Chapter 9 - Worker's Comp Flashcards
What type of law is Texas Workers Compensation, monopolistic or competitive?
Competitive
What code is the Texas workers compensation established under?
Texas Labor Code - Title 5
Is Texas Workers Compensation Compulsory or Elective
Elective
What are the 3 defenses that an employer has?
Contributory negligence - employee contributed to the cause of the injury
Assumption of risk - employee was involved in actions that were not part of their job when they were injured and therefore assumed the risk
Fellow servant - injury caused by the negligence of a fellow employee
If an employer does not have workers compensation, they do lot have these defenses
What is a legal beneficiary under Texas Workers Compensation?
Spouses and children only
What is Maximum Medical Improvement?
The earliest date after which, based on reasonable medical probability, further medical recovery from or lasting improvement to an injury can no longer be reasonably anticipated or the expiration of 104 weeks from the date when income benefits began to accuse, whichever comes first
What is occupational disease?
A disease arising out of and in the course of employment that causes damage or harm to the physical structure of the body, including a repetitive injury
What is a sanction in Texas Workers Compensation ?
A penalty or other punitive action or remedy imposed by the Commission on an insurance carrier, representative, employee, employer, or health care provider for an act or omission in violation of the Workers Compensation Law or a rule or order of the Commission
What is a settlement under Texas Workers Compensation?
A final resolution of all the damages in a workers compensation claim
What is the subsequent injury fund?
A fund used to compensate an injured employee for lifetime income benefits if a subsequent compensable injury, together with the effects of a previous injury, results in a condition which entitles the injured employee to receive lifetime income benefits.
The fund receives money by collecting the benefits from insurers when a compensable death occurs and there is no legal beneficiary.
Who is eligible to purchase Texas Workers Compensation?
An employer who has at least 1 employee
Can an employee reject workers compensation ?w
Yes, an employee can reject workers compensation
What is exclusive remedy under Texas Workers Compensation ?
A one time settlement except in cases of gross negligence
What is the waiting period for Texas Worker’s Compensation?
Employee must be disabled for at least one week.
Compensation begins after 1 week
If disability continues for at least 4 weeks, the compensation is retroactive back to the first day of the injury.
What are the statue of limitations for Texas Worker’s Compensation?
The employer must be notified within 30 days after injury
Failure to do so will relive employer of all liability
Employee must file claim within 1 year
Medical Care under Texas Workers Compensation
All reasonable and necessary medical expenses are paid without a time limit or dollar amount.
Continues to be paid until the injured employee has either recovered or reached a point where no further recovery is possible.
What is Average Weekly Wage under Texas Workers Compensation?
Average weekly wage is determined by averaging the last 12 weeks of pay to determine an employee’s usual salary on which to base benefits.
The average weekly wage is also compared with statewide AWW for same occupation
What is temporary income benefits under Texas Workers Compensation?
Benefits paid to disabled employees who have not yet reached maximum medical improvement.
Benefits are payable at least 70% of difference between their AWW before injury to to 100% of the statewide AWW
Computation of benefits under Texas Workers Compensation
Loss of income is paid on a varying scale for a maximum of 104 weeks, 2 years
Impairment Income Benefits under Texas Workers Compensation
These benefits begin the day after the employee reaches maximum medical improvement
3 weeks of income benefits, based on AWW, for every percentage point of permanent impairment.
Supplemental Income Benefits under Texas Workers Compensation
If an employee has an impairment rating of at least 15% permanent disability and is unable to obtain employment earning at least 80% of the previous AWW, this fund will supplement income until it reaches 80%
May also receive vocational rehabilitation
What is Lifetime Income Benefits under Texas Workers Compensation
Paid for the loss of 2 of the same body parts
75% of AWW up to 100% of statewide AWW with an automatic 3% annual increase.
Death and burial benefits under Texas Workers Compensation
Are paid to legal beneficiaries
Spouse until they die or remarry
Children under 18 or if a full time student until 25
Burial allowance of $6,000
If no beneficiaries benefits are paid to the subsequent injury fund
Compensation procedure for Texas Workers Compensation
30 days for the employee to report injury to employer
8 days for employer to report claim to TWCC
7 days for the insurance company to pay or contest claim
What are prohibited acts under Texas Workers Compensation
These are automatic denials
The employee creates an occasion to hurt him/herself through activities not a part of their job
The employee’s injury or death is a result of willful intention
Intoxication on the job causing harm to employee unless the employer was aware of the intoxication and allowed the situation to continue.
U.S. Longshore and Harbor Workers Compensation Act
Workers in maritime employment who are not masters or crew are ahi next to this law
Dockworker, harbor worker, ship builder
Outer Continental Shelf Lands Act
Requires benefits for workers exploring and developing natural resources (oil & gas) on fixed structures permanently attached to submerged land off coast
Federal Employers Liability Act
Requires workers compensation for employees of interstate railroads
The Jones Act
Applies to the injury or death of masters or the crew of vessels involved in commerce on navigable bodies of water
What is the information page on a Texas Workers Compensation policy?
The decelerations page
What is Part 1 of Texas Workers Compensation
Workers Compensation Insurance
Standard benefits
No dollar limit for medical expenses
What is the extra territorial clause on Texas Workers Compensation
Texas benefits are available to Texas workers injured anywhere in the world if they have significant contacts in Texas or their principle employment is located in Texas.
What is Part 2 of Texas Workers Compensation
Employers Liability Insurance
Covers lawsuits
$100,000 per occurrence
Covers:
Third parties suing on the basis of contributory negligence; subrogation
Spouses and children of injured employees may sue employer for loss of care and loss of services
Employees may sue based on dual capacity doctrine, product liability
Spouses and children of an employee killed on the job may sue for exemplary damages based on gross negligence of the employer
What are exclusions to employers liability under Texas Workers Compensation
Liability assumed under contract
Intentional injury
Discharge or dissemination of employees
What is Part 3 of Texas Workers Compensation
Other States Insurance
You can use other states workers compensation if that state offers better coverage.
What is Part 4 under Texas Workers Compensation
Your Duties of Injury Occurs
Must inform insurer within 30 days
What is Part 5 of Texas Workers Compensation
Premium
Rates are based on payroll per each $100
What is Part 6 of Texas Workers Compensation
Conditions (rules)
Inspect workplace
Annual aggregate
Assignment
Cancellation/non-renewal
What is Part 7 of Texas Workers Compensation
Our Duty to You for Claim Notification
The insurer is obligated to notify employer of any claim filed against their policy
Texas Workers Compensation Insurance Fund
Must maintain a 3:1 premium to surplus ratio
For high risk insureds that cannot find coverage with private insurers
Self-Insured Employers and Employee Groups
Self-insured companies keep their workers compensation defenses because they are still providing protection for their employees
Texas Workers Compensation Insurance Fund is capitalized by
Revenue bonds
Who protects policyholders of Texas Workers Compensation ?
Texas Certified Self-Insurer Guaranty Association
