According to a 2021 report by the Texas Department of Insurance, Division of Workers’ Compensation, in cooperation with the U.S. Department of Labor, Bureau of Labor Statistics, there were 178,900 cases of nonfatal workplace illnesses and injuries in the state.
Workers’ compensation in Texas is an insurance program that pays for an employee’s medical bills and income loss due to their job-related illness or injury. It aims to protect employers from lawsuits by injured employees. However, employers can be sued if a worker dies due to negligence.
This article provides an overview of the workers’ compensation system in Texas, including eligibility requirements, benefits, and procedures for filing claims.
Texas Workers’ Compensation Insurance Requirements
Workers’ compensation insurance in Texas helps pay for benefits, such as medical care, to treat employees who have been ill or injured on the job. It also pays for burial expenses and death benefits to a worker’s family if the employee dies due to a job-related illness or injury.
These benefits, though, are not paid to employees who:
Intentionally caused their own injuries;
Were injured by an “act of God,” such as a flood or hurricane, unless their job had a high exposure to these types of events;
Were injured by someone else for personal reasons not related to their job;
Were injured outside of work or while voluntarily participating in an off-duty social or sports event;
Were injured while intoxicated.
Texas does not require most private employers in the state to have workers’ compensation insurance. However, those employers who contract with government entities must provide coverage for employees working on a project. Some employers may also be required to have workers’ comp insurance for independent contractors and subcontractors.
If an employer does not have workers’ compensation insurance, they must:
File an annual notice with the DWC;
Post notices in their workplace;
Tell new employees in writing that they are not covered by any policy.
An employer may provide workers’ compensation insurance to their employees in several ways, such as:
Buying a workers’ compensation policy from a carrier licensed by the Texas Department of Insurance;
Joining a self-insurance group;
Self-insuring workers’ compensation claims.
To be required for workers’ compensation insurance, they must have at least one employee, even if they work part-time.
They may also obtain the policy to cover executive officers of a business that has no other employees or contractors who do not have workers’ compensation.
Texas Workers’ Compensation Benefits
Employees in Texas who have been hurt on the job have the right to receive income benefits if they meet certain requirements, obtain medical care to treat their work-related illness or injury, keep their claim private, and choose a doctor for their treatment.
A worker also has the right to a legal review of any disputes on their claim, hire an attorney at any time, and ask for help from the Office of the Injured Employee Counsel.
The benefits that an injured worker may receive are:
Temporary Income Benefits
Impairment Income Benefits
Supplemental Income Benefits
Lifetime Income Benefits
Income benefits replace some of the money the worker has lost due to their job-related illness or injury.
The amount an employee gets is based on their average weekly wage, which is the average amount of money they got each week from their work in the 13 weeks before they were injured, including overtime or other special pay.
Temporary Income Benefits
An employee may receive temporary income benefits if they have lost money from their job for more than seven days due to a work-related injury. The days do not have to be in the same week.
The two types of maximum medical improvement are clinical and statutory. The former is the date when the doctor says no further healing or recovery from the injury is expected, which is based on examining the patient and looking at treatments they have had.
By law, an employee is only able to receive temporary income benefits for up to 104 weeks.
Impairment Income Benefits
A worker may receive impairment income benefits if they have sustained permanent damage to their body due to their injury. An employee may receive these benefits even if they have returned to work.
The doctor may give an impairment rating if they examine the patient and find that no further healing or recovery from their injury is expected.
An employee gets three weeks of impairment income benefits for each percentage point of their rating. For example, if they have an impairment rating of 3%, they will receive a total of nine weeks of benefits.
Supplemental Income Benefits
An employee may receive supplemental income benefits if they have sustained plenty of permanent bodily damage due to their injury and still have not returned to work after their impairment income benefits end.
To receive supplemental income benefits, an employee must:
Have an impairment rating of 15% or higher;
Choose not to get their impairment income benefits in one lump sum payment;
Be out of work or earn less than 80% of their pre-injury wage;
Show that they are looking for work.
Lifetime Income Benefits
An employee may receive lifetime income benefits if they sustain certain serious injuries, such as complete blindness or loss of limbs. The benefits are 75% of the worker’s average weekly wage with a 3% cost of living increase each year. Unlike other benefits, they do not have a time limit.
Effective September 1, 2023, changes have been made regarding eligibility requirements for all injured employees seeking lifetime income benefits under HB 2468. A worker may receive benefits if they have:
A physically traumatic injury to the brain resulting in a major permanent neurocognitive disorder;
A serious bodily injury and they are a first responder;
An injury to the spine that caused complete and permanent paralysis of both arms or legs or one arm and one leg;
Lost both feet at or above the ankle;
Lost both hands at or above the wrist;
Lost one foot at or above the ankle and lost one hand at or above the wrist;
Suffered third-degree burns covering at least 40% of the body and requiring grafting;
Suffered third-degree burns covering the majority of both hands, or one hand and one foot, or one hand, one foot, and the face;
Suffered total and permanent loss of sight in both eyes.
To receive these benefits, an employee must send a request in writing to the insurance company. It has 60 days to reply to the request.
If they say a worker may not be able to get LIBs, the company must send a letter explaining why. If an employee does not agree with the decision, they may request a benefit review conference.
A worker may receive medical benefits to pay for the costs of treating their job-related injury. Their employer’s insurance company pays for these benefits to the healthcare provider who treats the patient.
An employer must tell their worker if their claim is in a healthcare network so they can use a doctor who belongs there. If an employee gets treatment from a doctor who is not in the network without getting approval, they could pay for the medical costs.
The DWC must approve any change in doctors if a worker’s claim is not in a healthcare network. If an employee or their doctor relocates or becomes unavailable, the worker may choose another doctor without getting permission from the division.
A deceased employee’s surviving beneficiaries may receive payment for their funeral expenses up to $10,000, depending on the date the injury happened.
To file a claim for burial benefits, the beneficiary must contact the insurance company in writing within 12 months of the date of the worker’s death and attach copies of related bills. After the carrier receives the request, they have seven calendar days to act.
The amount depends on the date the injury happened:
Expenses paid up to $2,500 for injuries sustained before September 1, 1999;
Expenses paid up to $6,000 for injuries sustained on or after September 1, 1999, and before September 1, 2015;
Expenses paid up to $10,000 for injuries sustained on or after September 1, 2015.
A deceased worker’s surviving family may receive compensation to replace some of the money lost due to the employee’s job-related illness or injury and eventual death. Spouses may get these benefits for life even if they remarry (for marriages on or after September 2017).
Death benefits may be paid to:
A surviving spouse;
Children less than 25 years old who are enrolled in an accredited college or university;
Other dependent family members;
Non-dependent parents, only when there are no surviving eligible dependent family members.
The legal beneficiary may start receiving death benefits the day after the worker’s death. The benefits are paid until the beneficiary no longer meets the requirements.
How to File a Workers’ Compensation Claim in Texas
To get the due benefits, an employer must have workers’ compensation insurance. The Texas Department of Insurance Division of Workers’ Compensation regulates the benefits in the state.
They help injured employees file claims and complaints in case of violations of Title 5, Subtitle A, of the Texas Labor Code or Texas Department of Insurance, Division of Workers' Compensation rules. They also resolve disputes between workers and their employers and insurers. To ask for assistance regarding workers’ compensation claims, one may call the Division at 800-252-7031, option 1.
When is the Deadline for Workers’ Compensation Claims in Texas?
There are different deadlines that an employee must know before filing workers’ compensation claims. These are the following:
The worker must report their injury to their employer within 30 days of the accident happening or the diagnosis of a job-related illness or injury;
They have 90 days to dispute the impairment rating of the doctor treating them;
They have 10 days to dispute a denial of request to change their doctor or extend their maximum medical improvement after undergoing a spinal surgery.
They have seven days to submit a supplemental income benefits application each quarter;
They have 10 days to respond to a request by the insurance carrier to undergo a required medical exam.
A Step-By-Step Guide on Filing a Workers’ Compensation Claim in Texas
This section breaks down the key steps injured employees need to take to have their claim approved and obtain the maximum benefits they deserve.
Step 1: Report the injury.
The worker must report their injury to their employer within 30 days from the date they were injured or knew their job-related illness or injury. If they miss the deadline, they may lose their right to claim benefits.
Step 2: Send a completed form to the DWC.
The employee must send a completed Form-041 or the Employer’s Claim for Compensation for a Work-Related Injury or Occupational Disease to the Texas Department of Insurance Division of Workers’ Compensation within one year of the date of the injury.
To file a claim for death benefits, eligible beneficiaries must complete Form-042 or the Claim for Workers’ Compensation Death Benefits and send it to the DWC or insurance company within one year from the date the worker passed away.
They must include a copy of the deceased employee’s death certificate and other documents to prove their legal beneficiary status.
Step 3: The worker must inform the doctor how they were injured and if it was related to their job.
The employee must provide their doctor with information about how they got injured at work and their medical care.
Step 4: The employee must inform the DWC and the insurance carrier about any changes in their information.
The worker must inform the DWC and the insurance company about any changes in their pay or work that they do.
They must also let them know if they have changed their mailing address or phone number so they can receive the benefit payments and important letters and reports.
Step 5: The worker may get a copy of their workers’ compensation claim file.
To get a copy of their workers’ compensation claim file, the employee must complete and submit Form-153 or Request for Record Check or Copies of Confidential Claim Information. They may also call 800-252-7031 to ask for a blank form to be mailed to them.
If they have multiple claims, they must return a separate form for each claim they want a copy of. They may submit the form by attaching it to an open records request at https://www.tdi.texas.gov/open-records.html, faxing it to the DWC Legal Services department at 512-804-4276, mailing it, or personally delivering it.
What Should One Do If a Workers’ Compensation Claim in Texas Has Been Denied?
If an employee’s application has been denied and they disagree with the decision, they may call their insurance adjuster to talk about their claims. If the problem is not resolved, they may contact the DWC customer service at 800-252-7031.
They may request a Benefit Review Conference by submitting a completed Form-045. They may also proceed directly to a contested case hearing.
Legal Resources for Injured Workers in Texas
This section describes three organizations that aim to help low-income clients with their workers’ compensation claims and protect their rights against denials or reductions by providing pro bono legal representation.
Legal Aid of Northwest Texas
The Legal Aid of Northwest Texas is a nonprofit organization providing free civil legal help through advocacy and representation to low-income people in 114 counties throughout the state. It comprises over 150 attorneys, supported by a staff of more than 100 paralegals and social workers. It represents clients with income up to 125% of the U.S. poverty guidelines and from different sectors of the community, including minimum wage earners and single parents. The LANT aims to preserve and protect employees’ rights in the workplace and helps eligible workers obtain and regain benefits and other financial assistance. To obtain legal assistance, one may fill out the intake form on their website.
Volunteer Legal Services of Central Texas
The Volunteer Legal Services of Central Texas is a nonprofit organization helping low-income people in the state obtain free legal advice by providing them with volunteer attorneys. It represents hard-working minimum wage earners with dependents as well as those with fixed incomes. VLS helps with various civil legal matters, such as employment law-related issues. To obtain legal assistance, one may visit their office in person or apply online.
Lone Star Legal Aid
The Lone Star Legal Aid is an organization providing free legal services to low-income people in Texas through advocacy, community education, and representation. It focuses on various practice areas, including employment law. It helps clients understand complex laws, including those related to workplace safety issues. To obtain legal assistance, one may apply online, visit their office in person, or call (800) 733-8394.
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