Texas Workers Compensation Benefits Guide


This Guide should not be a substitute for representation by an attorney.  You should have an attorney explain to you how the laws apply to the specific facts of your case. 

What is workers compensation?
Workers compensation is an insurance policy that is purchased by your employer to provide benefits to you if you are injured while working for your employer. The benefits are paid by the insurance company that sold the policy to your employer.

Do all Texas employers provide workers compensation to their employees? Texas employers are not required to buy workers compensation policies to protect their employees. Texas is the only state that does not require employers of a certain size to buy workers compensation insurance for their employees.  If the Texas employer does not buy a policy, the employer can be sued directly by the employee for the injuries the employee sustains.  If the Texas employer does buy a policy, then the employer is shielded from being sued directly by the employee; however, there are some exceptions to this rule.

Who else can I sue for my injuries? There also may be other individuals or companies who are responsible for the injury and who may be sued. These are called third parties. You may be able to sue a third party directly for causing the injury at the same time that you receive workers compensation benefits. You may be able to sue the workers compensation company for not treating you fairly on your claim in a bad faith suit. You may be able to sue your employer for treating you unfairly after your injury, such as discriminating against you for pursuing a workers compensation claim, for trying to get treatment for your injuries, or for missing work as a result of your injuries. You also have rights concerning how the employer treats you when you have disabilities as a result of your injuries. And you have rights concerning your job when you return from being off work.

Can I get Texas workers compensation if I was injured outside of Texas? Yes, if you were hired or recruited by a Texas employer who subscribes to Texas workers compensation and you are required to work out of state by that employer. You may have a choice of benefits if you are also covered by another state's workers compensation laws.

What are workers compensation benefits? Workers compensation benefits include income and medical benefits for your injury. Income benefits include temporary income benefits, impairment income benefits, supplemental income benefits, lifetime income benefits, and death benefits.

Am I getting the right amount in my weekly check? We often find that people don't receive the full amount of money that they should be receiving. this is a common problem. We will analyze your benefits, explain what is missing, and help you get the workers compensation benefits that you deserve.

How long are workers compensation benefits paid? Income benefits are paid in combination (combined temporary income benefits,impairment income benefits, supplemental income benefits) for a total of up to 401 weeks, depending upon your disability and impairment. Temporary income benefits are paid until you reach maximum medical improvement. Lifetime income benefits are paid for your lifetime. Death benefits are paid depending upon the beneficiary status. Death benefits are paid to the legal beneficiaries of the employee when a compensable injury results in death. Death benefits are paid at the rate of 75% of the average weekly wage. There may be other lawsuits available in these cases concerning wrongful death and gross negligence.

What about my medical bills? Workers compensation provides medical benefits for your injury. The medical bills must be reasonable and necessary. There is a medical fee guideline the doctors and insurance company are required to follow in paying the bills. The doctor should never charge you directly for providing medical treatment for your workers compensation injury.

What do I do about a denied claim? A claim denial often comes as a PLN-11 form filed by the insurance company. The insurance company may deny your claim completely, or it may start paying your benefits while it conducts an investigation and then file a denial. If the insurance company does not file a denial at the beginning, it may deny that you are entitled to income or medical benefits or deny the type of injuries that your doctors have diagnosed. The insurance company may deny the treatment that your doctor wants for you. We help with these denials. On some denials, there are short time limits during which you have to respond to fight the denial or you will lose the right to fight the denial. We can also pursue bad faith denials in separate bad faith suits against the insurance company. Please contact our office to discuss these denials and your rights.

What are temporary income benefits?  Temporary Income Benefits are paid when you have disability as a result of your injury on the job and you have not reached maximum medical improvement. You have disability if you are unable to work doing the regular duty job that you were performing when you were injured.

Ability to Work

Your doctor completes a DWC-73 form that states whether you are unable to work at all, able to work only at light duty, or able to work full duty. If your doctor states that you are unable to work at all, and you have not been certified as having reached maximum medical improvement, you should be receiving temporary income benefits each week. Temporary Income Benefits are paid when the doctor takes you completely off work. You are entitled to receive temporary income benefits until you are released to return to work in some capacity or until you reach maximum medical improvement.

Light Duty Work

If the doctor releases you to return to work in a light duty capacity, you may still be eligible for temporary income benefits. This depends upon your relationship with your employer. The insurance company has to continue to pay temporary income benefits to you unless your employer offers a light duty job to you. If the employer offers you a light duty job, it must be consistent with the requirements for a light duty job offer under the workers compensation rules. If the light duty job offer is made to you, the insurance company is allowed to reduce the amount of temporary income benefits that would be paid to you by the amount of money you would make if you worked the light duty job. There can be questions in this area regarding whether the job offer was a valid job offer under the workers compensation rules.

Your doctor needs to examine the light duty job offer and decide whether you can do the duties involved. You should show the job offer to your doctor for his opinion. If your doctor does not think you can do all of the duties involved, you can ask him to write his opinion for you so that you can show that to your employer. Your employer then needs to modify the light duty job offer to allow for your restrictions before the light duty job offer is considered valid. There can be a difference of opinion between your doctor and the insurance company doctors regarding your capacity for work. This is resolved through the dispute resolution process before the Texas Workers Compensation Commission.

Once you return to work at light duty, you may still be owed temporary income benefits on a partial basis while you are working. There is a formula used to determine the amount of temporary income benefits you are paid while you are working light duty. The amount that you receive weekly may fluctuate if your earnings fluctuate.

If you are not able to do part of the light duty job, you should discuss the problems you are having with your doctor to see if he will modify your restrictions.

Termination

If you are working light duty and your employer terminates you, you may be eligible for temporary income benefits as the employer is no longer offering the light duty job to you. The Texas Workers Compensation Commission looks at the reason for your termination. If your termination is not for cause, then you should be entitled to temporary income benefits. If your termination is for cause, and you are still released to light duty, then you may still be able to receive temporary income benefits if you show that you have looked for work that will fit your restrictions and have been unable to find it.

Even after you have been terminated for cause, if there was a difference between your average weekly wage and the amount of money the employer had offered to pay you to work light duty, you should still receive partial temporary income benefits while you are released to work light duty and are looking for other work. Once you find other work, you may still receive partial temporary income benefits based upon the difference in your pay at the new job.

Full Duty Release to Return to Work

Your doctor may release you to full duty. During the time that you are released to full duty, you are not entitled to temporary income benefits, regardless of whether your employer offers you a job or returns you to work.

Lump Sum Payment

If you return to work light duty or full duty, you are certified as being at maximum medical improvement, and the insurance company or employer offers you a lump sum of your impairment income benefits, it is usually better to refuse to take the lump sum payment. The paper that they have you sign to receive the lump sum payment cuts off your right to receive future income benefits. If your condition changes, or gets worse, while you are working, you may be entitled to have your maximum medical improvement certification changed to show that you are no longer at maximum medical improvement and receive additional temporary income benefits, but you will not be able to do this if you have signed the paper for your employer and insurance company. if you do not sign the paper, the impairment income benefits that you are entitled to will continue to be paid to you on a weekly basis in addition to your weekly paycheck. They are simply paid out over a number of weeks instead of in a lump sum.

Maximum Medical Improvement

There is often a rush to certify you as having reached maximum medical improvement after you have been released to work in some capacity. You should discuss with your doctor giving you time to see if you can do the work before certifying you as being at maximum medical improvement.

If you are certified as being at maximum medical improvement before you think that you are ready, you should dispute the maximum medical improvement certification with the Texas Workers Compensation Commission. There is a specific process for this and it should be done within 90 days of the date of certification. The rules technically say 90 days of the date that you receive the certification, but there are deeming rules on receipt of documents that may adversely affect you if you wait to file the dispute. If you are outside the 90 day time period, you may still be able to reopen the maximum medical improvement certification if you have sustained a substantial change of condition.

Spinal surgery may extend the date of your maximum medical improvement beyond your statutory date of maximum medical improvement. For more information regarding this, please contact our office.

Taken Off Work Again by the Doctor

Your doctor may take you off work again. You should receive temporary income benefits again while you are off work as long as you have not yet been certified as having reached maximum medical improvement. Your maximum medical improvement certification may have to be addressed in order for you to receive the temporary income benefits that you are owed.

Temporary income benefits are paid for 104 weeks (2 years) after your disability begins. The beginning of your disability may be delayed and this will delay the beginning date for payment of your temporary income benefits. This will also delay your statutory date of maximum medical improvement. Spinal surgery may extend the statutory date of your maximum medical improvement. For more information regarding this, please contact our office.

Common Issues

Common issues we see in this area include:

  • The insurance company may refuse to pay you even though your doctor has said that you cannot work. 
  • You know that you can not work but your doctor won't take you off work.
  • Your employer will not follow the light duty restrictions given by your doctor.
  • You can not perform the light duty restrictions.
  • The insurance company's doctor says that you can work.
  • The employer's doctor says that you can work.
  • You can't see your own choice of doctor.
  • You are not being paid the right amount.
  • We can help with these situations and provide advice and assistance to you regarding your workers compensation claim. 
Maximum Medical Improvement

After you are injured, your body's condition may improve or get worse. This improvement in your injury or the worsening of the injury may change back and forth. It may seem like you are getting better for a while, but then your condition may get worse. Each body is different. Someone else's body may heal more quickly or more slowly than yours. Maximum medical improvement is the point at which your injury improves the most that it will improve. This does not mean that your body is completely well or that you are able to work. Some people initially get better but then lapse out of maximum medical improvement. If your condition becomes worse, and there is a medical treatment that helps your condition become better, then you are said to have lapsed out of maximum medical improvement and to have reached maximum medical improvement again following the treatment and your condition getting better. If you are not at maximum medical improvement, you should receive temporary income benefits based on your inability to work your regular duty job. Once you are certified as being at maximum medical improvement, your temporary income benefits will stop. You may receive impairment income benefits, depending upon your impairment rating.

Trying to Work Before Being Maximum Medical Improvement is Certified

There is often a rush to certify you as having reached maximum medical improvement after you have been released to work in some capacity. You should discuss with your doctor giving you time to see if you can do the work before certifying you as being at maximum medical improvement.

Disputing the Certification of Maximum Medical Improvement

If you are certified as being at maximum medical improvement before you think that you are ready, you should dispute the maximum medical improvement certification with the Texas Workers Compensation Commission. There is a specific process for this and it should be done within 90 days of the date of certification. The rules technically say 90 days of the date that you receive the certification, but there are deeming rules on receipt of documents that may adversely affect you if you wait to file the dispute. If you are outside the 90 day time period, you may still be able to reopen the maximum medical improvement certification if you have sustained a substantial change of condition.

How Spinal Surgery Affects Maximum Medical Improvement

Spinal surgery may extend the date of your maximum medical improvement beyond your statutory date of maximum medical improvement. For more information regarding this, please contact our office.

Effects of Maximum Medical Improvement Certification

Being certified as being at maximum medical improvement can affect your ability to receive medical treatment for your injuries. The insurance company authorizes medical treatment based on medical treatment guidelines adopted by the state agency. The medical treatment guidelines can stop almost all medical treatment once you are at maximum medical improvement, even though the law says that you have lifetime medical treatment for your injuries. Your doctor must fight to prove why your condition still needs treatment even though you have been placed at maximum medical improvement. He must show why the guides don't apply to your condition so that he can obtain the authorization to treat you. If you have been placed at maximum medical improvement and received an impairment rating prematurely, your ability to get the medical benefits and income benefits you need can be greatly damaged.
For more information, please see the effects of the impairment rating in the Impairment Income Benefits Guide.

Common Issues

Common issues regarding maximum medical improvement that we see include:

  • whether you are at maximum medical improvement
  • your doctor and the insurance company's doctor or employer's doctor disagree about whether you are at maximum medical improvement
  • your doctor states that you are no longer at maximum medical improvement, but the insurance company refuses to pay you a weekly check
  • whether you have lapsed out of maximum medical improvement
  • whether you have had a substantial change of condition affecting whether you are at maximum medical improvement
  • you have had surgery and need to extend your date of maximum medical improvement to give you time to heal
  • the insurance company refuses to follow your doctor's statements regarding your maximum medical improvement.
  • If you are unable to work and are not receiving a check, please contact our office right away so we can help you.
What are impairment income benefits?  Impairment Income Benefits are designed to compensate you for the damage done to your body as a result of your injury on the job. Impairment Income Benefits are based upon the percentage of whole body impairment rating that is assigned to you when you are certified as being at maximum medical improvement. This percentage is critical because it decides how much you will receive for your impairment and it may entitle you to additional benefits. If you receive a 15% or higher impairment rating, then you will meet the first step of eligibility for supplemental income benefits, a type of benefit paid after impairment income benefits have been paid out.

How the Impairment Rating is Assigned

The impairment rating is assigned based upon impairment guidelines that are located in the AMA Guide to Impairment. Surprisingly, Texas does not follow the most recent edition of the Guide. Instead, Texas uses an older and more restrictive version of the Guide that does not provide as high of an impairment rating for many injuries that the newest edition of the Guide would provide. This older guide that is used is actually more restrictive than the guide that was previously used in Texas when the current workers compensation law went into effect and was found to be constitutional by the Texas Supreme Court. The Guide is divided into tables and charts for each different type of injury. If you have more than one type of injury, for example, an injury to your right arm and an injury to your back, the impairment is calculated for each injury individually and then combined into a whole body impairment rating using a combined values chart.

How Extent of Injury Disputes Affect Your Impairment Rating

The impairment rating is calculated based upon the extent of your injury. If the insurance company has disputed the extent of your injury, then the impairment rating may be limited and deprive you of benefits. The extent of the injury and the impairment rating are tied together, and that is why those notices from the insurance company denying that your injury includes certain conditions or parts of your injury are important in your case. We hear stories from people who have not been represented by an attorney at a Benefit Review Conference and have been offered temporary income benefits (weekly disability checks) in exchange for an agreement that their injury is limited to only a sprain or strain of a body part, even when medical testing shows more serious damage to their body, such as a herniated disk of the back that will require surgery. Unfortunately, these agreements were approved by Benefit Review Officers and became final, damaging their case. In some cases, these agreements were offered, signed, and approved at the same time that the insurance company was refusing to pay for any medical testing on the body part to determine exactly what damage had been done by the injury. The Benefit Review Officer has the power to refuse to approve the agreement and instead to order the insurance company to pay for medical testing for the body part to determine the extent of the injury.

You should also watch for forms that people give you to sign that limit the description of your injury, such as on the Notice of Injury or on a Designated Doctor Request. These forms will sometimes describe your injury as a sprain or strain, which is a soft tissue injury and is entitled to less of an impairment rating than other injuries. You have the right to write the full description of your injury on these forms and to refuse to sign forms that describe your injury as only a sprain or strain. Your signature on these forms can be interpreted at a later hearing as your claiming only the sprain or strain as your injury and voluntarily limiting the extent of your injury. This can raise credibility problems for you at a later hearing when you describe the symptoms you are having with your injury.

Disputing the Impairment Rating

The impairment rating can become final if it is not disputed timely. One of the ways that you become notified of the impairment rating is when the insurance company sends you a notice that states that you have received the impairment rating and that they will be sending you weekly checks. This notice also provides important information regarding your responsibilities to file a dispute of the impairment rating if you disagree with it. We have seen people who have looked upon the weekly checks as exciting news and have completely disregarded the language at the bottom of the notice. The language on the notice can be overlooked as it is near the bottom of the notice, doesn't really explain what to do, and doesn't stand out when you look at the notice. Some people have called their adjuster when they have gotten the notice and have been told things such as that they are trying to decide whether the impairment rating will become final or that it is under review. You can not trust the opinions or statements of any party in this process. We have heard horror stories about misinformation coming from all parties in the process, be it the employer, the insurance company, the doctor, and even the state agencies. As a result, they did not exercise their dispute rights and the rating became final and the checks stopped. This can be extremely damaging to your case. To protect your rights, you should discuss this notice upon receipt with an attorney. In this system, the only person that is going to protect you, outside of yourself, is an attorney.

Effects of the Impairment Rating

The impairment rating changes the type of checks you receive. Because the impairment rating is tied to you being certified at maximum medical improvement, your temporary income benefits stop when you are assigned an impairment rating.

If you are assigned a 0% impairment rating and the rating becomes final, you will not receive any more income benefits for the injury. If you are assigned an impairment rating greater than 0%, you will receive 3 weeks of impairment income benefit checks for each percentage point of whole body impairment rating. When this number of weeks is paid out, if your impairment rating is final, you will not receive any more income benefits for your injury unless you meet the requirements for supplemental income benefits or lifetime income benefits, or have a substantial change of condition.

The impairment income benefit checks may be in a different amount, including a lower amount, than the amount you received in the temporary income benefit check. This is because the maximum impairment income benefit amount is lower than the maximum temporary income benefit amount.

The impairment rating can also limit the type of treatment that you receive in the future. One reason is that the impairment rating is tied to maximum medical improvement. The insurance company authorizes medical treatment based on medical treatment guidelines adopted by the state agency. The medical treatment guidelines can stop almost all medical treatment once you are at maximum medical improvement, even though the law says that you have lifetime medical treatment for your injuries. Your doctor must fight to prove why your condition still needs treatment even though you have been placed at maximum medical improvement. He must show why the guides don't apply to your condition so that he can obtain the authorization to treat you. If you have been placed at maximum medical improvement and received an impairment rating prematurely, your ability to get the medical benefits and income benefits you need can be greatly damaged. In addition, insurance companies often refuse to approve treatment for conditions that have not been rated as part of the injury. It is important that you consult with an attorney and with your doctor regarding the impairment rating and what it means to your case.

If you do receive a 15% or higher impairment rating, the impairment rating can still limit your eligibility for supplemental income benefits in the future in this respect: supplemental income benefits are paid when you are unable to work at full duty as a result of your injury. There are appeals decisions within the Division of Workers Compensation relied upon by insurance companies at Contested Case Hearings to convince the hearing officer to deny supplemental income benefits to you when your inability to work at full duty is caused by a condition that is not included in your impairment rating.

Common Issues

Common issues that arise concerning this area include:
  • whether it is too early to assign an impairment rating for your injury.
  • whether the impairment rating is correct.
  • your doctor and the insurance company doctor disagree about your rating.
  • the division assigns a doctor who gives you a low rating.
  • the division assigns a doctor who works out of the same office or group as the insurance company doctor.
  • your impairment rating does not include a rating for all of your injuries.
  • the insurance company suddenly disputes part of your injuries to avoid paying the impairment income benefits for that part of your injuries.
We can help with these situations and provide advice and assistance to you regarding your workers compensation claim.

What are supplemental income benefits?  Supplemental Income Benefits are paid after impairment income benefits end. Supplemental income benefits are paid monthly. You apply for supplemental income benefits once every three months. The insurance company approves or denies your application. You have the right to appeal the denial to the division and have hearings and a determination made of whether you are entitled to supplemental income benefits for each quarter.

Criteria for Determining Eligibility for Supplemental Income Benefits

In order to be entitled to supplemental income benefits, you must meet the following criteria:

  • You have a 15% or higher whole body impairment rating, and
  • You are either completely unable to work or are unable to work making at least 80% of your average weekly wage due to your compensable injury.
If you are completely unable to work, your doctor will document your inability to work. The insurance company may dispute whether you are unable to work. The Division of Workers Compensation may appoint a doctor to examine you to determine your work ability.

If you are able to do some work, such as sedentary duty or light duty, and you are able to obtain employment, then Supplemental Income Benefits pay the difference between 80% of your average weekly wage and your current wage.

If you are able to do some work, and you have looked for work but have not been hired, then you should be entitled to the full amount of Supplemental Income Benefits. There are requirements regarding your work search that must be met for you to qualify for entitlement to supplemental income benefits.

While the above criteria seem simple, the rules for qualifying for supplemental income benefits are complex and there are many potential pitfalls as you go down the path to be eligible for each quarter. We have developed a SIBs package to aid you in being able to qualify for SIBs. These kits are personalized for you when you come in for a consultation with us.

Common Issues

Issues that we commonly see in this area include:

  • whether your inability to work is because of the injuries causing your impairment,
  • whether you have additional physical or mental conditions that affect your ability to look for jobs,
  • insurance company disputes the extent of your injuries to avoid paying supplemental income benefits for your injuries,
  • whether you are able to work and what your restrictions should be,
  • whether your employer will provide work that you are able to do,
  • whether you must look for jobs that your doctor or another doctor states you are able to do,
  • whether you work with the Division of Assistive and Rehabilitative Services regarding training,
  • the insurance company assigns a vocational rehabilitation counselor to your case to help you find work you can do,
  • whether the insurance company's vocational rehabilitation counselor is really trained and capable of helping you or is just gathering information to deny your supplemental income benefits applications,
  • whether the jobs the vocational rehabilitation counselor is finding for you are jobs you can do, if they are really available, if the counselor is selecting jobs that you are otherwise qualified for, if notices to you regarding the jobs and interviews is timely so that you can comply, whether they are sending the same job notices to everyone else on the counselor's case list so the employer is just overwhelmed by people with workers compensation claims and won't hire any of you, whether the counselor has you just spending gas and time for nothing over and over again to get you frustrated and make you quit the process,
  • insurance company denying your supplemental income benefit application repeatedly to see if they can get a decision that you are not entitled to four quarters in a row and prevent you from being further eligible for any supplemental income benefits, causing you extreme financial hardship.
We can help with these situations and provide advice and assistance to you regarding your workers compensation claim.

What are lifetime income benefits?  Lifetime Income Benefits are paid when there is a combination of injuries that prevents you from working. These benefits are paid at the rate of 75% of your average weekly wage. The benefit amount rises at the rate of 3% per year. The benefits may be paid by annuity, but the purchase of an annuity by the insurance carrier does not relieve the insurance carrier of the responsibility to pay the benefits timely and appropriately.

These combinations include:

  • total and permanent loss of sight in both eyes
  • loss of both feet at or above the ankle
  • loss of both hands at or above the wrist
  • loss of one foot at or above the ankle and loss of one hand at or above the wrist
  • an injury to the spine that results in permanent and complete paralysis of both arms, both legs, or one arm and one leg
  • a physically traumatic injury to the burn resulting in incurable insanity or imbecility
  • third degree burns that cover at least 40% of the body
  • third degree burns covering the majority of both hands or one hand and the face
The total and permanent loss of use of a body part is the same as the total loss of that body part.

We can help with these situations and provide advice and assistance to you regarding your workers compensation claim. We have 24 years of experience handling Texas workers compensation cases.

Contact Us

For more information, please contact our office to discuss your claim.
Call us at (817) 921-3220.
We are here to help you.

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