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’s 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 employees’ 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 employees’ 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
- 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 (TxDOT).
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 on the SORM website in the Subchapter 5.7 – Texas Risk Management for Texas State Agencies (RMTSA) guidelines.
What does it pay for?
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.
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 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
Injured employees can contact SORM through its toll-free number.
SORM Toll-Free Phone: (877) 445-0006
Phone numbers for preauthorization and pharmacy providers are available by calling SORM’s main number.
SORM Main Phone: (512) 475-1440
SORM Fax: (512) 370-9025
Suspected fraud or abuse of the workers’ compensation system can be reported to SORM’s toll-free fraud hotline.
SORM Toll-Free Fraud Hotline: (877) 445-0006
Fraud and Investigation Email: Investigations@sorm.texas.gov