Employees who suffer an injury at work, or contract a job-related injury, are typically interested in two things – feeling better and returning to work. For those who start to feel better, a return to work program is the best way of getting back into work safely and quickly. However, many times workers do not get better, and state-provided workers compensation is not enough to pay for the treatment they require, the wages they have lost, or the expenses incurred. Trimble & Grant, PLLC have years of experience helping injured and sick workers heal their bodies and mend their lives.
The following information is provided by Trimble & Grant, PLLC as a resource to help injured workers understand the rules governing their on-the-job injury under Texas workers’ compensation.
This information is provided for general information only and does not constitute legal advice nor does it create any kind of attorney client relationship. The information based upon assumed hypothetical fact situations which may or may not apply to a specific situation. As the law is constantly evolving, one should consult with an attorney about any of these matters.
Most Common Mistakes to Avoid
- Failing to report your injury to a supervisor within 30 days of the injury.
- Failing to file a Employee’s Notice of Injury or Occupational Disease and Claim for Compensationwith the DWC within one year of your injury.
- Failing to ensure that the insurance carrier accurately calculates your average weekly wage (AWW) and pays your income benefits at the correct rate.
- Failing to properly dispute an initial impairment rating (IR) and date of maximum medical improvement(MMI) within 90 days.
- Failing to seek immediate medical attention, and failing to follow up with the treating doctor.
- Failing to realize that the employer may not have your best interests at heart, and that a reliance on the employer to take care of it all may very well end in disappointment.
- Attempting to handle disputed issues against an experienced carrier representative at the benefit review conference (BRC) and contested case hearing (CCH) level without someone experienced on your side.
Why Trimble & Grant, PLLC?
Heart and Experience. We care about our clients. Everyone at Trimble & Grant, PLLC has at least seven (7) years’ experience assisting injured workers under the Texas workers’ compensation system. We’re down-to-earth, so you can be comfortable talking to us. All of our legal assistants are bilingual. Our knowledge and experience are the result of our focus on injured workers and their families.
Top questions about Texas workers’ compensation
I’ve been injured at work, what do I do now?
The first thing you need to do is report your injury to a supervisor at work. If an injury is not reported within the first thirty days, you may lose your right to compensation. Hopefully, the company you’re working for will have workers’ compensation insurance. This will allow them to cover the cost of medical bills or hospitalization, avoiding a legal battle. The next thing you must do is seek immediate medical attention, informing the doctor that you were injured at work, and then continue to follow up with your treating doctor.
What is meant by a “compensable” injury?
A compensable injury is an injury that arises out of an activity of any kind that has to do with and originates in the work of the employer, and is performed by an employee while engaged in the business of the employer.
How do I find a treating doctor?
If your employer is not part of a workers’ compensation health care network, you must choose your treating doctor from the list of doctors approved by the Division of Workers’ Compensation. This list is maintained at http://www.tdi.texas.gov/wc/txcomp.html. If your employer is part of a workers’ compensation health care network, in most cases you will be required to choose your treating doctor from its list of providers. Never delay medical treatment if you are unable to locate an approved doctor. Contact our office or go to the emergency room.
What are temporary income benefits (TIBs)?
Temporary income benefits (TIBs) are income benefits paid to an injured worker who has disability and has not reached maximum medical improvement. These are generally thought of as income replacement benefits.
What does “disability” refer to?
Disability is the inability to obtain and retain employment at wages equivalent to the preinjury wage because of the compensable injury.
When should I get my first TIBs check?
An insurance carrier who has received written notice of an injury and has not disputed the claim is required to begin income benefits no later than the seventh (7th) day after your eighth (8th) day of disability (this eighth day is called the accrual date).
My check always seems to be late, is there anything I can do?
As long as an insurance carrier has mailed the income benefit payment on or before the benefit payment due date, the law considers it to be timely paid. Thus, if your temporary income benefits check pays you from Friday to Thursday, your check would be considered timely as long as it is issued and mailed on or before the last day of the time period (i.e., Thursday) even if it is not received until the following week. You may want to consider having your benefit checks paid by electronic fund transfer and directly deposited in your bank account.
How much should the insurance carrier be paying me?
The income benefit rate for injured workers is based on the average weekly wage (AWW) of the thirteen (13) consecutive weeks immediately preceding the compensable injury, though the calculations may vary depending on the type of worker or employer. The Division has established maximum and minimum compensation rates based on the injured worker’s date of injury.
I was injured at work and now the adjuster is telling me they’re denying my claim. What do I do now?
You may request a benefit review conference (BRC) through the Division of Workers’ Compensation to resolve the issue. Before the BRC you will want to gather all the medical and other documentary evidence supporting your claim to exchange at the hearing. The medical evidence usually includes a detailed narrative from your treating doctor.
What is a benefit review conference (BRC)?
A benefit review conference is a nonadversarial, informal dispute resolution proceeding which is designed to attempt to mediate and resolve disputed issues.
What is a contested case hearing (CCH)?
A contested case hearing is an adversarial, formal dispute resolution proceeding in which a Division employee called a hearing officer hears and receives evidence in order to issue a written decision on the disputed issues.
What is an impairment rating (IR)?
An impairment rating is the percentage of permanent impairment of the whole body resulting from a compensable injury. The impairment rating is assigned by the injured worker’s treating doctor, a referral doctor, an RME doctor, or a Division-appointed designated doctor.
What does maximum medical improvement (MMI) mean?
Maximum medical improvement generally refers to the earliest date after which further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated. Another way to think of this is when your recovery is as good as it is reasonably going to get, and your improvement has reached a plateau. Maximum medical improvement can also refer to the expiration of 104 weeks from the date on which income benefits begin to accrue, this is often referred to as statutory maximum medical improvement (SMMI).
What are impairment income benefits (IIBs) and how are they calculated?
Impairment income benefits (IIBs) are income benefits paid to an injured worker who has reached maximum medical improvement and received an impairment rating higher than 0%. Injured workers are entitled to receive three (3) weeks of impairment income benefits (IIBs) for every percentage point of impairment.
Can I dispute an impairment rating and date of maximum medical improvement?
Yes, you may dispute a certification of maximum medical improvement and an assignment of impairment rating. In fact, if a first valid certification and assignment is not disputed within 90 days it becomes final.
What is commutation?
Commutation is a method of receiving impairment income benefits in a lump sum. Briefly, in order to qualify for commutation, you must have worked for at least three months earning at least 80% of your pre-injury average weekly wage. However, commutation terminates your entitlement to additional income benefits; this means you can never receive any additional income benefits for your injury.
Can I get an advance on my workers’ compensation checks?
Possibly. You may request an advance of benefits based on financial hardship. If the Division grants your request, your future weekly benefit payments will be reduced to repay the advance. An injured worker having a difficult time meeting financial obligations with full temporary income benefits checks, should seriously consider how much more difficult it might be with reduced temporary income benefits checks during the time the advance is being repaid.
What are supplemental income benefits (SIBs)?
Supplemental income benefits (SIBs) are income benefits paid to an injured worker who has received an impairment rating of 15% or greater; has not commuted any portion of impairment income benefits; has tried in good faith to get work equal to his or her ability to work; and has not returned to work, or has returned to work but is earning less than 80 percent of the pre-injury average weekly wage as a direct result of the impairment from the compensable injury.
What are lifetime income benefits (LIBs)?
Lifetime income benefits (LIBs) are income benefits paid to an injured worker until the death of the employee for specific extreme injuries including total and permanent loss of sight in both eyes, loss of both feet at or above the ankles, loss of both hands at or above the wrists, loss of one foot at or above the ankle and the loss of one hand at or above the wrist, a physically traumatic injury to the brain resulting in incurable insanity or imbecility, third degree burns that cover at least 40 percent of the body and require grafting, or third degree burns covering the majority of either both hands or one hand and the face.
The insurance carrier is not approving medications my doctor has prescribed for my compensable injury, what can I do?
Have your doctor send a letter of medical necessity to the insurance carrier explaining why you need the medications and how this is related to your compensable injury. If this does not resolve the issue, you may wish to file a request for medical dispute resolution. This form is at http://www.tdi.state.tx.us/forms/dwc/dwc60.pdf.
What’s the difference between a light duty release and a full duty release?
A light duty release includes restrictions on your ability to work; a full duty release contains no restrictions on your ability to work. You may still be eligible for temporary income benefits under a light duty release, whereas a full duty release will immediately terminate eligibility for temporary income benefits.
What’s a treating doctor (TD)?
A treating doctor is the doctor who is primarily responsible for the health care for an injury. A change of treating doctors must be approved by the Division.
What’s a required medical examination (RME)? Do I have to attend?
A required medical examination (RME) generally refers to an appointment with a carrier-selected doctor that has been approved and ordered by the Division of Workers’ Compensation. If an injured worker fails to attend an approved RME appointment without good cause, the insurance carrier may suspend temporary income benefits.
What’s a designated doctor (DD)?
A designated doctor is a doctor appointed by the Division of Workers’ Compensation to recommend a resolution of a dispute as to the medical condition of an injured employee.
Are there settlements in Texas workers’ compensation claims?
No, not as such. Occasionally, an injured worker who is receiving supplemental income benefits (SIBs) may enter into an agreement with the insurance carrier to pay some portion of these benefits, but this is rare.
Is there anyone who can help me with my claim?
Yes. You may either hire an attorney to represent you or contact the Office of Injured Employee Counsel for an ombudsman to assist you with a dispute with the insurance carrier. Ombudsmen’s services are free; however, ombudsmen do not represent injured workers.
Can I hire an attorney? When does my attorney get paid? How does my attorney get paid?
Yes, you may hire an attorney to assist you with your workers’ compensation claim. Your attorney is paid by the insurance carrier out of your income benefits and only gets paid if you get paid. You never pay an attorney representing you in a Texas workers’ compensation matter before the Division out of your own pocket.
How do attorney’s fees work?
Attorney’s fees are based on the attorney’s time and expenses, and must be approved by the Division of Workers’ Compensation. Once the Division approves the attorney’s fees, the insurance carrier is ordered to deduct attorney’s fees from the injured worker’s income benefits at a rate not to exceed 25 percent of the injured worker’s recovery.
The insurance company is disputing part of my injury, what can I do?
You may request a benefit review conference (BRC) through the Division of Workers’ Compensation to resolve the issue. Before the BRC you will want to gather all the medical and other documentary evidence supporting the extent of your injury to exchange at the hearing. The medical evidence usually includes a detailed narrative from your treating doctor explaining why the injuries to the disputed areas should be part of your compensable injury.
How long can I continue to treat for my work-related injury?
You have the right to receive reasonable and necessary medical care for your compensable injury for the rest of your life.
Can I get reimbursed for travel expenses for doctors’ visits?
Possibly. You may request reimbursement for travel expenses from the insurance carrier if medical treatment for your compensable injury is not reasonably available within 30 miles from where you live, and the distance traveled to secure medical treatment is greater than 30 miles, one-way. You must submit your request for reimbursement within one year of the date you incurred the expenses.
The form for travel reimbursement is at http://www.tdi.state.tx.us/forms/dwc/dwc048trvlreim.pdf .
I was injured on the job and my employer terminated me, am I eligible for unemployment benefits?
Possibly. You may be if your doctor has said you have any ability to work.
Workers’ Compensation Links
Texas Department of Insurance, Division of Workers’ Compensation (DWC) Home page
Texas Department of Insurance, Division of Workers’ Compensation (DWC) Online search for healthcare provider
Cambridge Integrated Services
Gallagher Bassett Services, Inc.
Provides claimants and providers with direct, online access to check status and payment information 24 hours a day, 7 days a week.
Health Administration Services (HAS)
Sedgwick Claims Management
Shorman Solutions Case Management
State Office of Risk Management
Texas Mutual Insurance Company
Social Security Administration
State Bar of Texas
Texas Workforce Commission (including unemployment benefits)
Trimble & Grant, PLLC
1602 Hamblen Street
Houston, Texas 77009
Office: (713) 863-8600
Fax: (713) 863-1161