Workers' Compensation Insurance

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What is Workers' Compensation Insurance?

Workers' Compensation Insurance is a type of insurance specifically designed to provide medical benefits and, in some cases, financial payments to employees on the payroll of The University of Texas System who suffer injuries or occupational disease in the course and scope of employment.

In instances of injury or illness arising out of or in the course of employment, the employee is entitled to all medical aid, hospital services and medication reasonably required at the time of injury and anytime thereafter to cure and relieve the effects naturally resulting from the injury.

In some instances, financial benefits will be available to offset a temporary loss of wage earning capacity and/or to compensate for permanent impairment due to the injury. Workers' Compensation Insurance is not health insurance , nor does it provide compensation for damage to or loss of personal property.

For more information, refer to "Workers' Compensation in Texas" from the Texas Department of Insurance, Division of Workers' Compensation (TDI/DWC).

 

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What type of injuries are covered?

The types of Injuries covered under Workers' Compensation Insurance are called compensable injuries.

When is an injury compensable?

An injury is compensable under the Workers' Compensation Program if the injury occurs within the course and scope of employment. Course and scope means an activity of any kind or character that has to do with and originates in the work, business, trade or profession of the employer and that is performed by an employee while engaged in or about the furtherance of the affairs or business of the employer. The term includes activities conducted on the premises of the employer or at other locations. The term generally does not include transportation to and from the place of employment. Even if an injury does occur within the course and scope of employment, it will not be compensable (Section 406.032, Texas Labor Code) if:

The injury:

  • occurred while the employee was in a state of intoxication;
  • was caused by the employee's wilful attempt to injure himself or to unlawfully injure another person;
  • arose out of an act of a third person intended to injure the employee because of a personal reason and not directed at the employee as an employee or because of the employment;
  • arose out of voluntary participation in an off-duty recreational, social, or athletic activity that did not constitute part of the employee's work-related duties, unless the activity is a reasonable expectancy of or is expressly or impliedly required of the employment;
  • arose out of an act of God, unless the employment exposes the employee to a greater risk of injury from an act of God than ordinarily applies to the general public; or the employee's horseplay was a producing cause of the injury. (Section 406.032, Texas Labor Code)

A mental trauma injury or emotional injury that arises principally from a legitimate personnel action, including a transfer, promotion, demotion, or termination, is not a compensable injury. A mental trauma is only recoverable if resulting from accidental injury traceable to a definite time, place and cause rather than repetitious mental trauma.

A heart attack is a compensable injury only if:

  • it occurs at a definite time and place;
  • it is caused by a specific event, either physical strain or a sudden stimulus but not mental or emotional stress; and
  • the work, not a pre-existing condition or disease, is a substantial contributing factor.

Even when it is questionable whether or not an accident or disease qualifies under the workers' compensation program, anEmployer's First Report of Injury (DWC-1 Form) must be filed with The University of Texas System Workers' Compensation Insurance program through CCMSI for evaluation.

If you have evidence tending to show that a reported injury is not compensable, or if you have any information about a questionable claim, submit this information to CCMSI by separate memorandum. All determinations regarding compensability will be made by licensed adjusters at CCMSI.

 

For more information

For more information refer to Employee InformationorCovered Injuries.

 

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Who will be handling my Workers' Compensation Insurance Claim?

Your claim file will be managed by a workers' compensation claims adjuster at CCMSI.

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How can I obtain more information about Workers' Compensation Insurance?

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What is the Employer's First Report of Injury?

What is the Employer's First Report of Injury designed to accomplish?

The Employer's First Report of Injury (DWC-1 Form)provides written notice to The University of Texas System Workers' Compensation Insurance program via CCMSI and toThe Texas Department of Insurance, Division of Worker's Compensation (TDI/DWC) of any potential compensation claim.

When does the Employer's First Report of Injury (DWC-1 Form) need to be completed and filed?

An employer must file a DWC-1 Form as follows:

  1. For each work-related death;
  2. For each occupational disease of which the employer has knowledge (even if there is no lost time from work); and
  3. For each injury that results in more than one day's absence from work for the injured worker.

Penalty

A monetary penalty may be accessed against the employer (i.e. The University of Texas System Institution responsible for the injured employee) for failing to file the DWC-1 Form on time. A $25,000 fine may be assessed for repeat violations. Therefore, it is extremely important to file the DWC-1 Form within the prescribed time period.

 

Is the date of injury counted in determining whether or not an employee has lost more than one day of work due to a work-related injury?

Yes. If an employee actually loses time from work on the date of injury, that lost time should be counted in determining whether or not the employee has missed more than one day of work. For instance, if an employee misses half a day on the date of injury and then misses the next full day, he or she has missed more than one day of work. [Note: Lost time from work need not be consecutive.]

Are partial days missed from work counted in determining whether or not an employee has missed more than one day of work due to a compensable injury?

Partial days missed from work should be counted if an employee is absent because he or she is disabled. For instance, if an employee's regular daily shift is eight hours long, but the employee is only able to work four hours per day pursuant to doctor's orders, the employee will have lost more than one day of work due to his or her injury after the third day of working only four hours per day.

If an employee's supervisor knows the employee has sustained a work-related injury, but the employee never formally reports the injury, must the Employer's First Report of Injury (DWC-1 Form) be filed if the employee misses more than one day of work due to the injury?

Yes. An employee who is injured on the job is not required to formally report the injury if his or her supervisor (or anyone with supervisory responsibilities) has actual knowledge that the injury was sustained in the course and scope of employment.

 

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What is the Employer's Supplemental Report of Injury?

What is the Employer's Supplemental Report of Injury (DWC-6 Form) designed to accomplish?

The Employer's Supplemental Report Form (DWC-6) is required by The Texas Department of Insurance, Division of Workers' Compensation (TDI/DWC) to account for any period of time lost from work for which the injured worker might be entitled to compensation benefits. The DWC-6 form also serves as written notice to The University of Texas System Workers' Compensation Insurance program via CCMSI of an employee's lost time, return-to-work after a period of disability and change in employment status.

When does the Employer's Supplemental Report (DWC-6 Form) need to be completed and filed?

For all injuries that require the filing of an Employer's First Report of Injury (DWC-1 Form), the employing department must also file anEmployer's Supplemental Report (DWC-6 Form) with The University of Texas System Workers' Compensation Insurance program via CCMSI and the injured employee no later than three days after the occurrence of any of the following events:

  1. The injured employee returns to work after having lost time from work.
  2. The injured employee, after returning to work, experiences an additional day or days of disability as a result of the injury.

The DWC-6 Form must be filed with WCI and the injured employee within ten days of any of the following:

  1. The injured employee has a change in earnings as a result of the work-related injury.
  2. The injured employee resigns or terminates employment.
  3. The injured employee has subsequent lost time from work due to the injury.

If an employee is missing intermittent periods of time from work, how often must a DWC-6 Form be filed?

A new DWC-6 Form should be filed each time the employee returns to work after having lost time from work and/or each time the employee, after returning from work, experiences an additional day or days of disability as a result of the injury.

Is time taken off for appointments with the doctor or physical therapist considered lost time?

No. Lost time is that period of time during which the injured employee is physically unable to work due to a compensable injury.

 

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What is the Employer's Wage Statement?

What is the Employer's Wage Statement Form (DWC-3) designed to accomplish?

The Texas Workers' Compensation Act provides for payment of weekly income benefits in certain instances. The rate of compensation to which an employee is entitled is based upon his or her average weekly wage as defined in the law. The information in the Employer's Wage Statement Form is necessary to properly calculate the employee's average weekly wage.

When does the DWC-3 form need to completed and filed?

The DWC-3 form is required whenever the employing department knows or should know that an injured employee has missed or will miss more than eight (8) days of work. An employer at The University of Texas System Institution shall file a signed DWC-3 Form with the carrier (The University of Texas System Workers' Compensation Insurance via CCMSI) within 30 days of the date weekly benefits begin to accrue (eighth day of disability). An employer that fails without good cause to file a complete DWC-3 Form may be assessed an administrative penalty not to exceed $500.

What should be done when the employee did not work for thirteen consecutive weeks prior to the date of injury and there is no same or similar employee who worked for thirteen consecutive weeks prior to the date of injury?

If no same or similar employee worked for thirteen full weeks prior to the date of injury, use the number of days and hours the employee actually worked and the gross amount the employee earned in wages or salary for each week listed.

If uniforms are provided to an employee, but the uniforms must be returned upon termination of employment, are they considered Fringe Benefits?

Although there has been no definitive ruling on this matter, it isThe University of Texas System Workers' Compensation Insurance WCI Office policy not to consider uniforms a Fringe Benefit for purposes of calculating an employee's average weekly wage if the uniforms remain the property of the employer and must be returned upon termination of employment.

Should the total amount paid for health insurance during the thirteen weeks covered by the Wage Statement be listed under Fringe Benefits on the DWC-3 Form or only the monthly contribution?

List only the monthly contribution for health insurance should be listed in the amount column under Fringe Benefits. To calculate the weekly amount for a fringe benefit that is paid monthly, divide the monthly amount by 4.34821.

If a fringe benefit is suspended during the course of a claim, is it necessary to submit a revised DWC-3 Form?

Yes. If a fringe benefit is identified as being continued and the employer later suspends that benefit, the employer must file an amended DWC-3 within 7 days, reporting the date of suspension.

 

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What is the Request for Paid Leave?

What is the Request for Paid Leave Form (Form-23) designed to accomplish?

The Request for Paid Leave Form (Form-23) allows an employee who has been injured on the job and is unable to work as a result of the injury to elect to remain on the payroll and use some or all of his or her accrued leave in lieu of receiving weekly payments from The University of Texas System Workers' Compensation Insurance. The employer is prohibited from requiring the use of paid leave to cover time lost. Therefore, the Request for Paid Leave form is used to verify whether the employee has chosen to use paid leave or to receive weekly WCI benefits.

Is a Form-23 required for all intermittent periods of lost time for an employee?

Yes. A new Form-23 must be completed each time an employee misses work due to a work-related compensable injury.

What is the process of filing a Form-23 when an employee misses work due to a work-related injury?

If the employee is unable to sign the Form-23 an employer may accept a signature from an individual designated by the employee.

If neither party is able to complete the Form-23, an employer may contact an injured employee by telephone and document the employee's decision on the form.

After the employee's decision is recorded on the form, the employer must document the information as follows:

 

APPROVED BY TELEPHONE:

 

 

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(DATE)

 

 

SUPERVISOR/EMPLOYER SIGNATURE:

 

 

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(YOUR SIGNATURE)

 

 

Does an employee need to exhaust all accrued sick and/or vacation leave before utilizing workers' compensation benefits?

No. An employee is not required to exhaust accrued sick and/or vacation leave even if the employee elects to take leave pursuant to The Family Medical Leave Act.

 

For more information

For more information refer to Request for Paid Leave.

 

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What are Benefits?

If an employee is receiving weekly workers' compensation benefits for loss of wages, how does it affect the State contribution toward benefits?

An employee who is off work and receiving weekly workers' compensation benefits is in a "Leave Without Pay" status. If the leave without pay covers a period of one month or more in which no paycheck is to be received, the employee is not entitled to the State contribution toward his or her insurance premiums. This does not mean that the employee may not retain his or her insurance coverage by paying premiums. Questions regarding continuation of insurance coverage should be directed to the institutional Benefits Office.

May an injured employee who is receiving workers' compensation benefits intermittently use sick and/or vacation leave in order to retain entitlement to the State contribution toward insurance premiums?

No.

Is an employee entitled to mileage reimbursement when he or she must travel to receive medical care?

An employee will be entitled to reimbursement for travel if it becomes reasonably necessary to travel more than 20 miles (one way) in order to obtain appropriate and necessary medical care.

Can an employee who is receiving workers' compensation benefits also be eligible for Long Term Disability, Unemployment Compensation, and/or Social Security Disability benefits?

Yes. Receipt of workers' compensation income benefits does not automatically make a person ineligible for the benefits listed above. However, the amount of benefits due under other programs may be affected by receipt of workers' compensation income benefits.
The institutional Benefits Office should be contacted for specific information regarding eligibility for Long Term Disability

Are workers' compensation benefits taxable?

Workers' compensation benefits are currently not subject to federal income taxation. If an employee has specific questions about this matter, we recommend the employee be directed to the Internal Revenue Service or to his or her legal advisor.

 

For more information

For more information refer to Employee Benefits.

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When do benefits begin?

When do benefits begin?

Medical benefits for compensable injuries are payable from the date of injury. An injured employee is specifically entitled to reasonable and necessary health care that:

  1. Cures or relieves the effects naturally resulting from the compensable injury;
  2. Promotes recovery; and/or
  3. Enhances the ability of the employee to return to or retain employment.

Temporary income benefits accrue from the eighth day of disability and are paid weekly. An employee's inability to work because of a compensable injury should be documented by his or her treating physician.

 

For more information

For more information refer to Employee Benefits.

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Workers' Compensation Insurance
Questions

Address:
The University of Texas System WCI
220 West Seventh Street
Austin, Texas 78701
Phone: 512.499.4675
Fax: 512.499.4671

 

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