Qualifying for Supplemental Income Benefits or SIBS

Few things are worse than when you’re injured on the job and unable to continue to support your family because you’re unable to return to work. There could be many reasons for not being able to return to work, such as your employer is unwilling to accommodate your work-duty restrictions imposed by your doctor or your employer has simply terminated your employment. 

 

Under the Texas Workers Compensation Act, workers compensation insurance companies are required to provide financial and medical support to employees injured on the job. Employees will have their reasonable and necessary medical bills covered and receive income benefits to offset their wages.

 

In cases of severe work-related injuries, an employee may be paid for ongoing disability after the most common types of benefits have been exhausted. This is called Supplemental Income Benefits (SIBs). SIBs are paid on a monthly basis. SIBs are based on a complicated formula that an attorney can assist an injured employee to calculate. 

 

 

An injured employee must apply and qualify for SIBs on a quarterly basis, about every 3 months. For the first quarter only, the Division of Workers’ Compensation (DWC) makes the SIBs eligibility determination. On all subsequent quarters, the employer’s workers compensation insurance carrier makes the determination. If the injured employee is denied by the insurance carrier or DWC, the injured employee has the right to pursue his or her entitlement to SIBs for that quarter through the dispute resolution system of the Texas DWC.


The important period for qualifying for SIBs is called the “Qualifying Quarter.” Whether an injured employee is eligible depends on the circumstances during the 13 weeks before the beginning date of the SIBs determination. If an injured employee qualifies during the qualifying quarter, then he or she becomes eligible to receive payment during the supplemental income benefits quarter.

 


In determining eligibility under SIBs, an injured employee must show that as a direct result of a work-related injured he or she:

1.      Received an impairment rating of 15% or more; and

2.      Is unable to return to work because of the impairment, or has returned to work but is earning less than 80% of his or her pre-injury average weekly wage because of the impairment; and

3.      Did not take a lump sum payment of impairment income benefits; and

4.      Met specific work-search requirements based on Texas Workforce Commission standards or is actively participating in a vocational rehabilitation program.

From the date of the injury, SIBs continue to be paid in each quarter that an employee applies and is approved until the employee demonstrates long-term employment by going 4 consecutive quarters without being entitled to SIBS or until a total of 401 weeks (approximately 7 1/2 years) of income benefits have been exhausted on the claim.

 

Often, an injured employee's SIBs application will be denied because they missed a deadline or failed to meet some SIBs requirement. Many injured employees think that a denial means they will no longer receive benefits. But this denial only applies to that particular quarter of SIBs to which the employee applied. The injured employee can still meet the requirements for the subsequent quarters of SIBs. It’s important to note that an injured employee will permanently lose entitlement to SIBs if the injured employee does not apply or applies and is rejected for four consecutive quarters. 


For all workers compensation needs, especially ensuring proper compliance with the SIBs qualifying requirements, it is better to have an attorney that is board certified in Texas Workers Compensation Law for representation. With proper legal representation, you can improve your chances of a favorable outcome.

 

 

Injured While Driving to Work: Implications of Texas Workers Compensation Insurance

Each day, Texas residents drive to and from work, expecting to arrive safely. On many occasions, employers may provide either (1) company-owned transportation or (2) financial reimbursement for travel expenses using a private vehicle. Both situations would be in furtherance of the responsibilities of the job and are directly connected with the performance of the employment. 

But what happens when the commute goes wrong and there’s an accident? If you become injured, who will pay for your injuries and damages? Does your employer carry workers compensation insurance? If they do carry it, are you entitled to receive benefits from your employer’s workers compensation insurance carrier?

The answers to these questions are complex and fact intensive. Not all cases are the same and not all injuries are the same. An attorney who specializes in workers compensation law will be able to assist you at every step of your workers compensation case. 

The law in Texas under the Workers Compensation Act provides for employee compensation when injuries arise out of and in the course and scope of employment for which compensation is payable. For an injury to arise in the course and scope of employment it must: (1) relate to or originate in, and (2) occur in the furtherance of, the employer's business. Travel to and from work generally does not meet this test, unless the employee's travel was pursuant to express or implied conditions of his employment. The claimant has the burden to prove that he was injured in the course and scope of his employment. (TWCC APD No. 931006) Whether an injury occurred in the course and scope of employment is a fact question that must be determined by the hearing officer. (TWCC APD No. 971607)

A recent Texas case helped clarify these legal issues. In SeaBright Inc. Co. v. Lopez, an employee was assigned to work at a remote job site. The employer provided a company vehicle but did not pay for the employee’s travel time to and from the job site. One morning, the employee was killed while driving to work with two other employees. The decedent’s wife sought benefits from the employer’s workers compensation carrier, but the insurance carrier denied the claim for benefits because the insurance carrier believed the employee was not on the job (a.k.a., the course and scope of employment) at the time of the accident.

The court concluded that the employer's business called for employing specialized, non-local work crews in constantly changing, remote locations on temporary assignments. It required employees to obtain temporary housing and travel from that temporary housing to that temporary, remote location. Based on these facts, the court held that the plaintiff had conclusively established that her husband was acting in the course and scope of his employment at the time of the accident and was entitled to benefits.

As mentioned above, not all cases are the same. But with the help from an attorney that is board certified in Texas workers compensation law, you will receive skilled and knowledgable representation. 

 

 

Top Ten Dangerous Jobs in America

 

National Media Examines Workers Compensation Disparities

 Two things happened this week to raise the consciousness of the public towards the inadequacies of workers compensation. First was a major piece of reporting by Pro Publica and NPR that conducted an exhaustive examination of workers compensation benefits, state by state. You can find the articles here:

www.propublica.org/article/photos-living-through-california-workers-comp-cuts

www.propublica.org/article/the-demolition-of-workers-compensation

The reporters chief findings:

  • Since 2003, legislators in 33 states have passed workers’ comp laws that reduce benefits or make it more difficult for those with certain injuries and diseases to qualify for them.
  • Where a worker gets hurt matters. Because each state has developed its own system, an amputated arm can literally be worth two or three times as much on one side of a state line than the other.
  • Many states, Texas among them, have not only shrunk the payments to injured workers, they’ve also cut them off after an arbitrary time limit — even if workers haven’t recovered.
  • Employers and insurers increasingly control medical decisions, such as whether an injured worker needs surgery.

As a workers compensation attorney who has been practicing since before 2003, I can attest that changes made to Texas' system that occurred after 2003 were the second such effort to reduce workers compensation benefits and make them more difficult to obtain.

Even though other states made changes to their workers' compensation schemes in part due to the success Texas has had reducing benefits, most of those states still did not take the more extreme path of reducing benefits to injured workers to the levels that Texas has done. This graphic is illustrative:

Texas Far Behind Other States in Workers' Compensation BenefitsTexas Far Behind Other States in Workers' Compensation BenefitsThose of us representing injured workers have complained for a long time that there is a race to the bottom amongst the states in what is being paid to injured workers. That race is on the verge of breaking the system. The only question is will Republicans in safely gerrymandered districts have the courage to fix the system before it breaks?

The second thing to raise some consciousness was a report put out by OSHA which can be found here:

www.dol.gov/osha/report/20150304-inequality.pdf

That report states another aspect of workers compensation law that has long been complained about by those of us who represent injured workers:

The costs of workplace injuries are borne primarily by injured workers, their families, and taxpayer-supported components of the social safety net. Changes in state based workers’ compensation insurance programs have made it increasingly difficult for injured workers to receive the full benefits (including adequate wage replacement payments and coverage for medical expenses) to which they are entitled. Employers now provide only a small percentage (about 20%) of the overall financial cost of workplace injuries and illnesses through workers’ compensation. This cost-shift has forced injured workers, their families and taxpayers to subsidize the vast majority of the lost income and medical care costs generated by these conditions.

That is, the public, not the workers' compensation insurer and not the business that purchases the insurance, bears the primary burden for the costs of injured workers. This occurs through the cost-shifting of workers onto other forms of payment.

I cannot even begin to count the number of times I have heard adjusters state that a workers isn't being disenfranchised because the worker can just apply for social security disability. Likewise, we frequently have problems on cases with doctors advising injured workers to just put their injury on medicaid so that the doctor can avoid all the pre-authorization hassles that comes with workers compensation.

One problem is the race to the bottom that impacts all injured workers. The public's attitude is "As long as it doesn't affect me, I don't care. Out of sight, out of mind." But this report confirms that it does affect the public. When the system finally breaks, remember that.

Texas Fights over State-Created Firm, Texas Mutual Insurance Company

              In 1991, Texas employers sought policy writers to create polices covering employees injured on the job. To fuel this need, the Texas legislature created the Texas Workers’ Compensation Insurance Fund, the largest writer of workers’ compensation insurance. In 2001, the state changed the fund's name to Texas Mutual Insurance Company (TMIC) but maintained the same goal: to stabilize the state’s workers’ compensation system. Since its creation, TMIC has accomplished just that, consuming 40% of Texas’s workers’ compensation insurance market. Today, TMIC insures over 60,000 employers and their 1.4 million employees. Despite its success, TMIC recently announced its desire to cut ties with the state. The purpose of this blog is to explain some of the pros and cons associated with converting the state fund into a private company.  

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TX DWC Announces September Workers' Compensation Violations

         On October 20, 2014, Texas's Division of Workers’ Compensation (DWC) announced final disciplinary actions against insurance carriers, health care providers, and employers for violating the state's workers' compensation laws. Division of Workers' Compensation Announces Recent Enforcement Action, Tex. Dep’t Ins. (Oct. 20, 2014), available at http://www.tdi.texas.gov/news/2014/dwc---10---20.html.

           Since January 1, 2014, administrative penalties for these violations total $1,774,345, including $1,658,245 against insurance carriers, $65,600 against health care providers, and $1,000 against employers.

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$97 Million in Workers' Comp Fraud: 2012's Top Cases

               Workers’ compensation fraud occurs when individuals intentionally make false representations to obtain or to deny workers’ comp benefits, which reimburse employees injured on the job.

             Individuals committing workers’ comp fraud carry many faces—employees, employers, and healthcare providers all qualify as potential violators. Employees become violators when seeking benefits by misrepresenting their injuries, employment status, or treatment. Alternatively, employers commit workers comp fraud not to receive benefits, but to avoid responsibility. Employers often seek to avoid responsibility by underreporting employee payrolls and avoiding premiums. Last, health care providers, such as doctors, counselors, and pharmacists, become violators by duplicating bills, billing patients for improper services, and receiving payments from multiple insurance carriers for the same treatment.

2012’s Top 10 Cases

             In 2012, the top ten workers’ comp fraud cases cost America $97,446,500. Below is a short description of each case and its damages:

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What to Watch For if You Are an Independent Contractor

According to a New York Times article, the feds are cracking down on employers that classify employees as independent contractors. 

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What To Do When You Are Injured On The Job

When injured on the job be sure and follow these steps:

  1.  Immediately report the injury to your supervisor. Make sure that the injury is properly logged or recorded by your supervisor.
  2. Request medical attention for your injury and take note of the names of the doctors who are treating you. Remember, you are not required to see a company doctor.
  3. Make sure to get contact information from any witnesses. If possible, use your phone to take photographs of the accident site. Take photographs of your injuries as well, both before and after treatment.
  4. Do not sign anything, or give any recorded statements, until you have spoken with an experienced workers compensation lawyer. You may be signing away your rights without even knowing it.
  5. If you are injured, stop working until released to work by your doctor. Additional labor could severely aggravate your injury. If your doctor releases you to light duty, you do not have to return to work unless your employer agrees in writing to abide by your doctor's restrictions.
  6. Contact an experienced workers compensation attorney as soon as possible after your injury.

Top Ten Most Unusual Comp Cases in 2009

 Larson's Workers' Compensation Reporter, the premier name in workers' compensation legal reporters, has issued their list of the top ten most bizarre or unusual workers compensation cases in 2009.  Among the highlights:

An Illinois man was awarded benefits for a displaced fracture through the right femoral neck when he attempted to dislodge a bag of potato chips from a vending machine for a female worker by giving the machine a "shoulder block."

A Missouri court upheld a denial of death benefits to the beneficiaries of a workers comp fraud investigator who was killed in a car wreck on the job. Alcohol and speeding were determined to be the causes.

Its important to remember that these lists are sensational by nature and not indicative of most workers compensation claims. Nevertheless, they do make for interesting reading, especially for those of us in the field of workers' compensation law.

Why Workers Comp is Important

Texas is the only state that doesn't make workers compensation insurance mandatory for at least some employers. This is a shame, because workers' compensation insurance is beneficial to both employees and employers as Sally Spooner, a school teacher, and the Cody School District, her employer, recently found out.

The Cody School District is the local school district in Cody, Wyoming. Recently, the district decided to discontinue providing workers compensation insurance for their employees as the superintendent and school board felt that $175,000.00 in annual premiums was not a good way to save money for the district. They couldn't have been more wrong. One of their teachers, Sally Spooner, slipped and fell and ended up having to have her right let amputated just below the knee after suffering serious injuries. Now, this incident will likely cost the district far in excess of what they would have paid in annual workers' comp premiums.

This incident illustrates the give and take of the workers' compensation system. For employers, workers' compensation insurance protects them from the big money judgments for pain and suffering, loss of future earning capacity, loss of consortium, disfigurement, etc. Typically, workers' compensation claimants recover their medical expenses, lost wages and some kind of future impairment benefit. They downside for the employer is that workers compensation is no-fault insurance. Thus, even if an employee is injured through no fault of the employer, the insurance compensates the claimant. For the claimant, obviously they receive benefits without having to prove fault--and typically those benefits start being paid very quickly versus the length of time it would take if you had to prove negligence in a court of law. However, the injured claimant gives up the right to sue their employer for their employer's negligence in causing the injury. Thus, the injured party cannot recover the big money damages that we often hear about in the news. Thus system serves both parties equally. But more importantly, providing workers' compensation insurance for employees is the right thing to do. Just look at the comments to the hyperlinked article about Ms. Spooner, above, to see what I mean.