What is it?
Workers' compensation laws are based upon the theory that the burden
of on-the-job injuries should be shifted from the worker to the
employing business, and ultimately to the consuming public, as a
cost of doing business. These laws protect and benefit the employee
by providing speedy, simple, effective, and inexpensive relief,
without regard to the fault of the employer, the employee, or third
parties.
Prior to the enactment of such laws, injured workers often were
denied any compensation for work-related injuries. In those cases
where they were granted relief by the courts, it was usually only
after a lengthy and expensive process.
In 1913, the Legislature passed Texas’ first workers’ compensation
law, but it did not apply to state employees. It was not until 1973
that a workers’ compensation statute was passed that is applicable
to most state employees (Texas Civil Statutes, Article 8309g, now
recodified as Chapter 501 of the Texas Workers’ Compensation Act).
Under this statute, the state is self-insuring with respect to an
employee’s compensable injury.
An employee may notify their employer within five days of beginning
work that they do not want to be covered by workers’ compensation
and prefer to keep the common-law right to recover damages for personal
injury or death. If the employee does not choose this option, then
workers’ compensation is that employee’s exclusive remedy for an
on-the-job injury. This means that the employee may not sue the
employer or co-workers for damages.
Workers’ compensation claims of state employees are filed with
and determined by the State Office of Risk Management, but income
and medical benefit disputes are adjudicated by the Texas Department of Insurance, Division of Workers’
Compensation (DWC). The SORM executive
director acts in the capacity of the insurer as an adversary
before DWC and the courts and presents the legal defenses and positions
of the state as the insurer. The SORM executive director is authorized
to make rules and prescribe forms.
Who is covered?
A state employee who has not opted out of the coverage, as discussed
above, and who sustains an injury in the course of employment is
entitled to receive compensation under this system. In the case
of a fatality, the deceased employee’s legal beneficiaries are entitled
to benefits. The term “injury” includes occupational diseases.
A state employee is a person who is in the service of the state,
whether that person is elected, appointed, or hired by oral or written
contract, whose duties require that the person work in a political
subdivision of the state, but who is paid from state funds. Certain
peace officers, as identified in Chapter 501 of the Act, are also
considered state employees for purposes of workers’ compensation.
However, the following people are not
considered employees of the state for purposes of workers’ compensation:
- Independent contractors;
- Volunteers, except during a Governor-declared State of Emergency;
- Members of the state military forces, except while on active
duty;
- Persons covered by federal workers’ compensation;
- Offenders; and
- Consumers or patients of a state institution or agency.
The following groups have their own workers’ compensation programs:
- Employees of the University of Texas System;
- Employees of the Texas A&M University System; and
- Employees of the Texas Department of Transportation.
In most cases it is easy to determine if an on-the-job injury has
occurred, but some cases require further investigation. However,
it is not the claims coordinator’s responsibility to make this determination.
If the injured employee feels that the injury or illness is work-related,
then it should be reported. The determination of compensability
is made by SORM, whose decisions may be disputed before DWC.
Claims investigation is discussed in more detail later in this
handbook.
What does it pay for?
Weekly Compensation
Payment of compensation for time lost from work due to an on-the-job
injury is made directly to the employee on a weekly basis, unless
monthly benefits are requested. Only those employees who are physically
unable to perform their usual job task for more than seven days
following the date of injury are eligible to receive weekly compensation
payments. The first seven consecutive or cumulative days following the injury date
are called the waiting period and no weekly compensation payment
is due for the time lost for that period. However, if an employee
is off work for more than 14 calendar days, the weekly compensation
for the waiting period is paid retroactively.
An injured employee may elect to use sick and/or annual leave instead
of receiving lost-time benefits. While sick/annual leave is being
used, lost-time benefits will not be paid.
There are differences if the employee elects to receive lost-time
benefits. The amount of each week’s lost-time compensation payment
is calculated as a percentage of the employee’s average weekly wage,
subject to a maximum and a minimum limit established by the Texas
Workers’ Compensation Act. The average weekly wage includes compensation
for the employee’s insurance premium and other regularly entitled
benefits. The injured employee is responsible for paying the insurance
premium when the agency is no longer covering that fringe benefit.
Compensation Due in Fatal Cases
Beneficiaries of a deceased employee are due weekly compensation
payments equal to a percentage of the employee’s average weekly
wages, subject to a maximum amount and a minimum amount established
by the Texas Workers’ Compensation Act. Weekly payments to the surviving
spouse are payable for life or until the spouse remarries. In the
event of remarriage, a lump-sum payment equal in amount to the compensation
due for a period of two years is paid. Weekly payments to a child
shall continue until the age of 18 or beyond such age if the child
is actually dependent (disabled at time of the injury), or until
25 years of age if enrolled as a full-time student in an accredited
educational institution. All other beneficiaries (where there is
neither a surviving spouse nor child) are due weekly payments for
364 weeks.
Medical Services Payments
Selection of Doctor
The State Office of Risk Management has partnered with Forte' Inc. to provide access to a certified Workers' Compensation Health Care Network, known as CompKey Plus. With the exception of emergency care, employees who live within the network's service area are required to obtain medical treatment for a work-related injury from a network provider. After any emergency situation has passed, employees will be required to seek necessary additional care for the injury from network providers. Employers are required to provide employees notice of the network's requirements, including a list of network providers.
If the employee does not live in a workers' compensation health care network service area, there is no requirement to receive health care from the workers' compensation network providers. In this case the employee is entitled to seek care from any provider they choose. Employees are entitled to request a change of their treating doctor if they wish. The process is different in and outside the network.
Medical Fees and Charges
SORM will pay only for those services that are determined to be reasonable and necessary and related to the injury. By statute and rule, DWC has specified 16 treatments which require pre-authorization or prior approval. Health care providers within the CompKey Plus Healthcare network have different preauthorization requirements. Without this approval, SORM may not be responsible for payment.
Employees eligible for workers' compensation medical services should be instructed to inform their health care provider that the injury may be covered by workers' compensation provided by the State of Texas, and to give the health care provider their SORM claim number.
Prescriptions
Prescriptions to treat the effects of a workers' compensation injury may also be covered. A pharmacy Preferred Provider Program is available to injured employees, through ScripNet, Inc., but is not required. SORM will pay only for prescriptions that are reasonable and necessary and related to the injury.
Useful Numbers and Addresses
The main phone number for SORM is (512) 475-1440. Phone numbers
for preauthorization and pharmacy providers are available by calling
SORM’s main number.
The fax number is: (512) 370-9025.
Injured employees can contact SORM through its toll-free number,
(877) 445-0006.
Suspected fraud or abuse of the workers’ compensation system can
be reported to SORM’s toll-free fraud hotline, (888) 445-0006.
Information about SORM and claims forms can be accessed from SORM’s
web site at WWW.SORM.STATE.TX.US.
Additional information about the CompKey+ Health Care Network (HCN) can be found on SORM's web site, Introduction to the CompKey+ HCN.
Network Numbers
List of network providers:
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