Patients

& Workers’ Compensation

INJURIES HAPPEN. WHEN THEY DO, YOU CAN COUNT ON ROC.

We are extremely well-versed in Workers’ Comp and offer ROC Connect to access your paperwork.

Connecting you to ROC.

Access patient paperwork online, track status, upload documents. All in one place.

Treatment Pathways

Employee's Rights and Responsibilities

1. DWC rules apply to the injured worker regardless of who is at fault for an injury, with the following exceptions:

  • The injured worker was not intoxicated at the time of the injury
  • The injury was self induced or while trying to injure someone else
  • The injury resulted from another person for personal reasons
  • The injury occurred by an act of God.
  • The injury occurred as a result of horseplay
  • The injury occurred while voluntarily participating in an off-work activity.

2. The injured worker has the right to receive medical care to treat the workplace injury or illness and there is no time limit for this medical care assuming the injury was reported timely.

3. There is no longer an approved doctor list under DWC. If you are not in a Network, you can choose any doctor that accepts Workers Compensation.

4. It is important to follow all the rules in the workers compensation system. If you don’t follow these rules, you may be held responsible for payment of medical bills.

5. You have the right to hire an attorney at any time to help you with your claim.

6. You have the right for your claim information to be kept confidential. Exceptions to this include:

  • Your employer or your employer’s insurance carrier
  • An employer that is considering hiring you may receive limited information about your claim from the Division of Workers Compensation.

7. As an injured employee in Texas, you have the right to free assistance from the Office of Injured Employee Counsel(OIEC). This assistance is offered at local offices across the state. These local offices also provide other workers compensation system services from the Texas Department of Insurance. This is the state agency that administers the system through the Division of Workers Compensation. You can contact the Office of Injured Employee Counsel by calling the toll free telephone number 1-866-EZE-OIEC (1-866-393-6432).


Disclaimer

The information provided in this section is a compilation of the experience gathered from medical professionals in the field of workers compensation and the DWC website and is not intended to override or supplant what is offered in the DWC website. With the information provided, ROC hopes to assist the injured worker in better understanding the workers compensation process and assistance provided by DWC after sustaining a work related injury. ROC desires to facilitate the injured workers ability to navigate their medical care with clarity and effectiveness to assist them in returning to their pre-injury condition.

Our chosen profession allows us to provide for ourselves and our loved ones. Through our professional productivity, we earn self-respect and contribute as productive members of our society, to the freedoms afforded to us as American citizens. During the course of employment, a productive worker may unexpectedly become injured and sustain a temporary or permanent disability. Employers and Workers form the foundation of our productive society and an injury during work activities impairs this productive union. Whether an injury is a one-time traumatic event or the result of repetitive microtrauma, a workers productivity, social standing, financial and family stability as a result of the injury, is challenged. The Reconstructive Orthopedic Center of Houston participates in the care of the injured worker and TDI-DWC because we believe in the Mission and purpose of this organization. This however, does not imply that the Workers’ Compensation system is easy to understand or navigate, and it is for this reason we offer this document.

In order to optimize how the system functions for the injured worker, it is imperative for the injured worker to understand the process, the individuals involved and the decisions that must be made along the way. Every person involved has a role and responsibility to play and each individual must be personally accountable for the system to work effectively. This includes the patient, employer, Insurance adjuster, treating doctor, consulting doctors, and case manager. At ROC, our goal of treatment is to restore the patient to the pre-injury condition and back to gainful employment as soon

To care for an injured worker and assist in restoring the injured worker to their pre-injury condition, the workers’ compensation insurance program, a State governed program was established. The Workers compensation program is financially responsible for the medical costs incurred from a work related injury, provides Temporary Income Benefits (TIB) that pays a portion of lost wages when placed off work, pays Impairment Rating wages when the injured worker reaches maximum medical improvement and Supplemental Income Benefits (SIB) when the injury is of such magnitude requiring further assistance.

The Workers Compensation Insurance program is governed by the Texas Division of Insurance (TDI), having responsibilities under both the insurance code and the labor code. The Division of Workers Compensation (DWC) falls under TDI and serves to provide direction to the resources required to assist the injured employee. The Office of injured employee Counsel (OIEC) falls within DWC and was established to represent the interests of workers compensation claimants in the state of Texas. More information about DWC can be found on their web site www.TDI.state.tx.usor by calling 1-800-252-7031. Once in the website, go to the left of the page to the resources section and click Employees. Click here for the OIEC website their direct number is
1-866-EZE-OIEC (1-866-393-6432).

Texas private employers have the option of choosing to join the Workers Compensation Insurance plan but are not mandated to do so. On the other hand, State employers or Political Subdivisions are mandated to participate. Examples include: School Districts, Cities and Municipalities, Counties, and Junior Colleges. Federal employees (USL & H, Jones Act, etc) are covered under the Federal program. All participants in the Workers compensation program have responsibilities to fulfill. The following are some of the rights and responsibilities of employees under DWC rules.

 

3 Steps After

The following presents three steps an injured worker must take when faced with an injury that interferes or impedes them from performing their work.

 

STEP I: Injury Documentation Method

1. Document in writing if possible, your injury with your immediate supervisor or someone in a managerial capacity. The documentation should include all the events surrounding the injury and how your symptoms came about. When describing your symptoms, include when your symptoms started, how they started, what symptoms are present including pain, numbness, weakness, presence of a wound and so on. Document all body parts affected. Include all body parts having symptoms, because what is not included in writing will later not have treatment permitted.

2. Define specifically the mechanism of injury (MOI) which is simply means that you describe in detail how the injury occurred. This is like describing the actions witnessed in a movie with attention to detail being important. As an example, let’s use the description of a fall to clarify this point. When a fall occurs, note the circumstances of the fall. Was it the result of tripping on a cord, rug, or other object? Was the surface where the incident occurred wet, slippery, unlevel, hard, or soft? Was the fall on level ground, or from a height of how many feet? Did you fall forward, to the side, or backwards? What position was your body when contact with the ground occurred and what part of the body struck the ground first? After impact, did you roll or strike another surface or object. After the impact, was there a wound, swelling, bruising, pain, loss of consciousness etc.?

3. Were you referred to an employer nurse or doctor? If so, what does that documentation show?

Employees responsibility of injury documentation

1. You have the responsibility to inform your employer if you have been injured at work or in the scope of your employment. You must tell your employer within 30 days of the date you were injured or first knew your injury or illness might be work related.

2. You have the responsibility to know if you are in a workers compensation health care network. If you do not know whether you are in a network, ask your employer where the injury occurred. If you are in a network, you have the responsibility to follow the network rules. Your employer must give you a copy of the Texas Department of Insurance network rules. Read the rules carefully. If there is something you do not understand, ask your employer or call the Office of Injured Employee Counsel (OIEC).

3. You have the responsibility to inform your doctor how you were injured and whether the injury occurred during work activities.

4. You have the responsibility to send a completed claim form (DWC-41) to the Division of Workers Compensation. You have one year to submit this form after you are injured or first knew that your illness might be work related. Send the completed DWC-41(employee’s claim for compensation for a work related injury or occupational disease) form even if you are already receiving benefits. You may lose your right to benefits if you do not send the completed claim form to the Division of Workers Compensation. Call 1-800-252-7031 or 1-866-393-6432 for a copy of the DWC-41 form.

5. You have the responsibility to provide your current contact information including address, working telephone number, and employer information to the Division of Workers Compensation and the insurance carrier. At any time you change address or phone numbers, you are required to notify DWC and your insurance adjuster of the change in address or phone number.

 

STEP II: Treatment History

1. Do you have a job description from the employer? Have you sent a DWC 74 form to the employer?. How was your injury report handled? Were you sent to a doctor on the premises, in a clinic or to an emergency room?

3. How did you choose your doctor? Did your company, emergency room, a friend, an advertisement refer you? Who has been directing your care? A doctor, Case manager, an Adjuster or attorney?

4. What objective tests have been performed to document and quantify your injury? Plain x-rays, MRI, CT scan, EMG/NCS, blood work, or none at all.

5. What treatment was rendered? Rest, Medication, injections, therapy, splints, work modification or were you taken off work? How did you respond to the treatment provided? Has your condition improved, stayed the same or gotten worse?

6. Work status: Were you taken off work, placed on restricted duty that allowed you to perform your work safely?

 

STEP III: Making an appointment at ROC

To make a productive initial appointment at ROC, you will be asked by the ROC scheduler Demographic information, Insurance information, Injury information, and Treatment information:

Demographic Information:

1. Name
2. Date of Birth
3. Address
4. Social Security number
5. Home phone
6. Cell phone
7. Employer Information.

Insurance Information:

1. Type of insurance,
2. Insurance number
3. Adjuster name & contact information,
4. Case manager & contact information
5. Claim number

Injury Information:

1. Date of injury
2. Location/State where the injury occurred
3. Mechanism of Injury (MOI)
4. Compensable body part
5. Whether you have had impairment rating performed
6. Been placed at maximum medical improvement (MMI)
7. Work status

Treatment Information:

1. Treating doctor
2. Referring doctor
3. Case manager
4. Treatment provided and a copy of all of the studies you have had.
5. Do not rely on the treating doctor sending the information. It is imperative that you collect and bring your medical information (including any diagnostic information, prior treatment and other tests performed) with you for you to be seen. Do not rely on the Treating doctor’s office to send it, even if they state they will send it because it is often not done.

Workers' Compensation Forms

If you have any questions about which forms you need for your case, please call us at 713-520-1210.

FAQ

We are happy to answer any of your questions at 713-520-1210.

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?

It is a physical change that happens as a result of repetitive activity over time. This activity causes tissue injury which is then felt through symptoms. The disorder happens when insignificant activity is performed on a regular basis, causing trouble in a person’s day to day functions.

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 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 performing 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 probable 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. If you experience a flare up or consequence of your original injury, it is reasonable to return for a follow up visit. Release from the doctor’s care occurs when improvement remains steady without the need for further treatment.

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. 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, regardless of the stage you are at in your treatment, you are declared at Mandatory Maximal Medical Improvement (MMI). At this time your Temporary Income Benefits (TIBs) will stop. If your impairment rating is over 15% and lasts for 401 weeks, you qualify for Supplemental Income Benefits (SIB).

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 employee 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 work.
  • 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 (sedentary, light, medium, heavy, very heavy) assists DARS in placing a worker in an adequate retraining program.
  • The results of the FCE may be 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 worker to their previous work capacity.

Definitions...

Adjuster

The adjuster is the insurance representatives that supervises and approves your initial evaluation, diagnostic studies. Any duplicate testing must be approved by a pre-authorization company. The injured body part is the critical basis for an approved treatment or a denial. This goes back to the original injury documentation given and the symptoms reported that affect the various body parts.

Activity of Daily Living (ADL)

A person’s ability for self care, personal hygiene, eating, preparing food, communication, speaking writing, sustaining a posture, standing, sitting, caring for the home, personal finances, walking traveling, moving about, recreation, social and work activities.

Benefit Review Conference (BRC)

If a dispute for treatment occurs, the injured worker should contact first the adjuster to see if resolution can be obtained. If resolution is not reached, the injured worker should contact OIEC. TDI-DWC may schedule a BRC which is an informal attempt to obtain resolution regarding the disputed claim. Prior to going to the BRC, contact OIEC so you can have an Ombudsman represent you if you do not have an attorney.

Benefits

The Maximum Benefit Amount is the maximum amount of weekly benefits an employee may receive. This maximum benefit amount may not exceed the state average weekly wage (SAWW). Below is a rough schedule of income benefits. If you are not satisfied with benefits received, you should contact DWC or OIEC.

  • Temporary Income Benefits (TIBS) 104 weeks = 100% of SAWW
  • Impairment Income Benefits (IIBS) % based = 70% of SAWW
  • Supplemental Income Benefits (SIBS) 401 weeks = 70% of SAWW
  • Lifetime Income Benefits (LIBS) = 100% of SAWW
  • Death Benefits (DBS) = 100% of SAWW

Compensable Injury

A compensable injury is an injury occurring during the performance of your regular job duties that has been appropriately reported and documented. The first determination of compensability is designated by the insurance company adjuster and not DWC. If the injured worker is not satisfied with the decision of disputed compensability, they have the right to contact OIEC and discuss their concern. This will entail a conversation between OIEC, the adjuster , a possible Benefit Review Conference or a Contested Case Hearing.

Compensable body part

A compensable body part is the body part that the physician is allowed to treat as a result of the injured workers work related injury. The mechanism of injury reported will dictate which body part is approved for treatment since it must match the injury report. For example, back pain that occurred after you slammed your finger with a hammer, will not be treated because the back pain will be considered a coincidental problem not related to the mechanism of injury. This underlies the importance of immediately reporting and accurately documenting the original injury and symptoms experienced. The treating or consulting physicians cannot treat a body part that is not deemed compensable.

Contested Case Hearing (CCH)

A contested case hearing is a formal hearing held by TDI-DWC between the injured worker and the insurance carrier when the informal BRC has not been successful in resolving a dispute for treatment. Prior to attending the CCH, the injured worker should contact OIEC so that an Ombudsman will be assigned to represent the injured worker, if the injured worker does not have an attorney.

Case manager (CM)

A case manager is typically a registered nurse or has specialty training in medical, vocational or rehabilitation services and can be a Certified Case Manager (CCM), Certified Rehabilitation Counselor (CRC), Certified Disability Management Specialist (CDMS). The CM is hired by the employer or the insurance carrier to assure the injured worker is receiving timely accurate treatment that is appropriate for the injury sustained. The case manager is there to confirm the treatments rendered are appropriate for the injury and that the treatments are improving your condition and to communicate to all having a need to know basis, about your clinical status so as to move your progress along. The case manager acts as an intermediary between the adjuster and medical provider to get approval for your treatment, and facilitate the approval of consultants with specialty training that you might need for further treatment.

Consulting Doctor

A consulting doctor is normally a specialist that your treating doctor requests an evaluation from. ROC is commonly asked by treating doctors to assist in treating and guiding the patient treatments because injuries most commonly involve the musculoskeletal system requiring an orthopedic surgeon with expertise in the upper extremity, lower extremity or spine.

Causation

Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. Causation is looked at both medically and non-medically. Documenting causation or aggravation of symptoms will depend on what has been documented. Estimation of causation requires confirmation of exposure, its severity and the timelines involved.

Department of Assistive & Rehabilitative Services (DARS)

Established to assist all Texas with disabilities of all kinds including an injured worker who has reached maximum medical improvement and has a permanent disability. It is not necessary however, to wait to be referred to DARS if the treating doctor believes the injured worker will not likely return to the previous employment. The OIEC can assist in referring the injured worker to DARS and DARS has their own website.

Disability

A disability is the inability of the injured employee to perform certain functions, in this case, the job description the employee was involved in prior to an injury event. It must be differentiated between Temporary and Permanent Disability. The presence of a temporary disability determines whether or not the injured worker is entitled to receive Temporary Income Benefits (TIB) which is determined at the beginning of the injury claim. At Maximum Medical Improvement, the treating doctor will address whether the disability and work restrictions are permanent, which requires the objective demonstration of permanently altered anatomy preventing the worker from adequately performing personal, social or occupational demands. If a permanent disability after maximum medical treatment has been reached cannot be improved by assisted devices, then they are deemed permanently disabled in relation to job performance.

The law defines a permanent disability as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or has lasted or can be expected to last for a continuous period not less than 12 months. To meet the definition of disability, an individual’s impairment or combination of impairments must be of such severity that he or she not only is unable to do the work previously done, but also cannot perform any other kind of substantial gainful work considering the individual’s age, education and work experience.

Designated Doctor Examination

Can is requested by the injured worker and or his representative, the insurance carrier or DWC to settle a dispute. If requested by the Insurance carrier, it must first be approved by DWC and scheduled by the DWC. The Designated Doctor is a licensed physician, authorized by TDI-DWC to render a second opinion and recommend a resolution of:

  1. Impairment caused by the compensable injury.
  2. Maximum Medical Improvement.
  3. Extent of the compensable injury
  4. Whether the injured employee’s disability is a direct result of the work related injury
  5. The ability of the employee to return to work
  6. A dispute regarding the medical condition

This type of review is usually mandated by the TDI-DWC to resolve questions about a compensable body part, appropriate care if it has lasted too long, maximal medical improvement and impairment rating accuracy. A Designated Doctors opinion is given presumptive weight regarding the MMI status and impairment rating.

Employability

The capacity of an individual to meet the demands of a job and the conditions of employment associated with that job as defined by an employer, with or without accommodations for a adaption.

Functional Capacity Evaluation (FCE):

An FCE is a measure of your capacity to accomplish specific tasks that may be required during the performance of a job. A qualified staff person documents your level of performance during the evaluation and a final report is elaborated with this information. The test takes four hours to perform. Effort during this test is also documented.

Handicap:

An individual is handicapped if he or she has an impairment that substantially limits one or more of life’s activities. A handicap exists when there is a barrier to accomplishing tasks or life activities and an accommodation which may include modification of the environment to overcome the deficit does not exist. A disabled individual is not necessarily handicapped if an accommodation to the environment or assisted device can help them accomplish a specific task. If an assisted device or environment is not able to be accommodated, the individual is both disabled and handicapped.

Hazard

A potential source of danger.

Independent Medical Examination (IME)

An Independent Medical Examination is normally obtained by an injured workers attorney to provide an expert medical opinion regarding causality, mechanism of injury, disability, employability or functional capacity to name a few.

Impairment

Impairment is the loss, loss of use, or derangement of any body part, system or function. It is called a permanent impairment when the medical condition is no longer changing, has become static, and will not change by more than 3% in one years time, with our without medical treatment.

Impairment Income Benefits (IIBS) and Impairment Rating:

When you are insured by a DWC insurance carrier, it is a number obtained when you have reached maximum medial improvement that allows you to be paid income benefits. The calculation is based on the patient’s level of function as measured in sensation, motion and when indicated strength and is performed according to rules and tables provided by the AMA guidelines. The results are expressed as a percentage of the total body affected and follow charts and tables based on clinical measurements. The exam is performed during your final exam and cannot be influenced by your doctor. The final number obtained from the impairment is then translated into a financial number that reimburses the patient approximately 3 weeks of temporary Income Benefits (TIBS) per percent of impairment based on Average Weekly wage (AWW) for the 13 weeks prior to the date of injury and at 70% of the AWW. These benefits are not included in earnings for the IRS and are different from the Temporary Income benefits received during your convalescence.

Letter of Clarification (LOC)

An LO C is a letter requested by the carrier or an injured worker’s attorney and is drafted by the Texas Department of Insurance, Division of Workers Compensation (TDI-DWC) and sent to a designated doctor requesting clarification on certain issues in a report the doctor submitted following the examination of an injured employee.

Letter of Medical Necessity (LMN)

When a denial for treatment is received from an adjuster, it is typically because the treatment does not fall under the compensable body part, the injury in question has not been accepted or a peer review doctor or IME doctor has not agreed with the recommended tests or treatment. The treating doctor or the consultant doctor will write a letter of medical necessity which attempts to further explain and support the request that was denied.

Liability for medical services

This is the sole responsibility of the carrier prior to final disposition of a claim to pay fair and reasonable charges for necessary medical services rendered to an injured worker. This is the responsibility of the injured worker if:
(A) After final disposition of a claim for services that are not related to the compensable injury; (B) for services not related to the compensable injury; and (C) for services rendered after the liability of the carrier has been terminated.

Maximum Medical Improvement:

There are two types of Maximum Medical Improvement:

  1. Clinical Maximum Medical Improvement
  2. Mandatory Maximum Medical Improvement.

Clinical Maximum Medical Improvement

Clinical MMI has been reached, when the patient has reached the optimal function achievable. This assumes that reasonable treatment has been provided and sufficient time has passed for all involved tissues to heal and further improvement is not likely to occur over approximately over a 12 week period in spite of appropriate non-operative and operative treatment provided. The conditions is thus stable and no more than 3% improvement over one year is expected to occur.

Mandatory Maximal Medical Improvement

Defines Maximum medical improvement occurring at 2 years (105 weeks) from the first time the worker has lost time from work.

Mechanism of Injury (MOI)-

The Mechanism of Injury (MOI) is a detailed explanation of how the injury occurred. It should specify the timing, the insulting force magnitude, force direction, and the position of the body during impact. It is also important to note immediate symptoms or changes observed. This information is important both in acute and chronic injuries.

Office of the injured worker Counsel (OIEC)

Is a state run agency that falls under DWC and represents and assists the injured worker through education, referrals to other agencies and in settling disputes by providing an Ombudsman.

Ombudsman

The Ombudsman is a specially trained employee of the office of injured employee council created by TDI-DWC, who represents and assists free of charge, the injured employee when a dispute with an employer’s insurance carrier occurs. The ombudsman can be contacted through the local DWC office or the central Austin office:

  • Austin Central: 7551 Metro Center Drive, Suite 100, Austin, Tx. 79744. Phone: 512-804-4000 and fax: 512-804-4001.
  • Houston East: Elias Ramirez Building, 5425 Polk Street, Suite 130 Houston, Tx. 77023. Phone: 713-924-2200 and Fax is 713-514-0700.
  • Houston West: 507 N. Sam Houston Parkway East, Suite 600, Houston, Tx. 77000-4021. Phone: 281-260-3035 and Fax: 281-272-0825.
  • Missouri City: 2440 Texas Parkway, Suite 240, Missouri City, Tx. 77489-4008. Phone: 281-403-7050 and Fax: 281-403-7060.

Peer Review

A peer review is a review of medical records to include: medical reports, diagnostic studies, medication history, mechanism of injury and compensability questions. A peer to peer is a verbal conversation between the peer review physician and the physician requesting a diagnostic study or medical procedure. The peer review’s intention is to obtain more information on your treatment to better understand why the request for such treatment is being made.

Possible

The likelihood or chance that an injury or illness was caused or aggravated by a particular factor is less than 50%.

Probable

The likelihood or chance that an injury or illness was caused or aggravated by a particular factor is more than 50%.

Required Medical Examination (RME)

The RME is requested by a carrier, DWC or a injured workers attorney to address if the medical care is reasonable and necessary unless a designated doctor appointment has been completed and then the RME doctor can address any part of the DD physician has addressed.

Risk

The percent probability that an adverse event will occur.

Social Security Disability

the social security administration (SSA) has national responsibility for the administration of the social security disability insurance program based on medical inability to perform gainful employment. Everyone who pays into the social security contributes to the social security Disability Trust Fund. The program provides cash benefits to disabled workers and their dependents who have contributed to the trust fund through the FICA tax on their earnings.

Supplemental Income Benefits (SIBS)

An injured worker is eligible for SIBS if he has received impairment equal to or greater than 15%. SIBS are not guaranteed and an injured worker must follow the Statute under Rule 130.102. The SIBS begin payment when payment from Impairment Rating ends (IIBS) and is given on a monthly basis. It is calculates as 80 percent of the difference between 80 percent of your average weekly wage (earned prior to your work-related injury) and your weekly wages (if you have any earnings or offered wages during this 13 week period) after the work-related injury. This form of assistance lasts for 401 weeks or 7.5 years. The injured worker is eligible to receive SIBS if they have demonstrated job searching if capable, have medical documentation why you cannot be employed, you demonstrate cooperation with DARS.

Symptoms

Symptoms an individual feels are described according to the type of symptom affecting the neurologic, vascular and musculoskeletal symptoms and can include pain, numbness, tingling, instability, locking, weakness, cold sensation, discoloration, or poor function. Symptoms are further characterized in severity based on the intensity and frequency the symptoms occur. Intensity is:

  • Minimal- annoying but do not interfere with function
  • Slight- are tolerated but do cause some interference of function.
  • Moderate- symptoms cause serious diminution of function
  • Marked- Symptoms preclude the ability to carry out activities of daily living.

Frequency is:

  • Intermittent- Symptoms occur <25% of the time while awake
  • Occasional- Symptoms occur 25-50% of the time when the patient is awake.
  • Frequent- Symptoms occur 50-75% of the time when the patient is awake
  • Symptoms 75-100% of the time while the patient is awake.

Temporary Income Benefits (TIBS)

The wages are accepted or denied by the insurance company/adjuster. If not approved, the injured worker has the right to contact DWC or an attorney.

Treating Doctor:

A treating doctor is the doctor who is in charge of your medical treatment and work status determination. However, any physician involved in your care is required to submit a D73 work status form after you are evaluated by them. The injured worker must receive the DWC-073 form on the day of the exam and the employer and insurance carrier must receive it within 2 days. The treating doctor is responsible in obtaining consults, diagnostic studies, and therapy services, dictates your work status, designates when you have reached maximum medical improvement and obtains or orders an impairment rating at the end of your care.

Work Conditioning Program

The purpose of work conditioning is to restore a patient’s full duty capacity by evaluating the specific job description and then tailoring the rehabilitation program to address the flexibility, endurance, strength, and functional capacity for that specific job. Work conditioning is done four hours per day and typically for a four week period.

Work Hardening

Work Hardening is a multi-disciplinary program that simulates specific work activities for the purpose of restoring physical, behavioral and vocational functions and has with it specific goals. Work hardening starts at four hours per day and ends with eight hours per day for a period of 8 weeks.

Work Type Categories

  1. Sedentary work: Work that may involve lifting up to 10 lbs.
  2. Light Work: Work that may require lifting up to 20 lbs
  3. Medium Work: Work that may require lifting up to 20-50 lbs
  4. Heavy Work: Work that may require lifting up to 50-100 lbs
  5. Very Heavy Work: Work that may require lifting greater than 100lbs