Workers’ compensation is a non-mandatory state program that requires employers to have insurance policies covering employees for accidental work-related injuries. If you are injured on the job, your employer or the insurance carrier pays for your medical care and lost wages due to your injury.
Am I covered?
- Am I covered?
- What happens if I am injured at work?
- Can I sue my employer for getting hurt at work?
- Do I have the right to choose my own doctor?
- What type of benefits am I entitled to under workers’ compensation?
- What happens if my claim for workers’ compensation is denied?
- My doctor has recommended that I have surgery, but the insurance carrier has denied it, what can I do?
- I received an impairment rating, but it was too low, what can I do?
- How are attorney fees paid?
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Not all employers (except for governmental entities who are required by statute to insure for workers’ compensation) elect to be covered under the workers’ compensation program in Texas. Texas law allows employers to choose whether they will be covered or not. Employers who choose not to be covered lose their right to assert certain defenses if they are sued as a result of your injury. Employers must give notice to their employees as to whether they are covered by workers’ compensation insurance. To determine whether your employer is covered under the workers’ compensation program you may contact the Texas Workers’ Compensation Commission at (512) 804-4345.
What happens if I am injured at work?
You must notify your employer of your injury immediately. The law states that you must report your injury to your employer within 30 days of its occurrence or within 30 days of the date that you became aware that your injury was work-related, however, it is always better to report your injury immediately to avoid any unnecessary delay in your treatment and benefits.
A claim of injury may be reported in several ways: requesting and filling out a claim form to your employer; orally notifying your employer, or having a representative – i.e. attorney – submit the claim for you. Although you may orally inform your employer of your injury, it is always recommended that you get something in writing evidencing your report of the injury.
In many instances, your employer will have you fill out a Notice of Injury Report. When filling out this form, it is important to be as specific as possible as it relates to the type of pain and body part that has been affected as a result of your injury. Many times, the insurance carrier will attempt to deny your claim if you fail to mention a body part on this first report of injury. Furthermore, you should write down who you reported your injury to and whether there were any witnesses.
In addition, you are required to file a notice of injury report with the Texas Workers’ Compensation Commission within one year of the injury.
Can I sue my employer for getting hurt at work?
No. Recovery of workers’ compensation benefits is the only remedy that you have against the employer. However, in cases where the work injury results in the death of an employee, the employee’s surviving spouse or heirs may recover exemplary damages against the employer where the death was caused by an intentional act or omission of the employer or by the employer’s gross negligence.
Do I have the right to choose my own doctor?
Yes, but get help before choosing your doctor. Call our office before choosing a doctor because your health, job and future benefits depend upon the doctor you choose. Texas requires that you seek medical treatment for a work-related injury with a doctor on their approved list. This doctor is referred to as your “treating doctor.” The treating doctor is primarily responsible for your medical care. We have opinions about which doctors fight for their patients and which doctors favor the insurance company. We can help you avoid the mistake of choosing the wrong doctor.
If your doctor tells you that they have to release you to light duty because the insurance carrier expects it, then your doctor may have a conflict of interest. Also, if your doctor is reluctant to prescribe medication, physical therapy, and request diagnostic tests such as MRIs, then your doctor may have a conflict of interest. Your treating doctor should be willing and able to do what is medically right for you regardless of what the insurance carrier may think. In addition, your treating doctor must be willing to fight for the approval of any and all reasonable and necessary medical treatment through the Texas Workers’ Compensation Commission. We can work with you and your doctor to appeal the insurance carrier’s denial of recommended medical treatment by filing a dispute through Medical Dispute Resolution.
If you have discovered that you need to change treating doctors, contact our office so that we may assist you in filing out your Request to Change Treating Doctor form.
What type of benefits am I entitled to under workers’ compensation?
There are four types of benefits available under workers’ compensation: Medical; Income; Death; and Burial.
Medical benefits: pays for all reasonable and necessary medical treatment related to your work injury or illness. You are entitled to all reasonable and necessary medical treatment for the rest of your life as long as that treatment is related to your work injury.
Income benefits: replace a portion of any wages you lose due to your work-related injury or illness. There are four types of income benefits:
1. Temporary income benefits
2. Impairment income benefits
3. Supplemental income benefits; and
4. Lifetime income benefits.
Temporary income benefits are equal to 70 percent of your average weekly wage prior to the injury, however if you earned less than $8.50 per hour before the injury, then your benefits are 75 percent of your average weekly wage for the first 26 weeks. As of September 1, 2003, the state set temporary income benefits at $537.00 maximum per week and $81.00 minimum per week.
You become eligible for temporary income benefits on the eighth day of missed work. Benefits are not paid for the first week of lost time unless you remain off of work for four weeks or more due to the injury or illness.
Temporary income benefits end when you reach maximum medical improvement or when you are physically able to earn the average weekly wage again, whichever comes first.
Impairment Income benefits are equal to 70 percent of your average weekly wage. You are eligible for impairment income benefits if you have a permanent impairment as a result of your work-related injury or illness.
Impairment income benefits begin once you reach maximum medical improvement. For each percentage of impairment that you receive, you will receive 3 weeks of benefits. For example, if you receive a 5 percent impairment rating, you will receive impairment income benefits for 15 weeks.
Supplemental income benefits are paid if you receive an impairment rating of 15 percent or more and you have not returned to work because of the work-related injury or illness or you have returned back to work but are earning less than 80 percent of you average weekly wage because of the injury or illness and you did not take a lump sum payment of your impairment income benefits and you have tried to find a job that matches your ability to work.
Supplemental income benefits are equal to 80 percent of the difference between 80 percent of your average weekly wage and the weekly wage after the injury.
Supplemental income benefits begin once impairment income benefits end and are paid monthly as opposed to temporary income benefits which are paid weekly.
Supplemental income benefits are handled in quarters. Each quarter, you must send a form to the insurance carrier showing that you are eligible for benefits. If you are eligible, your benefits will start the next quarter.
Supplemental income benefits will end 401 weeks from the date of the injury.
Lifetime income benefits are paid to those whose work-related injury results in a loss of the hands, feet, or eyesight, or if you meet the conditions of the Texas Workers’ Compensation Act.
Lifetime income benefits are equal to 75 percent of your average weekly wage, with a 3 percent increase each year. Lifetime income benefits begin whenever the work-related injury or illness causes you to meet the conditions of the Texas Workers’ Compensation Act and are therefore retroactive. You are entitled to lifetime income benefits for the rest of your life.
Death benefits: replace a portion of lost family income for the eligible family members of workers killed on the job.
A family member gets death benefits if the family member is the spouse, dependent child or grandchild, or another eligible family member of a worker killed on the job.
Death benefits are 75 percent of the deceased worker’s average weekly wage and begin the day after the worker dies. The length of time a family member may receive death benefits depends on the family member’s relationship to the worker.
Burial benefits: pay some of the deceased worker’s funeral expenses. For a death occurring before September 1, 1999, burial benefits pay up to $2500 of the worker’s funeral expenses. For a death occurring on or after September 1, 1999, burial benefits pay up to $6000 of the worker’s funeral expenses.
What happens if my claim for workers’ compensation is denied?
Once your claim has been denied, you should request a benefit review conference. If the issues in dispute are not resolved at that time, then a contested case hearing should be requested where you will be allowed to testify and present witnesses.
Your employer or insurance carrier will use any reason they find to deny or limit your claim to limit their responsibility. If this happens, contact this office immediately. We will work with you and your doctor to ensure that you get all of the benefits that you are rightfully and legally entitled to.
My doctor has recommended that I have surgery, but the insurance carrier has denied it, what can I do?
Your doctor must appeal the insurance carrier’s denial immediately. We can work with you and your doctor to file an appeal with the Medical Dispute Resolution Board regarding the denial of your future medical treatment.
I received an impairment rating, but it was too low, what can I do?
To dispute an impairment rating given by an insurance carrier’s RME doctor, your treating doctor must file a written dispute within 7 days of receiving the report.
To dispute your own doctor’s impairment rating, you will need to talk to your doctor about increasing it. If your doctor refuses, then you must request a benefit review conference.
To dispute a Texas Workers’ Compensation Commission designated doctor’s impairment rating, your doctor must write a letter explaining why he or she disagrees with the impairment rating.
We can help you with all of the above disputes but call us immediately to ensure that no deadlines are missed in filing your appeal.
How are attorney fees paid?
You only pay attorney fees when legal work is done on your case. All charges for attorney’s fees are submitted to the Texas Workers’ Compensation Commission for their review. The Commission will determine whether the fees fall within their guidelines. Once the Commission approves the fees, a copy of the letter which details the charges, is sent to you for your review. If you do not dispute the fees, the Commission will order the insurance carrier to start deducting the attorney’s fees from your weekly check. The amount deducted from your check will not be more than 25 percent of your check until the attorney fees are paid. However, if your checks permanently stop before all approved attorney’s fees are paid, you are not responsible for the balance.