Texas workers’ compensation benefits are available to people who have suffered job injuries. The adjuster is responsible for the investigation and establishment of medical and financial benefits.
The adjuster has up to 60 days to investigate the claim as it pertains to compensability, relatedness or extenuating circumstances such as employee drug policy violation or fraudulent claim of injury.
Upon acceptance of the claim, the adjuster is to respond timely to any doctor requesting care of non pre-authorized services such as initial office visits or specialist visits as well as inform the healthcare providers of the pre-authorization information for further on-going treatment if needed.
The second form of benefits is the financial benefits. These benefits are due to the injured worker at a rate of 70% of the injured worker’s weekly check based on a 13 week average of pay prior to the injury and capped at a rate not to exceed 70% of $2500 per month. The benefit check will be provided weekly as long as the injured worker is not at work, active treatment is documented and on –going and medical necessity is agreed upon by the insurance company in accordance with the Official Disability Guidelines (ODG).
The benefit checks will stop for the following reasons: return to work, clinical plateau, completion of ODG or similar evidenced based medical guidelines, at the establishment of maximal medical improvement (MMI), or exceeding 102 weeks from date of injury.
The MMI will be based on the nature of the injury and diagnosis that can be objectively documented. The diagnosis and injured body region will be figured into a percentage rating of impairment that is in increments of 5%. The impairment is calculated by multiplying the percentage granted by 3 and that equals the amount of weekly checks paid to the injured worker, basically in the form of a settlement. For example, if the injury is rated as a 5% then 5% x 3 = 15 weeks of pay (at 70% of weekly established wage). Of course, if the nature of the injury is resolved or yields no objective continued clinical deficits then the impairment rating would be zero (0%x3=0) and thus there would not be an impairment benefit awarded.
In extreme cases such as the need for multiple surgical procedures, it is possible to be receiving medical benefits and not financial benefits as treatment has continued beyond the 102 week point from date of injury. Similarly, it is also possible to be receiving financial benefits but not current medical benefits, such as an injured worker awaiting surgical approval but having completed all available therapy.
We hope this explanation will be of assistance regarding benefit expectations. Be proactive in demanding effective communication from everyone involved in the work comp process and timely benefits should be the result.
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