Who do I…

Who do I contact if my payments stop?

Your adjuster or the Office of the Injured Worker Counsel (OIEC) will assist you in finding out why your payments have been withheld and will assist you in having the payments reinstituted. Your Temporary Income Benefits (TIB) are approved by TDI-DWC and are stopped if you have been put back to work, or proper forms indicating that you are off work have not been submitted.

Who do I contact to get my work status DWC form-073?

Your treating doctor is the primary doctor responsible for placing you back at work or taking you off work and filling out the DWC-073 form. Your work capacity is also required to be filled by all physicians that evaluate you. Make sure that after every doctor visit provides you with a DWC-73 Work status form and that you keep your employer informed about your work status.

Who do I contact when I have been placed at Maximum Medical improvement?

Contact your adjuster or OIEC. You should also, always be in contact with your employer, providing work updates given by your treating doctor.

Who do I contact to receive the compensation for my Impairment Rating?

Contact your adjuster, DWC or OIEC.

 

Injury and Compensable…

What if the pain or symptoms I feel is in the compensable body part but the cause of that pain or symptoms is caused from a different body part and my treatment is in dispute?

Your treating doctor most importantly must explain how your injury, and current symptoms are causing symptoms that are referred to a distant body part. You can contact your adjuster or OIEC. If an agreement cannot be made with the adjuster, the Division of Workers Compensation (DWC) can request a Designated Doctor evaluation. An Injured worker also has the right to request a Designated Doctor evaluation.

What happens if my symptoms are related to an aggravation of an arthritis process that did not cause me symptoms prior to my injury?

The definition of an injury under Subchapter B. Definition; Sec. 401.011 General Definitions (26) is damage or harm to the physical structure of the body and a disease or infection naturally resulting from the damage or harm. Pain in and of itself, does not necessarily constitute an injury and objective findings must be documented in the medical records, diagnostic exams performed. Diagnostics performed prior the date of injury helps determine a new injury or an aggravation of an existing injury. What your treating physician states regarding an aggravation is helpful to clarify pre-existing conditions.

What is a Cumulative Trauma Disorder?

Is a physical alteration resulting from repetitive activity that over time causes tissue injury expressing itself through clinical symptoms. This frequently occurs when forces that are otherwise insignificant but performed routinely for a extended period of time and on a regular basis will, in the appropriate individual, cause disturbances of function.

What is the difference between Micro-trauma and Macro-trauma?

Micro-trauma implies multiple small forces that may cause alterations as a result of their cumulative effect. Macro-trauma alludes to a one time major force causing disruption of tissues and the consequent dysfunction imposed by the injury.

What kind of injury is work related?

Injury is damage or harm to the physical structure of the body-this does not necessarily mean anything that happens to an employee while they at work. This will be determined by the insurance Carrier/Adjuster and the injured worker has the right to appeal to DWC. Work related injuries are those injuries that result while perforating work activities.

What options do I have if I have symptoms that do not match my mechanism of injury and I am refused treatment?

The insurance carrier representative, the adjuster may file a dispute for treatment if the mechanism of injury does not match the symptoms and diagnosis given on initial evaluation. The denial can be addressed by a Benefit Review Conference (BRC) by contacting OIEC or DWC. The BRC is an informal process and if the dispute is not settled, a formal Contested Case Hearing (CCH) is set. If the dispute is not agreed to by the injured worker a review by the appeals panel can be requested.

 

Doctor and Provider…

What can I do if I don’t like my doctor and what do I have to do to change from one doctor to another?

This answer can vary depending on whether the carrier is in or out of Network. If, in network, the injured worker must pick a Primary Care Physician from the in-network list. The injured worker has the right to change one time to another physician on the list. The adjuster needs to be notified and approve the change. If the injured worker wishes to change a second time, it must be approved by the network. Each Network has their own forms that need to be completed. DWC does not approve changes of treating doctor’s if the carrier is in a Network. If the carrier is not in-network, then a change of treating physician would go through DWC and form DWC-53 must be filled out. In both cases, the form must state why the injured worker wants to change treating physicians and the physician must agree to accept to treat the patient.

How do I know if my doctor is not taking good care of me?

When you attend a medical visit, after performing a History and Physical exam your doctor should inform you of the presumptive diagnosis or name of your disease, he should provide non-operative and operative treatment options according to your diagnosis, length of time your condition has occurred, the severity of your disease, prognosis and whether it is believed you will return to your previous type of work

Should I attend a scheduled visit with a Designated Doctor?

Absolutely. It is mandatory to comply with this requirement, and your benefits may be dramatically affected if you do not attend.

When am I released from the doctor’s care?

When you have achieved clinical maximal medical improvement your physician will follow you as needed. There are times, however that you may require follow-up care and or medications related to your original injury, and under this condition, as long as the continued treatment is reasonable and necessary and related to the original injury, treatment will be approved.

Do I have to let my case manager sit with me during my doctor’s visit?

We strongly recommend you do because they are there to help guide and facilitate your care. However, you have the right to decline their presence in your doctor visit. They are not your adversary although if you have an attorney, you might be asked by your attorney not to allow your case manager to sit during your visits to maintain you attorney client privileges.

 

Benefit Questions:

If my Temporary Income Benefits (TIB) stop at two years, will my medical coverage stop at the same time?

No. Once you are granted medical treatment for a compensable injury you are entitled to receive lifetime benefits for the injured body part and you will continue receiving reasonable treatment for that injury even after you have been placed at clinical maximum medical improvement (MMI).

What can I do if I don’t agree with the result of my Impairment Rating?

You can appeal your rating to DWC and they will determine if a Designated Doctor evaluation is warranted to resolve the dispute.

How will I receive a salary during my recovery process?

If you are an injured worker with a compensable injury, you are entitled to receive Temporary Income Benefits (TIB) during your recovery process for up to 104 weeks. Furthermore, you are entitled to receive impairment income benefits once an impairment rating is completed. If the impairment is 15% or greater, the injured worker is entitled to Supplemental income Benefits (SIB). If an injured worker is released to full duty, or modified duty, assuming the employer can provide such employment, the temporary income benefits cease at that time. Benefits may also cease if the injured worker is given a Bona Fide Offer of Employment outlining the restrictions and they refuse to accept it.

How long will I receive workers compensation during my recovery process?

Your Temporary Income Benefits (TIBS) can continue while you are receiving treatment for a maximum of two years. Also, the impairment rating is a form of Temporary income benefit that is given to you when you have reached maximum medical improvement.

What happens after two years if I am still receiving treatment?

At two years, you are declared at Mandatory Maximal Medical Improvement (MMI) regardless of the stage where you are in your treatment and your Temporary Income Benefits (TIBs) stop, unless you qualify for Supplemental Income Benefits (SIB) which can be received if your impairment rating is over 15% and lasts for 401 weeks.

Are there any other financial benefits that I may receive other than Temporary Income Benefits (TIBS)?

At the end of your treatment and once you are placed at MMI you will receive an evaluation to determine your Impairment Rating. You are entitled to receive roughly 3 weeks of pay for every percentage of impairment that you have been assigned.

If your Impairment Rating is equal to or more than 15 %, you may apply for Long Term Medical Disability through Supplemental Income Benefits (SIBS) or social security if you are not a candidate for retraining. If you are a candidate of retraining and alternative work that is available, you are not eligible for SIBS.

 

Work Status Questions

How is work status determined?

Your work status is determined by your treating doctor and is determined by considering the injury you sustained, your physical limitations as demonstrated by objective clinical exam parameters and diagnostic tests, and whether your employer has work that fits your functional capacity. A FCE can be done to determine your exact work requirements.

If I do not feel well and do not report for work or to my doctor, can my doctor give me a work slip excuse? The work form TWCC 73 is given for future work status recommendations and not back dated. It is also important to talk directly to your employer during our treatment and inform them of your needs and progress.

What are my options if I lose my job during my recovery?

Whether the em1ployee has a job to return to or not, does not impact their medical treatment. When your treatment is completed, your options include:

  1. You can find another job that fits your physical ability which is measured by a Functional Capacity Evaluation (FCE).
  2. If your injury has created a permanent disability, you can be referred to the Department of Assistive Rehab (DARS) by DWC who can assist you in finding another job or provide assistance in obtaining retraining according to your abilities as measured by the FCE.
  3. If you have a permanent disability that is significant, and your IR is equal to or exceeds 15%, you are eligible to receive Supplemental Income Benefits for a period of 401 weeks.

Why is a Functional Capacity Evaluation performed?

An FCE determines the worker’s ability to complete tasks, and the result of the evaluation assists in determining:

  • If a particular worker’s capacity matches the workers job description he will be returned to.
  • If a mismatch between the worker’s capacity and job description is demonstrated, the FCE assists in recommending a safe job placement.
  • The specific work capacity capacity (Sedentary, light, medium, Heavy, Very Heavy) assists DARS will in placing a worker in an adequate retraining program.
  • The results of the FCE may used as a method of determining disability.
  • Documents a baseline to compare against at the end of treatment when an FCE is repeated at the end.
  • The appropriate time to safely return a worker to the job at the expected capacity.
  • If a work conditioning or work hardening program is required to return the work to their previous work capacity.
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