After a work injury in Texas, many workers are entitled to benefits through the Texas Workers’ Compensation system. These benefits include medical benefits and indemnity benefits (money).
From the date of injury, up to the day after an injured worker is found to be at Maximum Medical Improvement, an injured worker may receive Temporary Income Benefits (TIBs), if they are disabled due to the compensable injury.
The Texas labor Code defines disability as the inability because of a compensable injury to obtain and retain employment at wages equivalent to the preinjury wage.
The medical providers fill out DWC-73 forms providing the restrictions to the injured workers’ ability to return to work. If the restrictions prohibit the injured worker from working their normal hours or duties, they are disabled.
Even if the injured worker is working, they are entitled to TIBs if they are not making their pre-injury wage. This can be due to reduced hours or a lower weekly wage due to their injury.
Workers may go in and out of disability up until the date that they are found to be at Maximum Medical Improvement.
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When a Worker in Texas has a neck or back injury that is being handled through the Division of Workers’ Compensation, they will receive a Whole Body Impairment Rating. To determine that Impairment Rating, the medical provider will typically use a DRE Category (Diagnosis Related Estimate) that best suits the claimant’s (injured worker) condition.
To avoid a DRE Category I, which means no impairment at all, there must be clinical findings of injury, observed or documented muscle guarding or documented neurological impairment.
Many cases deal with the observed or documented muscle guarding. The Fourth Ed. of the AMA Guides to Permanent Impairment define Guarding under Table 71 Pg. 3/109 of the Guides as: paravertebral muscle guarding or spasm or nonuniform loss of range of motion, dysmetria, is present or has been documented by a physician. Radicular components that follow anatomic pathways but cannot be verified by neurologic findings belong with this type of differentiator.
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Spinal injuries for cervical, thoracic and lumbar which in radiculopathy may be eligible for a DRE Category III. Radiculopathy is a condition due to a compressed nerve in the spine that can cause pain, numbness, tingling, or weakness along the course of the nerve.
To qualify a person must have an ongoing minor neurologic impairment low the lower extremity related to cervical, thoracic or lumbar injury. This is documented through examination of reflexes and findings of unilateral atrophy above or below the knee related to no other condition, and it may be verified by electrodiagnostic testing. The injured worker must have one of the two following findings:
- Decreased circumference (atrophy) Spine-injury-related circumferential measurements show loss of girth of 2 cm or more above or below the elbow or knee. The atrophy cannot be explained by non-spine-related problems or contralateral sypertrophy, as might occur with a dominatnt limb or greatly increased use of a limb. The neurologic impairment may be verified by differentiator 4 below.
2. Electrodiagnostic evidence Unequivocal electrodiagnostic evidence exists of acute nerve root compromise, such as multiple positive sharp waves or fibrillation potentials; or H-wave absence or delay greater than 3 mm/sec; or chronic changes such as polyphasic waves in peripheral muscles.
If a person receives a DRE Category III, that is equal to a 15% Impairment Rating for the Cervical spine and a 10% Impairment Rating for the Thoracic or Lumbar spine.
In Texas Workers’ Compensation claims there are medical and indemnity (money) benefits. Each of these benefits are governed by the Texas Department of Insurance (TDI) through the Division of Workers’ Compensation (DWC).
Indemnity benefits are cash payments paid directly to the claimant (injured worker). They are paid for disability (TIBs or SIBs); for the claimant’s whole body impairment (IIBs); payment to claimant’s who qualify for life time income benefits (LIBs); and benefits to beneficiaries of a deceased claimant.
Medical benefits are requested by a medical provider and approved or denied by the insurance carrier. If approved, the medical provider receives payment for the medical care directly from the insurance carrier. If they are denied, it can be for a number of different reasons (i.e. compensability, improper treatment, etc.).
To dispute adverse determinations of indemnity or medical benefits by an insurance carrier, the DWC allows the parties to resolve disputes through a hearing process at a field office of the DWC.
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Texas Workers’ Compensation benefits are based upon the injured workers’ Average Weekly Wage. The Average Weekly Wage includes wages from other employers.
Appeals Panel Decision 151496-s dealt with a case where the injured worker failed to provide the information regarding his additional wages. the carrier argued that the injured worker failed to provide his additional wages in a timely manner.
The Appeals Panel held that there is no deadline to file the DWC-3ME. The insurance carrier is required to pay benefits retroactively to include all the wages.
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The Texas Penal Code §31.03 explains what theft is in the State of Texas.
THEFT. (a) A person commits an offense if he unlawfully appropriates property with intent to deprive the owner of property.
(b) Appropriation of property is unlawful if:
(1) it is without the owner’s effective consent;
(2) the property is stolen and the actor appropriates the property knowing it was stolen by another; or
(3) property in the custody of any law enforcement agency was explicitly represented by any law enforcement agent to the actor as being stolen and the actor appropriates the property believing it was stolen by another.
Basically, you commit theft in the state of Texas when you take something that doesn’t belong to you, without consent or any other legal justification for doing so, and at the time of the offense you have no intention of giving the property back to its rightful owner.
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Once an insurance carrier receives written notice of a work related injury, they should begin an investigation of the claim. Most investigations involve getting information from the employer, medical providers and the injured worker.
To avoid complications, an injury worker should make sure that how they report and describe the injury to the employer, medical provider, Division of Workers’ Compensation and to the insurance carrier are all consistent. Generally this is the information the insurance carrier uses to accept or deny a claim.
From the date the insurance carrier receives written notice, they have 60 days to accept or deny the claim. However, they must pay benefits after day 15 until the claim is denied.