This page provides answers to the following questions:
- I had an accident at work. How do I file a workers compensation claim in my state?
- Should my employer have workers compensation insurance? How do I know I am covered?
- What are the conditions that enable me or prevent me from claiming benefits under my state's law?
- What benefits might I be eligible to receive?
- How much time do I have to file my claim? What are the stages of the claim process? What should I expect?
- If I'm not happy with the determination, how do I appeal?
1. I had an accident at work. How do I file a workers compensation claim in my state?
If you are injured as a result of a work-related accident, seek the necessary medical care and attention the injury requires (especially in cases of an emergency). To best ensure the receipt of potential benefits, you must report your injury to your employer within thirty (30) days of the date the injury occurred or from the date you realized the injury was work-related.
Complete an Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease (DWC Form-041) and submit this to the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) within one (1) year of the date of your injury. This will begin your claims process.
2. Should my employer have workers compensation insurance? How do I know if I am covered?
Your employer is expected to partake in some form of a workers' compensation insurance program. Some examples of insurance schemes your employer may be a part of include: your employer has purchased a policy from a private insurance group; your employer is certified by the TDI-DWC as self-insured; your employer is a part of a group of employers certified as self-insured; or is a self-insured governmental entity. Your employer should have information regarding the insurance program applicable to you freely available; however, if you are unsure you should contact your local TDI-DWC Office.
3. What are the conditions that enable me or prevent me from claiming benefits under my state's law?
Keeping a detailed record of your injuries, medical procedures, and copies of forms you have filed will best ensure your receipt of benefits. This will also help to ensure the strongest protection of your rights should a dispute with your employer or employer's insurance provider emerge during the claims process.
4. What benefits might I be eligible to receive?
The TDI-DWI oversees the disbursement of four kinds of benefits within the workers' compensation scheme. These include the following:
- Medical Benefits: payments for all necessary medical care and treatment for your work-related injury.
- Income Benefits: this category of benefits is further divided into four (4) subcategories, each of which contain their own requirements and conditions to qualify to receive.
- Temporary Income Benefits are paid to you if your work-related injury prevents you from returning to work for more than seven days or you have lost wages at another job as a result of this injury. The amount of benefits paid to you is roughly seventy (70) percent of the difference between what you earned prior to the injury and what you are capable of earning now.
- Impairment Income Benefits: these benefits may be paid to you depending on the extent of your injuries. The health care provider treating you for your injury will determine when you have reached Maximum Medical Improvement (when your injury is treated as well as it can be treated). That individual will then assign an impairment rating (identifying the extent of physical damage on your body) to your injury which will correspond with a certain amount of benefits and the duration for which those benefits will be paid.
- Supplemental Income Benefits: you will be qualified to receive quarterly benefits payments if you a) have an impairment rating of 15 % or more; b) you have either not returned to work due to your impairment or you have returned to work, but earn less than eighty (80) percent of your pre-impairment wages; c) you have complied with TDI-DWC work-search requirements; and d) you did not take you impairment benefits in a lump sum. If you qualify, you should expect to receive roughly eighty (80) percent of the difference of what you earn now and what you earned pre-impairment.
- Lifetime Income Benefits: these are payments of roughly seventy-five (75) percent of the average weekly-wages you earned prior to your injury made over the course of your lifetime. To qualify, you must suffer from a permanent injury, as in the loss of an appendage (like an arm, leg, eye, etc.), the loss of function to an internal organ, or permanent disfigurement.
- Death Benefits & Burial Benefits: a surviving spouse or dependent(s) may be eligible to receive Death & Burial Benefits. Qualifying individuals may submit a Beneficiary Claim for Death Benefits (DWC Form-042) to begin the claims process. These are usually paid as seventy-five (75) percent of your pre-injury average weekly wages.
5. How much time do I have to file my claim? What are the stages of the claims process? What should I expect?
If you are planning on filing a workers' compensation claim, contact the Office of Injured Employee Counsel (OIEC). This is a state agency designed to advocate and counsel for injured employees. The agency provides a wide-array of services for injured employees, ranging from education and general assistance to assigning an ombudsman to help you through the actual dispute process.
The claims process begins when you complete the Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease form (DWC Form-041) and submit it to the TDI-DWC. Remember, you must file this form within one (1) year from the date of your injury; if you do not, you may lose your ability to successfully file a claim.
Both the OIEC and the TDI-DWC will encourage you to exhaust all opportunities to handle any potential disputes with your employer or employer's insurance provider before seeking a hearing before the TDI-DWC. This may include resolving the dispute or any pending issues with your employer or your employer's insurance provider directly or attending a Benefit Review Conference along with the adverse party. The Benefit Review Conference in an informal meeting overseen by a Benefit Review Officer. The Benefit Review Officer will help you and the adverse party to reach an agreement. If no agreement can be made, the Benefit Review Officer may encourage other forms of remediation, including an arbitration. However, you may decline to pursue arbitration; it is not mandatory.
A Contested Case Hearing follows the Benefit Review Conference. It resembles a formal hearing and is overseen by a TDI-DWC Hearing Officer. The role of the Hearing Officer here is to resolve all issues left unresolved at the Benefit Review Conference. The Hearing Officer will issue a written decision and order. This decision is appealable to the TDI-DWC Appeals Panel. The Appeals Panel will issue a written decision regarding the appeal. This is last administrative option available through the TDI-DWC.
6. If I am not happy with the determination, how do I appeal?
If you or the opposing party remain unhappy with the determination, you may appeal the decision of the TDI-DWC to a state court of law. The rules and procedures of the relevant court will apply.