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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Texas uses the Fourth Edition of the American Medical Association Guides to the Evaluation of Permanent Impairment to determine Impairment Ratings for injured workers. The Guide is to only apply to permanent impairments, defined as adverse conditions that are stable and unlikely to change.
The Guides require that a doctor performing an evaluation must first gather through and complete historical information on the medical condition(s) and then carry out a medical evaluation supported by appropriate tests and diagnostic procedures.
The doctor should determine the condition that seems to be of the most concern to the injured worker. That condition needs to be assessed and given a whole body impairment. Each of the unrelated conditions must be assessed and given a whole body impairment. Then all the conditions are combined using the Combined Values Chart.
The Guides find the impairment by DREs (Diagnosis Related Estimates), ROM (Range of Motion) and specific Diagnosis ratings. The Guides determine if the methods are combined or one method is to be used with the exclusion of the others.
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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.
Daniel L Morris, The Morris Law Firm, firstname.lastname@example.org, (214)357-1782
In a Texas Workers’ Compensation claim, the income benefit rate is calculated from the injured workers’ Average Weekly Wage (AWW). for full time employees, the AWW is calculated by adding up the wages for the thirteen weeks prior to the date of injury. This calculation includes overtime pay, bonuses or any fringe benefit the included in the employment. The employer shall provide a DWC-3 form which provides pecuniary wages and non-pecuniary wages.
If there are not thirteen weeks of income prior to the date of injury, the parties may uses a same or similar employee or a calculation of the weeks worked. Always consult with a person experienced in workers compensation
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