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A Texas workers’ compensation case is a claim for benefits that you can make if you have been injured on the job.  When an employee has an injury in the course and scope of their employment, workers’ compensation insurance will cover the costs of medical treatment and will pay a portion of any lost wages, as well as compensation for any permanent impairment.  These benefits are available if the employer has workers’ compensation insurance coverage.  If the employer does not have workers’ compensation insurance coverage, then they are called a nonsubscriber, and different rules apply.

Subscribers and Nonsubscribers

When you hear people talk about workers’ comp insurance, you may hear the terms subscriber and nonsubscriber.  A subscriber is a business that has a workers’ comp insurance policy that is the regular policy regulated by the State that comes with all of the benefits afforded under the Texas Workers’ Compensation Act.  A nonsubscriber is a business that either does not have workers’ comp coverage at all, or they have an accident plan for injured workers that is not regulated by the State and does not have the traditional workers’ compensation benefits.

If your employer has a real workers’ compensation policy, then you have access to all of the benefits that the State requires an insurance company to provide under the law.  The downside is that you cannot sue your employer for its negligence in causing your injury.  That is the tradeoff that the State set up in order to entice companies to buy workers’ comp insurance.

If your employer does not have a real workers’ comp policy, but instead has an accident plan or no plan at all, then you are only eligible for the benefits that the plan provides, or nothing at all.  Sometimes these businesses provide absolutely nothing for injured workers.  When an employer chooses to not buy a real workers’ compensation policy, then injured workers are able to sue them for any negligence of that employer that causes their injury.  For instance, if you work at one of these places and the forklift driver runs you over in the warehouse because they couldn’t see where they were going, you can sue the employer for a recovery that includes the costs of your medical treatment, lost wages, permanent impairment, as well as pain and suffering.

A claim for benefits under a real workers’ comp policy is handled through the Division of Workers’ Compensation.  Any claim against a nonsubscriber will generally be made first to the company to do the right thing, and then to a court where a jury can decide the outcome.

If you need to figure out whether or not your employer has real workers’ comp insurance, you can do a search to see if they have registered their coverage. 

How Do I File For Workers’ Comp in Texas?

Most employees in Texas are covered by a real workers’ compensation policy.  This means that the rules set up in the Texas Workers’ Compensation Act apply to most people.  There are a couple of things that you have to do after you get injured at work in order to set up a case. 

The first is that you must report your injury to a supervisor or to HR within 30 days of the day the injury occurred.  If your injury is an occupational disease like carpal tunnel syndrome or the effect of some type of exposure over a long period of time, then you have to report the injury within 30 days of the date you knew or should have known that you were injured at work.  Sometimes you can be exposed to something at work, like a chemical, and not suffer the effects of that exposure until much later in time after multiple exposures.

The main requirement is to report that you have an injury, that it occurred at work, when it happened, how it happened, and what parts of your body are injured.  You can do this verbally or in writing.  If you don’t trust your employer, make sure you report it in writing so that there is evidence that you told someone.

The second thing you have to do to set up a claim for workers’ compensation is to file a form called a DWC-041.  This form is titled, “Employee’s Claim for Compensation for a Work-Related Injury or Occupational Disease.” 

This form is filed with the Division of Workers’ Compensation.  You should file it in person at your local DWC office.  Ask them to stamp it “received” and give you a copy for your file.  You have one year from the date of injury to file this form or you could lose your right to benefits forever.

Third Party Claims After A Work Injury

Sometimes you can make a second claim for damages in addition to your workers’ compensation claim.  Although having workers’ comp insurance protects your employer from getting sued for negligence, this coverage does not protect third parties.  Third parties are other companies or people who do not work for your employer.  If a third party is negligent and causes your injury, you can pursue a case against them in addition to your workers’ compensation claim. 

As an example, if you are a traveling repairman and while you are traveling to your next customer’s house you get in a wreck with someone who runs a red light, you can collect workers’ comp and still file a claim or file suit against the person that ran the red light causing your injuries.  Another example would be when multiple companies are on a job site, like a construction site or in the oilfields, and one of their workers causes your injuries.  You can pursue a claim for workers’ comp and a claim against the other company whose employee caused your injury.

In a third party claim, you will want to use the same attorney for your workers’ comp case and your third party claim if necessary.  These two claims are separate and distinct but still so intertwined that the attorney must understand workers’ comp law to get you the best outcome.

How Do I Get Medical Treatment For A Texas Workers’ Comp Injury?

If you have an injury that is serious, you may need to go to the emergency room immediately.  Otherwise, you can go to any doctor who will see someone with a workers’ comp claim.  Insurance companies and employers try to send you to occupational medicine clinics where they have contracts and control the process.  This may be okay for immediate care but should not be your long-term treatment option.

After emergency care, you will want to find a treating doctor who listens to you and treats you based on what is required to get you well rather than one who just gives in to insurance company demands.  You will want to seek advice on which doctors to use for your Texas workers’ compensation case.  MLF Legal counsels people every day about their treatment options taking into account who the insurance company is, network status, the type of injuries they have, and where they live.  You can call us at 1-214-357-1782 to discuss patient-friendly treatment options for your situation.

Network Claims and Non-Network Claims

Some employers have workers’ compensation policies that do not limit an injured workers’ choice of doctor.  These are called non-network claims.  This means there is no network of doctors that you have to use for treatment.  You can treat with any doctor willing to see a patient with a workers’ compensation injury.

Many employers buy insurance and opt for a policy that contains network medical care.  This means that you have to seek treatment with doctors who are part of the treatment network set up by the insurance company who sold the policy to your employer.  This is similar to your regular health insurance.  For instance, if you have Blue Cross Blue Shield health insurance, then you have to see doctors that accept that insurance or you have to pay the cost yourself.  In a network claim, you have to see doctors that are allowed to provide treatment for the network your employer’s insurance uses.  For instance, if you have a claim with Texas Mutual Insurance, you will likely have to seek treatment from a doctor that is listed on the “Work Well” network of doctors.

What Kind Of Monetary Benefits Do I Get In A Workers’ Comp Claim?

In Texas, we have benefits for lost wages and for permanent impairment.  If you are not able to earn your full wages, you can qualify for Temporary Income Benefits.  These benefits cover 70% of your lost wages for any particular week that you sustain lost wages.  You can receive these benefits for up to two years.  They will end when you return to work earning your full wages, you reach maximum medical improvement, or you have been off work for two years, whichever comes first.

After treatment is completed, you will be given an impairment rating.  This is a measure of the permanent impairment that you sustained as a result of your work injury.  It is reported as a percentage of loss of your whole person.  Most people with a low back injury will get a 5% impairment rating.  These benefits pay 3 weeks of benefits for every percentage of impairment.  So, a 5% impairment rating will get you 15 weeks of additional benefits.

What Do I Do If My Workers’ Compensation Claim Is Denied By The Insurance Company?

Fight.  There is a dispute resolution process set up to resolve these disputes.  First there is a mediation called a Benefit Review Conference where the issues can be resolved by an agreement negotiated between you and the insurance company.  If that doesn’t work, then the dispute goes to a Contested Case Hearing which is a trial before an administrative law judge.  You will need a lawyer to attend these hearings with you.  Although you are allowed to go through this process without a lawyer, your chances are significantly greater with an attorney.  The insurance company will have its attorney at the hearings whether you have one or not.

What Kind Of Settlement Should I Get In My Workers’ Comp Case?

There are no settlements in a Texas workers’ compensation case.  We can make agreements or “settlements” of disputed issues along the way in a workers’ comp case, but there is no settlement at the end like there is in a car wreck case.  You are entitled to all of the benefits that the Texas Workers’ Comp Act allows, and for which you qualify, but there is no settlement payment at the end of the case.

You can get more detailed information about Texas workers’ compensation claims in our book, The Ultimate Survival Guide For Texas Injured Workers:  Everything You Need To Know To Beat Insurance Companies At Their Games.