The University of Texas System Workers' Compensation Insurance (WCI) benefits may include medical, income or death benefits for an employee's work-related injuries.
For more information regarding employee benefits, refer to, Texas Department of Insurance, Division of Workers' Compensation Employee Benefits.
Medical benefits for compensable injuries are payable from the date of injury. An injured employee is specifically entitled to reasonable and necessary healthcare that:
- cures or relieves the effects naturally resulting from the compensable injury;
- promotes recovery; and/or
- enhances the ability of the employee to return to or retain employment.
What is the process of choosing a doctor?
The injured employee is initially entitled to choose a primary physician for medical treatment. The doctor's information must be documented on the Employer's First Report of Injury Form (DWC-1).
What is the process of changing the primary physician?
The employee may not change treating doctors without authorization from The Texas Department of Insurance, Division of Workers' Compensation (TDI/DWC). If the employee changes treating doctors without authorization from TDI/DWC, the employee may become personally responsible for any medical treatment rendered by the unauthorized physician. The TDI/DWC may provide any further information regarding changing doctors for injured employees.
What is the process of purchasing prescription medication?
When purchasing prescription drugs for treatment of the work-related injury, the employee will use the Modern Medical Instant Access Form. Most pharmacies will submit bills to Modern Medical upon verification of coverage. Personal and non-prescription items are generally not covered by the workers' compensation program.
What payments are expected of employees?
Unless the injured employee has received medical treatment from an unauthorized physician, the employee will not be billed directly for health care intended to treat a work-related injury. If the employee receives a bill from a health care provider, the employee must send the invoice to WCI immediately. All medical related expenses are subject to fee guidelines established by TDI/DWC.
Benefit payments for the injured employee are generally expressed in terms of "weeks of compensation." One week's benefit is equal to seventy percent (70%) of the employee's average weekly wage. The benefits will be equal to (75%) of the employee's average weekly wage for the first twenty-six weeks of disability if the employee earns less than $8.50 per hour.
An income benefit for an employee who is employed on less than a full working basis not to exceed sixty percent (60%) of the employee's average weekly wage. The average weekly wage is calculated from the Employer's Wage Statement using a formula defined in the law. The weekly benefit is subject to a statutory minimum and maximum payment.
No compensation accrues during the first seven days of absence from work due to the injury. During this waiting period, the employee must utilize accrued sick leave, vacation leave or placed on leave without pay status. If the disability continues for two weeks, the waiting period then becomes payable provided the employee was not in a paid leave status for that time.
If absence beyond seven days, the employee may continue to receive full wages under accrued sick or vacation leave or receive weekly compensation benefits. If weekly compensation benefits are paid, the employee must be placed on leave without pay until the employee returns to work.
It is the employee's responsibility to inform his or her department of this choice and the department must keep CCMSI advised of current leave status. The employee may also be responsible for maintaining his or her other insurance coverage while on leave without pay.
Payment of weekly compensation benefits for work-related injuries or occupational disease will not extend beyond 401 weeks except in very limited circumstances.
If the injury or occupational disease results in the death of the employee, current statute provides for a lump sum funeral expense benefit not to exceed $2,500 for compensable injuries occurring prior to 9/1/1999. Funeral expenses for compensable injuries occurring after 9/1/1999 will be reimbursed up to $6,000. In addition, the surviving spouse is eligible for a weekly benefit payable until the spouse's death or re-marriage.
In the event of re-marriage, a lump sum payment equal in amount to the benefits due for a period of two years will be paid to the surviving spouse. Surviving children may be eligible to share a portion of weekly death benefits.
Any beneficiary entitled to receive death benefits must first file a "Statement of Beneficiary" form with both CCMSI and TDI/DWC. More detailed instructions regarding claims for death benefits may be obtained by calling CCMSI.
For more information regarding benefits, refer to the Injured Employee's Benefits section of the Texas Department of Insurance, Division of Workers' Compensation Insurance.
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