Texas Workers Compensation: Claims, Denials and Appeals
The Texas workers’ compensation program provides reimbursement for lost wages and medical benefits to covered employees if they sustain a work-related injury or illness. In Texas, unlike most other states, employers are not required to have workers’ compensation insurance coverage. Most employers, however, do have workers’ compensation insurance. Also unlike other states, money to fund the Texas workers’ compensation program is obtained through taxation of insurance carriers, and fees from self-insured employers.
You are eligible for the same benefits regardless of your employer’s insurance status; however, whether your employer is insured will often determine who will administer your claim. If your employer is insured, you will likely be dealing with an adjuster at your employer’s workers’ compensation insurance company.
If you are injured on the job in Texas, and you are an employee, not an independent contractor or a volunteer, you most likely have a legitimate workers’ compensation claim. A covered injury can include a physical health issue that arises suddenly in an accident or one that occurs over the course of time due to continued exposure to a substance or certain work conditions.
Filing a Claim
Report your work-related injury or illness to your employer as soon as possible. You should report the injury within 30 days of the date of the injury, or 30 days from the date your doctor informed you that your illness was related to your work. If you don't tell your employer within 30 days, you can lose your right to workers’ compensation benefits.
Your employer should provide you with a DWC Form-041, which is the form entitled, “Employee’s Claim for Compensation for Work-Related Injury or Occupational Disease.” Send this completed form to the Texas Department of Insurance, Division of Workers’ Compensation.
Texas Workers’ Comp Benefits
In Texas, there are four major categories of workers’ compensation benefits you may be eligible for: income benefits, medical treatment, burial costs, and death benefits. There are also benefits available for injured workers who sustain permanent physical impairment as a result of their industrial injury or occupational disease.
Burial costs and death benefits apply only if a worker is killed during the course and scope of employment. If this occurs, the family will receive money for burial expenses, and money to compensate for the deceased family member’s lost income.
You are eligible for medical treatment benefits immediately following your injury or the onset of occupational disease. Medical treatment can include doctor visits, diagnostic studies, physical therapy, surgery, and other treatment that is proper and necessary to cure your illness or treat your injury. When you go to the doctor, tell them you were involved in a workplace injury, and provide your workers’ compensation claim information. The doctor or clinic will then bill your employer or their workers’ compensation insurance carrier directly.
Your employer may require that you see a specific doctor for treatment related to your workers’ compensation claim. This is true if your employer participates in a certified workers’ compensation health care network. You may choose any doctor within the network. If your employer does not participate in a network, talk to your primary care doctor about whether he or she treats patients with workers’ compensation injuries. If not, your doctor should be able to provide you with information about doctors in your area that regularly treat injured workers.
If you are unable to work due to your work-related injury or occupational disease, you may be eligible for compensation for your lost wages. In Texas, these are known as “income benefits.” There are four types of income benefits depending on the circumstances involved: temporary income benefits, impairment income benefits, supplemental income benefits, and lifetime income benefits.
Temporary income benefits are paid to workers that cannot work for more than seven days due to their injury or illness. You may also receive temporary income benefits if you return to work in a light duty or part-time capacity necessitated by your recovery, and you earn less money than before your injury or illness. If you qualify, you will receive 70% of your lost wages in most cases, subject to certain maximum dollar amounts. These payments are made directly to you on a weekly basis.
Your temporary income benefits end as soon as you reach maximum medical improvement, or whenever you return to work on a full-capacity basis, whichever occurs first. The maximum amount of time you can receive these benefits is 105 weeks after your date of disability, regardless of your medical situation.
If you are permanently impaired as a result of your workplace injury or occupational disease, you will likely be eligible for additional benefits, including “impairment income benefits.” These benefits are available once you reach maximum medical improvement, meaning there is no additional curative medical treatment that will improve your condition.
Your doctor will rate your permanent impairment and determine any permanent work restrictions at that time. Your impairment rating and work restrictions determine your eligibility for additional workers’ compensation benefits.
For each percentage point of impairment, you are eligible for three weeks of impairment income benefits. The weekly benefit amount is equivalent to 70% of your average weekly wage, subject to a maximum.
Supplemental Income Benefits
“Supplemental income benefits” are another type of lost wages benefit and are paid to workers that have an impairment rating of 15% or more. These benefits are also available to workers that are earning less than 80% of their former wages because of their level of permanent impairment due to the workplace injury. These payments begin after the impairment income benefits end.
The formula for determining the amount of supplemental income benefit is complicated: it is 80% of the difference between 80% of your average weekly wage at the time of your injury and your current average weekly wage. Supplemental income benefits end 401 weeks following the date of injury, or at the date you become ineligible for the benefits due to your physical ability to work, whichever is earlier. (You must show each quarter that you continue to be eligible for these benefits to continue to receive supplemental income benefits. )
Lifetime Income Benefits
If your workplace injuries or illnesses are severe, you may be eligible for “lifetime income benefits.” These are for workers that lose total eyesight in both eyes, amputations to multiple appendages, severe spinal injuries resulting in paralysis, or severe third degree burns.
Workers who meet the criteria for lifetime income benefits will receive 75% of their average weekly wage, with a 3% increase each year. These benefits are paid for the remainder of the worker’s life.
Appealing a Denial of Your Claim
If your workers’ compensation claim is denied, contact your employer's insurance adjuster to see if it is a matter of missing, incorrect, or inaccurate documentation. Providing this additional documentation can sometimes ensure your workers’ compensation claim will be allowed.
If your claim is denied, you have the right to appeal this decision by contacting the Division of Workers’ Compensation Insurance of the Texas Department of Insurance. You can go to a dispute resolution conference called a Benefit Review Conference, but if you don't settle your disagreement with the insurance company, you may go to arbitration or to a contested case hearing.
To learn more, see our article on Appealing a Denied Workers Compensation Claim in Texas.
You should consider hiring an attorney if you would like to appeal your claim denial further. An attorney can ensure that as much evidence as possible in your favor can be submitted on your behalf. This is important, especially because in subsequent appeals, you cannot present additional evidence than what is presented at the contested case hearing level.