum Medical Improvement (MMI) and Impairment Rating (IR): whether you have reached the maximum the doctor thinks you will improve, meaning the doctor does not think more treatment will make you better. If you have any residual issues from the injury, you will be assigned an impairment rating.
  11. 11. FOR A FREE CONSULT CALL US AT (800) 444-5000 Information about MMI & IR • You have only 90 days from your receipt of the report to dispute this or the certification is considered FINAL! • Once you receive an impairment rating (IR), your temporary income benefits will STOP and impairment income benefits will begin. • The insurance pays you 3 weeks of checks for each point that you receive. For example, if you receive a 5% rating, you will receive 15 weeks of checks. • These checks are sent weekly, just like your temporary income benefits checks were. • You can request to receive them in a lump sum, but only if you have been working for 3 months when the request is submitted. • If you receive a rating of 15% or greater, DO NOT ask for a lump sum. You will waive your right to future benefits if you do.
  12. 12. FOR A FREE CONSULT CALL US AT (800) 444-5000 How to calculate the amount of benefits: AWW • The insurance carrier takes your gross wages from the 13 weeks prior to your injury to determine what your Average Weekly Wage (AWW) is. It then pays 70% of that amount. • Please note that taxes are not applicable to workers’ compensation income. • If you have not worked for 13 weeks prior to your injury, then the insurance will either use your actual wages or get a similar wage statement from a fellow employee who worked similar hours and received similar pay. • This can often lead to disputes over the amount paid. • If you have some weeks during this period where work is not available (for example Christmas and New Year’s), those weeks should be excluded so that you get a fair and reasonable amount for your AWW calculation. • All income benefits are subject to a maximum amount, which changes annually. Please contact an attorney or the Division of Workers’ Compensation to confirm which amount is applicable to your date of injury.
  13. 13. FOR A FREE CONSULT CALL US AT (800) 444-5000 My case is being disputed. What next? • The first step is to try to resolve it with the adjuster. The Division of Workers’ Compensation (DWC) requires you to attempt to resolve it before you can move on to the next level. • If you cannot resolve the dispute with the adjuster (or are not getting a response), then you can request for a Benefit Review Conference (BRC). This is an informal hearing that operates similar to a mediation wherein you try to resolve the issues with a representative from the insurance company. If you cannot resolve the issue, you have one of 3 options: 1. Reset the BRC so that you can get more information/documentation in the hopes of resolving the dispute. 2. You can only attend 2 BRCs, and at the second one, you either have to drop the issue if it is not resolved or set it to go before an Administrative Law Judge (ALJ). 3. Set the case to go to a Contested Case Hearing before an ALJ. This is a formal administrative hearing where a decision will be made on the issue. The Administrative Law Judge has 10 days from the date of the hearing to mail a decision (the decision will not be made the day of the hearing).
  14. 14. FOR A FREE CONSULT CALL US AT (800) 444-5000 Legal Options Outside of Workers’ Comp Employers who have no workers’ compensation insurance are subject to lawsuits for payment. Occasionally, employers who have workers’ comp insurance may also be sued under special provisions, such as employer gross negligence or willful intent to injure you. And if a third party (such as a visitor to your job facility) had a hand in causing your work injury, you can bring a lawsuit against them. If you were off-site but performing work for your employer and were injured, traditional civil liability lawsuits may be filed against those defendants.
  15. 15. We’re Here to Help The Terry Bryant Accident & Injury Law Firm understands the subtle ins and outs of the Texas Workers’ Compensation claims process and how to take all the necessary steps to benefit you and your claim. Third-party lawsuits – if applicable – may fully compensate you for what workers’ comp doesn’t pay.We can also help injured workers whose employers are non-subscribers to Texas workers’ comp. Don’t fight your workers’ comp fight alone. Contact us today at (800) 444-5000 or fill out our online form to arrange a free consultation. FOR A FREE CONSULT CALL US AT (800) 444-5000