Workers’ compensation benefits are intended to address only certain losses connected to a workplace injury. They do not necessarily reimburse every financial or personal consequence of the accident.
Medical Benefits
Medical benefits cover reasonable and necessary care related to the compensable injury. Depending on the condition, this can include doctor visits, hospital treatment, physical therapy, diagnostic testing, and prescription medication.
Disputes may arise over whether a particular treatment is related to the work injury, medically necessary, or properly authorized. A carrier may deny a referral, test, surgery, therapy plan, medication, or other recommended care. Treatment can also be delayed by network or authorization requirements.
A denial of one treatment does not necessarily end all medical benefits. The reason for the denial and the type of dispute may determine what review process applies.
Temporary Income Benefits
An employee who cannot work, or who earns less because of an injury, may qualify for temporary income benefits. These benefits provide partial wage replacement based on the employee’s average weekly wage, which is generally calculated from the 13 weeks of wages immediately before the injury, and generally do not equal the employee’s full paycheck. Different methods apply when an employee worked for the employer less than 13 weeks, worked irregularly, or held more than one job.
Payments do not begin on the date of injury. Income benefits start accruing on the eighth day of disability, and days of disability that are not consecutive are added together to reach that point. Questions may arise over when payments should begin, how the employee’s average weekly wage was calculated, or whether modified work complies with medical restrictions. Benefits may also change when the employee returns to work, earns less than before the injury, reaches maximum medical improvement, the point at which the condition is not expected to improve further with treatment, or is released to full duty.
Impairment and Other Income Benefits
Maximum medical improvement, or MMI, is not a date the employee chooses. A doctor certifies it when further material recovery or lasting improvement is no longer reasonably anticipated, and Texas law also sets an outside date after which an employee is treated as having reached it regardless of ongoing treatment. After MMI is certified, the certifying doctor evaluates the employee’s condition and may assign an impairment rating. That rating may affect eligibility for impairment income benefits.
Some workers with qualifying injuries and reduced earning ability may also be eligible for supplemental income benefits. Lifetime income benefits are reserved for specific catastrophic injuries identified under Texas law. Each category has separate requirements.
Disputes may involve the date of maximum medical improvement, the impairment rating, or whether the employee qualifies for additional income benefits. A first certification of maximum medical improvement and a first impairment rating generally become final if they are not disputed within 90 days after written notice is provided, and they can be challenged after that only in limited circumstances.
Burial and Death Benefits
When a work-related injury or illness results in death, certain surviving family members may qualify for death benefits. Burial benefits may also reimburse some funeral expenses to the person who paid them. Eligibility depends on the claimant’s relationship to the employee and other applicable requirements.
