Texas Workers Compensation Supplemental Income Benefits Guide


Texas Labor Code §408.141 – 408.151
28 Texas Administrative Code §130.100 – 130.109
 
Supplemental income benefits (SIBs) are income benefits paid monthly by the insurance carrier after your impairment income benefits have ended.  You must have at least a 15% impairment rating to be eligible for supplemental income benefits.  This is another reason why your impairment rating is important.  You also must not have chosen to have any of your impairment income benefits paid to you in a lump sum. 
 
Supplemental Income Benefit Quarters
 
Eligibility for supplemental income benefits is determined on a quarterly basis, once every three months.  Supplemental income benefits are paid to you once a month for three months.  Supplemental income benefits continue to be paid in quarters until a total of 300 weeks of supplemental income benefits is exhausted or a total of 401 weeks of income benefits has been exhausted on your claim. 
 
Qualifying Quarter for Supplemental Income Benefit Quarter
 
Whether you are eligible for supplemental income benefits depends upon the circumstances of your situation during the thirteen weeks before the beginning date of the supplemental income benefit quarter that is being determined.  This thirteen week period before the beginning of the supplemental income benefit quarter is called the "qualifying quarter."  If you qualify during the qualifying quarter, then you become eligible to receive payment during the supplemental income benefit quarter that follows the qualifying quarter. 
 
Application
 
You must file an application for supplemental income benefits.  The first application is filed with the Texas Division of Workers Compensation.  The Division will determine whether you are eligible for supplemental income benefits for the first quarter of supplemental income benefits.  This determination will be based upon whether you meet the eligibility requirements during the qualifying quarter for the first supplemental income benefits quarter. 
 
This first qualifying quarter actually occurs during the last thirteen weeks that your impairment income benefits are paid.  Many people do not realize that they have to meet this eligibility requirement during this time when they are actually receiving a workers compensation check, and this causes a problem when the impairment income benefit period ends and the impairment income checks stop.  Suddenly faced without a check, the people discover that they are required to apply for the supplemental income benefits, and that the eligibility period has already expired for the first quarter.  This often results in a denial by the Division of Workers Compensation for entitlement to the first quarter of supplemental income benefits. 
 
Some people receive this initial denial and think that their case is over.  This initial denial does not mean that you will never receive any supplemental income benefits.  The denial only applies to the first quarter of supplemental income benefits.  You can still meet the requirements for the second quarter and for subsequent quarters of supplemental income benefits.
 
Starting with the second quarter of supplemental income benefits, you will file your application with the insurance company.  The insurance company will either accept the application and pay the supplemental income benefits for that supplemental income benefit quarter, or the insurance company will deny the application for supplemental income benefits.  If the insurance company denies your application for supplemental income benefits, you have the right to pursue your entitlement to supplemental income benefits for that quarter through the dispute resolution system of the Texas Division of Workers Compensation. 
 
Eligibility
 
To be eligible for supplemental income benefits, you must show that as a direct result of your work related injury:
  • you are unable to work, OR
  • you have been released to return to work in some capacity but have not been able to find a job making at least 80% of your average weekly wage, OR
  • you have returned to work but are earning less than 80% of your average weekly wage.
For each of these situations, it is better to have an attorney represent you on your claim.  An attorney studies the cases that apply the law to your situation and will be better able to explain how the nuances in the law apply to your situation.  An attorney can fight for your rights by taking your case to trial at the courthouse and appealing the decisions of the Division of Workers Compensation.   
 
There may be a dispute as to whether you are unable to work.  You have the right to have whether you are unable to work determined through the dispute resolution process.
 
If you have been released to return to work, you must meet the requirements of the Texas Division of Workers Compensation relating to your work search.  There are many factors involved in the work search requirements, and there are court cases and administrative decisions from past cases that may apply to your particular situation regarding whether your work search meets the qualifications for supplemental income benefits.  You need to consult an attorney about how these cases apply to your situation.
 
If you have returned to work, you may be making your old hourly rate of pay but still not be making at least 80% of your average weekly wage.  This is because average weekly wage is a term that includes several other factors in what you were actually earning during the 13 weeks prior to your date of injury.  The determination of whether you are making at least 80% of your average weekly wage varies from quarter to quarter based upon what happens during the qualifying quarter for that supplemental income benefit quarter.  The determination has to be made on a case by case basis depending upon the facts during that qualifying quarter.
 
Losing Entitlement to Supplemental Income Benefits Permanently
 
If you are determined to not be eligible for supplemental income benefits for four quarters in a row, then you permanently lose entitlement to supplemental income benefits.  This entitlement determination is not just the insurance company's denial of your quarter.  This entitlement determination is the final determination that is made on the supplemental income benefit quarter after the dispute resolution process has completed. Some people receive the insurance company's denial on a quarter or on multiple quarters and think that is it. This is not true.  You have the right to challenge the insurance company's denial and go through the dispute resolution process of the Division of Workers Compensation to have your right to each quarter of supplemental income benefits determined. 
 
Going to Court
 
You also have the right to challenge the Division of Workers Compensation determination by taking your case to court over whether you are eligible for supplemental income benefits for each quarter.  Because Texas workers compensation is a piecemeal, issue driven system, you are actually entitled to a jury trial for each individual quarter of supplemental income benefits.  As a practical matter, once the insurance company starts denying quarters of supplemental income benefits, several quarters in a row may stack up as the insurance company tries to see if it can get a determination that you have not been entitled to 4 quarters in a row so that you would permanently lose entitlement.  It may be judicially more economical to try several quarters together at the courthouse. 
 
 

Contact Form