Claims Kit

Penalties for Late Reporting  409.021 (e)

An insurance carrier may be found to have committed an administrative violation if they do not initiate payments or file a notice of refusal as required statute.

Carriers must either commence payment of benefits (for accepted compensable injuries) or notify the Division and employee in writing of its refusal to pay benefits (for claim not accepted or otherwise requiring further investigation) no later than the 15th day after the date on which the carrier received written notice of the injury. 

Posting Requirements  Rule 110.101

An employer who has secured and purchased workers' compensation insurance coverage is considered a subscriber. As a subscribing employer, these parties are required to post notice at their workplace that provides all employees with the employer's insurance carrier name, information regarding the Ombudsman program at the Texas Department of Insurance within the Division of Workers' Compensation, and a contact number for reporting unsafe work conditions. This notice must be placed in the employer's personnel office and in a prominent place where employees can see it regularly. The following notice is to be completed and posted to satisfy these requirements. 

Notice to Employees Concerning Workers Compensation in Texas - Notice 6-English, Notice 6-Spanish

Such employers are also required to provide written notice of their applicable coverage to new employees upon hire. They must inform these new hire employees of their right to reject the employer's workers' compensation coverage and retain their common law right for action in district court. If at any time the employer's coverage lapses and is later retained, they are required to provide all employees with the information effected during and following the change of coverage.This must be provided to employees in writing. The following notice should be provided to satisfy these requirements.

New Employee Notice-English, New Employee Notice-Spanish

If an employer does not carry workers' compensation insurance coverage they are considered a "non-subscriber." These employers must must notify their employees and the Division that they do not have workers' compensation insurance.

Any notices posted so as to meet the above requirements should be posted in the language common to the employer's employee population. In all cases these notices must be posted and prominently displayed in the employer's personnel office, if any, and located about the workplace in such a way that each employee is likely to see the notice on a regular basis;

Employer Notice of No Coverage or Termination of Coverage - DWC005-English, DWC005S-Spanish

Notice to Employees Concerning Workers Compensation in Texas - Notice 5-English, Notice 5-Spanish

Failure to post or to provide notice as required in the above rule is a violation of the Act and Division rules. The violator may be subject to administrative penalties.

Reporting of Claim by Employer  120.2

The employer must report each death and occupational disease for which they have received notice of injury or knowledge to their insurance carrier. Employers must also report any injuries that result in more than 1 day of absence from work. As used here, the term "knowledge" includes receipt of written or oral information regarding diagnosis of an occupational disease, or the diagnosis of an occupational disease through direct examination or testing by a doctor employed by the employer.

The report of injury or illness is to be filed with the insurance carrier no later than the 8th day after having received notice of or having knowledge of an occupational disease or death, or not later than the 8th day after the employee's absence from work for more than one day due to a work-related injury. The report is considered filed when delivered personally, mailed, reported via tele-claim, electronically submitted, or sent by fax.

The employer will provide a written copy of the report and a written copy of the Notice of Injured Employee Rights and Responsibilities in English or Spanish or other language common to employee.

The employer must maintain a record of the date the copy of the report of injury and the date the notice of rights were provided to the employee. The employer must also maintain a record of the date the report of injury is filed with the insurance carrier.

If the insurance carrier has not received the report, the employer has the burden of proving that the report was filed within the required time frame. The employer has the burden of proving that good cause exists if the employer failed to timely file or provide the report.

The Division establishes the form, format, and manner of the Employer's First Report of Injury or Illness. The form filed with the Division by the insurance carrier thereafter is the DWC-005.

A party who fails to comply with this section may be found to have committed an administrative violation.

Physician Selection  408.022

Except in the case of emergency, the Division will require an injured employee to receive medical treatment from a doctor approved by the Commissioner. A doctor may perform only those procedures that are within the scope of the practice for which the doctor is licensed. The employee is entitled to the employee's initial choice of a doctor from the Division's approved provider list. The state also maintains a list of doctors who are not permitted to treat workers' compensation claims. Both of these can be found on the TDI's site. 

If the worker's employer has a formal network in place only network providers may be selected as their elected physician related to the workers' compensation claim. The employer should distribute copies of the network provider list, if applicable, upon receipt of notice or knowledge of an alleged work-related injury. If there is no network in place the worker may select a physician of their choosing to be their elected provider related to their claim. 

If an employee is dissatisfied with the initial choice of a doctor--either selected from an employer network or of the employee's choosing--the employee may attempt to secure a change of physician. If there is a network in place, the employee should notify the network administrator of their dissatisfaction and desire to select anew. The network may have options for the worker to consider moving forward. If there is no network in place, the employee will need to contact the Division to request a change of providers. This can be requested with a completed Employee's Request to Change Treating Doctors (DWC-053, English; DWC-053S, Spanish). A change of doctor may not be granted solely to secure a new impairment rating or medical report. 

The following are not considered selections of new or alternate doctors:

• A referral made by the doctor chosen by the employee if the referral is medically reasonable and necessary;
• The receipt of services ancillary to surgery;
• The obtaining of a second or subsequent opinion only on the appropriateness of the diagnosis or treatment;
• The selection of a doctor because the original doctor:
  • Dies;
  • Retires; or
  • Becomes unavailable or unable to provide medical care to the employee; or
• A change of doctors required because of a change of residence by the employee.