Procedure 8-7

Workers' Compensation Insurance (WCI)

Responsible Officer: Vice President for Administration and Campus Operations

Sponsoring Department: Environmental Health & Safety

Revision Date: 09 August 2013

Errors or changes to: aim@uta.edu

Procedure Objective

Workers' Compensation Insurance (WC) provided by The University of Texas at Arlington (UT Arlington) is funded through a self-insured WC program administered by The University of Texas System (UT System) in accordance with Chapter 503 of the Texas Labor Code. All costs associated with the program, including benefits to employees and administrative expenses, are paid from these funds. This policy does not supersede state law, any applicable UT System rules, regulations, or other policies governing WCI.

Scope

All employees of UT Arlington whose names appear on the payroll are eligible for Workers' Compensation Insurance as provided by Chapter 503 of the Texas Labor Code.

Responsibilities

The program is administered by the UT System Office of Risk Management.

Procedures

 

Section I. Introduction

The term "injury" referred to in this policy also encompasses the category of "occupational disease". The category of occupational disease includes disorders resulting from repetitive trauma, skin disorders, toxic effect of chemicals, and respiratory disorders.

In order to report one of these disorders as a Workers' Compensation claim, the employee is required to identify a specific date that he/she knew, or should have known, this disease might be related to his/her employment.

Section II. Non-Compensable Injuries
  1. The injury occurred while the employee was intoxicated.
  2. The injury was caused by the employee's willful intention and attempt to injure themselves or other persons.
  3. The injury arose out of an act of a third person intended to injure the employee because of personal reasons.
  4. The injury arose out of an act of God, unless the employment exposes the employee to a greater risk than ordinarily applies to the public.
  5. The injury was caused by the employee's horseplay.
  6. The injury arose out of voluntary participation in an off-duty recreational, social, or athletic activity not constituting part of the employee's work-related duties.
Section III. Benefits
  1. Medical
    The UT System Adjuster is responsible for determining if an employee's injury claim is compensable after carefully reviewing all available medical and investigative documents. Persons knowledgeable about each claim are also a part of this process. An employee is entitled to all health care reasonably required by the nature of the compensable injury.

    • An employee has the initial choice of whether or not to seek medical attention for the work-related injury. If the employee chooses medical attention, he/she must choose a treating doctor from the list of physicians within the IMO Med-Select Network.
    • Unless medical treatment was received from an unauthorized physician, the employee should not be billed directly for health care required to treat the work-related injury. If an employee receives a bill from a health care provider, the employee should immediately send the bill to the UT Arlington WC Claims Analyst who will then forward it to the UT System WCI Office for review and/or payment. All expenses for medical treatment are subject to fee guidelines established by the Division of Workers' Compensation (DWC).
    • An employee should not incur any out of pocket expense when purchasing prescription drugs for treatment of a work-related injury. An employee should present the Workers' Compensation Pharmacy Card (Form 8-14) to the pharmacist. Generally personal and non-prescription items are not covered.
    • If an employee is required to pay out of pocket expense for a prescription or over the counter medication, the employee may request consideration for reimbursement by calling the UT System Adjuster.
  2. Income Benefits
    Income benefits replace a portion of wages an employee loses due to a work-related injury. There are four types of income benefits to which an employee may be entitled:

    • Temporary Income Benefits (TIBs) are benefits an employee receives if the work-related injury causes him/her to lose all or some of his wages for more than seven (7) days when placed on leave without pay.
    • Impairment Income Benefits (IIBs) are benefits received when an employee has a permanent impairment from a work-related injury.
    • Supplemental Income Benefits (SIBs) are benefits an employee will apply for quarterly (four times per year, or every three months) and are paid monthly to an injured employee who meets specific eligibility requirements referenced in Texas Labor Code (TLC) 408.141-408.151.
    • Lifetime Income Benefits (LIBs) are benefits paid to an employee when determined that the injury resulted in a condition that meets one of the qualifiers for lifetime income benefits referenced in TLC 408.161-408.162.
  3. Death and Survivor Benefits
    If the injury or illness results in the employee's death, the current statute provides for a lump sum funeral expense benefit. In addition, the surviving spouse is eligible for a weekly benefit payable until the spouse's death or remarriage.

    • In the event of remarriage, 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 claiming entitlement to receive death benefits should contact both the UT System WCI Office and the DWC directly.
Section IV. Seeking Medical Attention

In the event of a work-related injury, follow these steps:

  1. If an injured employee needs immediate emergency medical attention, call UT Arlington Police Dispatch at 817-272-3003 to request an ambulance.
  2. Unless it is a medical emergency or the employee is unable to drive, an injured employee should transport himself/herself for medical treatment.
  3. For a minor injury to an employee, it is the employee's choice whether or not to seek medical attention. If the employee requests medical attention, he/she must choose a doctor from the list of physicians in the IMO Med-Select Network.
Section V. Reporting Work-Related Injuries

All work-related injuries, no matter how minor, must be reported to the UT Arlington WC Claims Analyst in the Environmental Health and Safety Office (EH&S) immediately at 817-272-5563.

  1. The employee has the responsibility to notify his/her immediate supervisor or someone in a management position if injured at work while performing his/her job duties.

    Reporting a work-related injury to someone who is not the employee's immediate supervisor or someone not in a management position may not be considered an actual report of the injury.
  2. When reporting a work-related injury, an employee must provide his/her supervisor with the following information:

    1. name, current address and current telephone number;
    2. date, time and place the injury occurred;
    3. a description of the circumstances and nature of the injury;
    4. names of any witnesses, and contact number;
    5. the name of the physician who treated them for the work-related injury.
  3. An injured employee must complete the Employee's Report of Work-Related Injury or Occupational Disease (Form 8-6) and the Workers' Compensation Network Acknowledgement (Form 8-20A) within twenty-four (24) hours of the injury. These forms must be faxed within twenty-four (24) hours to the UT Arlington WC Claims Analyst at 817-272-0273, and the original sent to the EH&S Office through campus mail at Box 19257.
  4. The supervisor should also give a copy of the Notice of Network Requirements (Form 8-21A) to each injured employee.
  5. An employee may also receive correspondence from the DWC regarding the employee's claim for compensation. He/she has the responsibility to send a completed Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease to the DWC. The form should be completed as soon as possible and mailed directly to the DWC.
  6. The supervisor must complete the Supervisor's Report of Employee Work-Related Injury or Occupational Disease (Form 8-2) within twenty-four (24) hours from the time the injury was reported to the supervisor.

    This form must be faxed within twenty-four (24) hours to the UT Arlington WC Claims Analyst at 817-272-0273 and the original sent to the EH&S Office through campus mail at Box 19257.
  7. The supervisor must complete Notification of Work-Related Injury or Occupational Disease (Form 8-9) and give it to the injured employee to present to his/her medical provider, unless the employee is being transported to the hospital for emergency care.

    This form acknowledges that the employee has reported the injury and informs the medical provider where to send billing statements and Work Status Reports.

    The form must be faxed within twenty-four (24) hours to the UT Arlington WC Claims Analyst at 817-272-0273 and the original sent to the EH&S Office through campus mail to Box 19257.
Section VI. Medical Only Claims

A medical only claim is defined as a reported work-related injury where the employee did not miss any time from work, excluding the day of injury (i.e., no lost time). In this category of injury, the employee may or may not have required medical attention.

  1. Charges will not be made to an employee's accrued leave for any time missed from work on the day of injury, whether or not the employee seeks medical attention. Under these circumstances, if an employee returns to work the next regularly scheduled workday after the injury, it is considered a "no lost time" injury and the employee will not lose any time or pay as the result of the injury.

    Note: However, for all doctor and physical therapy appointments, excluding the day of injury, employees will be required to utilize accrued leave time. If leave time is not available, the employee will be placed on leave without pay, or he/she may try to negotiate an adjustment in his/her work schedule with his/her supervisor to offset the time away from work.
  2. The employee must notify the UT Arlington WC Claims Analyst immediately upon seeking medical attention for the injury, if medical attention was not needed at the beginning of the claim. In addition, the UT Arlington WC Claims Analyst must be notified when employees begin losing time away from work due to the work-related injury.
  3. During the course of medical treatment, an employee is required to bring to his/her supervisor current Work Status Reports completed by his/her treating physician. In addition, the employee is expected to go to all scheduled doctor appointments and comply with medical treatment until he/she receives a release to return to work without restrictions from the treating physician.
Section VII. Lost Time Injuries

A lost time injury is defined as a work-related injury that resulted in bodily injury and an absence of one or more regularly scheduled days of work, excluding the day of injury.

The following rules apply to employees who have sustained lost time injuries:

  1. An employee is eligible to receive WCI income benefits for a compensable injury only when he/she goes on leave without pay.
  2. An employee is not eligible to receive workers' compensation temporary income benefits (TIBs) while he/she is using sick or other accrued leave during absence from work because of a work-related injury.
  3. An employee may elect to use accrued sick leave for the time away from work, however, if this designation is chosen, he/she will be required to continue to use sick leave for the duration of the workers' compensation claim, as long as sick leave is available.
  4. If an employee has exhausted all of his/her accrued sick leave, he/she may elect to use all, or a self-specified amount, of accrued vacation leave.
  5. An employee may elect to go on a leave without pay status, whether or not he/she has accrued sick or other leave available. However, if the employee does not have any sick or other accrued leave available, he/she will be required to go on leave without pay status.

    The UT Arlington WC Claims Analyst will complete a form to reflect the employee's choice of how he/she will designate the time off work, and the injured employee and his/her supervisor will be required to sign this document and return it to the UT Arlington WC Claims Analyst.
  6. The supervisor needs to notify the UT Arlington WC Claims Analyst when an employee injury results in an absence of one or more regularly scheduled days of work, excluding the day of injury. The UT Arlington WC Claims Analyst should be notified of any changes as described below:

    1. within three (3) working days of the date the employee returns to work
    2. within three (3) working days if the injured employee returns to work and then has an additional day(s) missed from work due to the injury
    3. within ten (10) working days if the employee has a change in earnings as a result of the injury
    4. within ten (10) working of the date the employee resigns or is terminated from employment
  7. Family Medical Leave Act (FMLA), Procedure 3-16 will run concurrently with the use of paid leave and WCI leave of absence when the injury is one that meets the criteria for both a serious health condition and for FMLA eligibility.
  8. An employee placed on leave without pay (accident benefit) may be eligible to receive WCI income payments for compensable injuries. The employing department is required to submit the correct documents in order to remove the employee from the payroll.
  9. During the course of medical treatment, an employee is required to bring the Work Status Reports provided by his/her treating physician to his/her supervisor. In addition, the employee is required to go to all scheduled doctor appointments and comply with medical treatment until he/she receives a release from the treating physician to return to work without restrictions.

    An employee will be allowed to work his/her regular job, even with restrictions, if the restrictions will not interfere with the performance of his/her regular job duties. Under these circumstances, the employee is still required to present current Work Status Reports to his/her supervisor until he/she is released to return to work without restrictions. Supervisors are required to fax all Work Status Reports they receive to the UT Arlington WC Claims Analyst at 817-272-0273.

    An employee's treating physician will sometimes document on the Work Status Report that he/she must adhere to specific work restrictions in order to return to work. If the work restrictions will prevent the employee from performing his/her regular job duties, it may be possible for the UT Arlington WC Claims Analyst to negotiate a modified duty work assignment for the employee. Please refer to the Return to Work Policy for Work Related Injury or Illness (Procedure 8-8).
  10. When an injured employee returns from leave without pay (accident benefit), the employing department is required to place the injured employee back on regular payroll.

    The UT Arlington WC Claims Analyst must be notified immediately the day an injured employee returns to work in order to notify the insurance carrier to discontinue the weekly WCI income checks.
Section VIII. Payment of WCI Income Benefits

WCI income benefit payments for injured employees are generally expressed in terms of "weeks of compensation."

  1. Currently, one week's benefit will be equal to seventy percent (70%) of the full-time employee's average weekly wage based on monies earned for thirteen (13) weeks pre-injury, unless employees earn less than $8.50 per hour, in which case the benefit will be seventy-five percent (75%) of the employee's average weekly wage (AWW) for the first twenty-six (26) weeks of coverage.
  2. If the employee is less than a full-time basis, the TIB will be paid at sixty percent (60%) of the AWW, regardless of the hourly wage, for the duration of the claim.
  3. The average weekly wage is calculated from the "Employer's Wage Statement" using a formula defined by statute. The weekly benefit is subject to a statutory minimum and maximum payment.
  4. An employee will not receive income benefits for the first seven days of absence from work due to the injury. During this "elimination" period, the employee may elect to utilize sick leave, or if sick leave is not available, he/she may use accrued vacation leave, or be placed on "leave without pay" status. If the disability continues for two weeks, the elimination period then becomes payable, provided the employee was on leave without pay during that period.
  5. Payment of weekly compensation benefits for a work-related injury will not extend beyond 401 weeks from the date of injury, except in very limited circumstances.
Section IX. Nondiscrimination Against Claimants

The University shall not discharge or in any other manner discriminate against any employee because the employee has filed a claim, instituted, or caused to be instituted, any proceeding under the Texas Workers' Compensation Act, or has testified or is about to testify in any such proceeding.

  1. An employee discharged in violation of this policy is entitled to reinstatement to his/her former position, upon appropriate adjudication.
  2. Nothing contained in this policy shall prevent discipline or discharge of any employee for just cause, in accordance with established discipline and discharge policy. Discipline and discharge actions must be pursuant to established policy and may be due to repeated violation of established safety regulations.
  3. This policy does not prohibit discipline and discharge for reasons other than retaliation.
  4. The University shall cooperate with the DWC and the Department of Assistive and Rehabilitative Services (DARS) in seeking to provide rehabilitation to disabled employees.
  5. Refer to Employee Leave of Absence Without Pay (Procedure 3-61) of the UT Arlington Human Resources Procedures for leave of absence limitations.
Section X. Frequently Asked Questions
  1. What is a compensable injury?
    A compensable injury is an injury that arises out of, and in the course and scope of employment, for which compensation is payable
  2. What is disability, as defined by the Division of Workers' Compensation?
    Disability means the inability, because of a compensable injury, to obtain and retain employment at wages equivalent to the pre-injury wage
  3. What are Temporary Income Benefits (TIBs)?
    TIBs are intended to replace income that is lost because a compensable work-related injury keeps an employee off work for more than seven (7) days while he/she is on leave without pay.

    The first seven (7) days of lost time will be paid to the employee if, or when, he/she loses more than fourteen (14) days from work because of the compensable injury and if he/she was on leave without pay during the first seven (7) days.
  4. How is eligibility for TIBs determined?
    An employee is entitled to receive Workers' Compensation TIBs if he/she has a compensable disability and has not attained Maximum Medical Improvement. (See Question #10)

    However, an employee cannot receive TIBs at the same time he/she is receiving an income from UT Arlington. If an employee elects to take sick leave, vacation or other leave while off work he/she will not be eligible to receive TIBs.
  5. How are TIBs calculated?
    If an employee is employed on a full-time, forty (40) hour per week basis, TIBs will be calculated at seventy percent (70%) of the average weekly wage earned during the thirteen (13) weeks immediately preceding the date of the employee's work-related injury.

    If the employee earned less than $8.50 per hour during the thirteen (13) weeks immediately preceding the date of the work-related injury, his/her TIBs will be calculated at seventy-five percent (75%) during the first twenty-six (26) weeks he/she receives TIBs.

    For an employee who works on a less than full-time basis during the thirteen (13) weeks immediately preceding the date of injury, the TIBs will be calculated at sixty percent (60%), regardless of his/her average hourly wage.
  6. What happens to the TIBs of an employee if the treating physician releases him/her to work with restrictions, but his/her employer does not have any modified or alternate work for him/her?
    If an employee is receiving TIBs and the physician releases him/her to return to work with restrictions, but UT Arlington does not have a modified duty position available that can accommodate the medical restrictions, he/she may continue receiving the TIBs
  7. Why would employers want an employee back at work before he/she is released to full duty?
    In most cases, some work is better than no work. UT Arlington can benefit from an employee's skills, even if he/she is not working in his/her regular job. And studies have shown that the healing process will be accelerated when an employee is involved in meaningful work-related activities
  8. What if a treating physician tells an employee that he/she can go back to work, but the employee does not think he/she can?
    If a treating physician releases an employee to go back to work and his/her employer is willing to accept him/her back to work in his/her regular position, but the employee chooses not to return to his/her regular position, the employee could be terminated from his/her job.

    In addition, if an employee chooses not to return to his/her regular position after his/her treating doctor has released him/her to full duty, he/she may lose his/her WC TIBs.
  9. What happens to the income and medical benefits of an employee when he /she goes back to work?
    If an employee is receiving TIBs, his/her weekly benefit check may be suspended while he/she is working, or the amount of his/her check may be reduced, depending on the amount of actual wages he/she earns.

    If an employee returns to work and his/her physician takes him/her back off work later, his/her income benefits may be restored, if he/she is still eligible.

    Medical benefits for an injured employee will continue for reasonable and necessary treatment that is related to his/her injury
  10. What does Maximum Medical Improvement (MMI) mean?
    MMI means the earliest of the following:

    1. The date the treating physician says the employee has reached the maximum recovery possible from his/her injury;
    2. The date the employee received 104 weeks of Workers' Compensation income benefits; or,
    3. The date of an approved extension beyond 104 weeks that was requested by the employee or the insurance carrier.

Forms and Tools/Online Processes

Employee's Report of Work-Related Injury or Occupational Disease (Form 8-6)

Supervisor's Report of Employee's Work-Related Injury or Occupational Disease (Form 8-2)

Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease (DWC)

Definitions

The term "injury" referred to in this policy also encompasses the category of "occupational disease". The category of occupational disease includes disorders resulting from repetitive trauma, skin disorders, toxic effect of chemicals, and respiratory disorders.

A medical only claim is defined as a reported work-related injury where the employee did not miss any time from work, excluding the day of injury. In this category of injury, the employee may or may not have required medical attention.

A lost time injury is defined as a work-related injury that resulted in bodily injury and an absence of one or more regularly scheduled days of work, excluding the day of injury.

Rationale

Insurance specifically designed to provide medical benefits and in some cases, financial payments to employees on the payroll who suffer injuries or occupational diseases in the course and scope of employment.

Appendices

N/A

Contacts

If you have any questions about this procedure, contact the following departments:

SubjectOffice NameTelephone NumberEmail/URL
All topics in Procedure
Environmental Health & Safety
817-272-2185
ehsafety@uta.edu
Website accessAdministrative Information Management817-272-0222aim@uta.edu
http://www.uta.edu/aim

Website Address for this Procedure