FAQ on Texas Injury Benefit Programs
Are there supporters of Texas injury benefit programs within the workers' compensation industry?
- There are thousands of workers’ compensation industry professionals who believe in and support Texas injury benefit programs. For example:
- Many sophisticated Fortune 500 risk managers, who are very aware of their brand value, manage Texas injury benefit programs covering billions of dollars in payroll;
- Many “A” rated insurance companies support the Texas injury benefit insurance marketplace and write approximately $100 million in annual premiums;
- Many nationally respected TPAs handle Texas injury benefit claims, successfully resolving tens of thousands of injury claims every year, and;
- Several nationally respected actuarial firms have confirmed Texas injury benefit program success.
- These professionals have openly worked together for the past two decades to deliver better results for injured workers, fewer disputes, and a better value for employers.
Is a Texas injury benefit program the same as "Opt-Out"?
No. Texas employers have three choices:
- Opt-in to Workers’ Compensation – Texas innovation and competition has created one of the best-performing workers’ compensation systems in America.
- Opt-in to QCARE – A responsible Texas injury benefit program that delivers better medical outcomes, improved benefits and cost savings, and meets 10 essential standards to earn the QCARE designation.
- Opt-Out – May not meet industry standards for the QCARE designation or provide any injury benefits.
How do Texas injury benefit programs compare to workers' compensation?
There are significant differences.
Hyper-regulated, government-run workers’ compensation programs can cost a state tens of millions of taxpayer dollars every year to operate and the programs often struggle with efficiency and effectiveness.
There is a need for more employer engagement, more employee accountability and more insurance market competition. A Texas injury benefit program operates beneath an umbrella of state and federal employee protections, similar to what workers’ compensation delivers.
Workers’ compensation systems frequently tell workers nothing about their rights or responsibilities until after they are injured, at which point workers find that their right to sue has been revoked.
Workers’ compensation frequently supports delays in injury reporting and delays in medical treatment. Injured workers bear very little personal responsibility for their care and recovery. Too often, injured workers are engaged in a system that they don’t understand and are vulnerable to less than ethical medical practitioners eager to resort to surgery and narcotics.
Seriously injured workers commonly have no choice but to hire a lawyer to navigate a highly complex workers’ compensation maze. Those lawyers then explain fundamental rights to an employee and family members, in a time of crisis, in exchange for a big cut of the payments.
In contrast, Texas injury benefit programs are about better “customer” service. All Texas injury benefit program requirements must – by law – be fully communicated to workers, in language they can understand, before an injury occurs. Employers are then allowed to further communicate and support the injured worker’s needs when an injury occurs by gaining faster access to the best medical providers (many of whom will not accept workers’ compensation claimants due to bureaucratic hassles and low-fee payments).
Texas injury benefit programs support more continuous medical care and earlier return to work. Texas injury benefit programs require workers to follow the direction of treating medical providers. As a result, Texas injury benefits programs result in fewer tragic cases for injured workers and their families, as described further below.
Is a Texas injury benefit program just like workers' compensation reform legislation?
Workers’ compensation reforms have historically tended to focus on reducing benefits, reducing physician reimbursements and narrowing compensability. Such reforms also commonly do little (if anything) to create a more competitive insurance marketplace.
Do Texas injury benefit programs pay "reasonable and necessary" medical expenses?
- Injury benefit plans include a promise to pay reasonable and necessary medical expenses.
- Texas injury benefit programs commonly limit medical expense payments to a significant dollar amount or duration because the employer must also pay for any economic, non-economic and punitive damage awards or settlements for employer negligence that may have caused the injury. (More detail below in Q&A on “better benefits.”)
Are exclusions and limitations on benefits only found in Texas injury benefit programs?
- The Texas workers’ compensation system relies on various exclusions and limitations on benefits, buried among hundreds of pages of statutes, rules, guidelines and court decisions.
- One difference is that Texas injury benefit program exclusions and limitations are much more transparent and easy to find in Texas injury benefit program documents and summary descriptions. These documents are readily available to every covered employee.
- Texas injury benefit programs use certain exclusions and limitations on benefits primarily as a means of confirming payment for work-related injury and in consideration of the employer’s unlimited negligence liability exposure in Texas. Those plan provisions should be continuously reviewed and refined for best practices, as employers and insurance carriers are doing in Texas. Many micro-limitations on benefits that have been criticized in recent years have been removed from almost all programs.
Do Texas injury benefit programs focus on saving money by reducing benefits?
- Texas injury benefit programs have never been about reducing benefits to injured workers. Instead, they rely on better communication, accountability and medical management to achieve superior outcomes for both workers and employers.
- In Texas, Texas injury benefit programs deliver broad coverage through a combination of voluntary benefits and liability settlements and awards. (More detail below in Q&A on “better benefits.”)
Do Texas injury benefit programs remain static over time?
- Texas injury benefit programs are commonly reviewed on an ongoing basis, continually improving benefit entitlements and outcomes.
- Change in traditional workers’ compensation programs occurs at a glacial pace. The ability to more rapidly respond to best medical and claims handling practices are a key advantage of Texas injury benefit programs. They do not have to wait on enabling legislation and rules. If a need or new best practice is identified, it can be immediately acted upon in a competitive environment that requires full disclosure to all covered workers, and in which employers seek value and better medical outcomes.
Are Texas injury benefits "self-insurance?"
- Both workers’ compensation and Texas injury benefit programs allow employers to insure, self-fund or do a combination of insurance and self-funding. This is just a matter of how benefit claims are financed.
- Over $100 million in Texas injury benefit insurance premiums are paid by Texas employers every year. Virtually any deductible or self-insured retention and coverage level is available in the open market. Insurance companies vigorously compete to offer the broadest coverage at the lowest price.
Do Texas injury benefit programs provide protections against discrimination and retaliatory discharge of injured workers?
- Texas injury benefit employers are subject to several federal laws that make it unlawful for any person to discriminate or retaliate against an injured worker or death benefit beneficiary for exercising any right under an injury benefit program, including the filing of a claim.
Do injured workers have access to the courts for benefit disputes?
- Employees have extensive internal and external rights to appeal any benefit denial, including access to state and federal courts.
- Federal law prohibits mandatory, final arbitration of injury benefit disputes.
- Some Texas employers require arbitration of negligence liability claims by injured workers, but that does not apply to any dispute regarding payment of injury benefits.
- Injured workers covered by an arbitration agreement in Texas still retain all rights to sue for employer negligence and can recover the same damages allowed in a court of law. Many state and federal statutes and court decisions over the past 25 years have specified clear requirements to ensure fairness both to injured workers and employers.
Have independent studies been performed on Texas injury benefit programs?
- Independent studies of this competitive alternative to Texas workers’ compensation have already been conducted by Stanford University School of Law and other prominent, national researchers, actuaries and other authorities. More independent studies are in progress now and will be most welcome. Click here for recent articles and studies.
Do Texas injury benefit programs reduce cost shifting of occupational injury costs to government programs?
- Texas injury benefit programs to workers’ compensation are saving money for federal and state governments not costing them money.
- Cost shifting to government programs happens when employees are dissatisfied and not getting good medical outcomes. The vast majority of cost shifting relates to whether the employer or the government is paying medical and wage replacement costs on injury claims. Over two decades of experience and data on Texas injury benefit programs and over two years of data on Oklahoma Option programs, indicate that these programs deliver superior medical outcomes and replace more lost wages for injured workers than workers’ compensation systems. This reality is further supported by the fact that, in comparison to workers’ compensation programs, fewer injured workers covered by Texas injury benefit programs hire lawyers or file claim disputes.
- Also, the injury benefit programs for most large employers have been amended in recent years to make clear that the injury benefit program is the employee’s primary source of recovery.
- Public policy discussions can start with high level reviews of a few injury claims and benefit levels. But serious, objective data analysis is needed on medical outcomes for injured workers, how many claims are disputed and which system is shifting more cost to government programs. We are confident that analysis will demonstrate that Texas injury benefit program employers and their insurance companies are bearing much more of the cost of occupational injuries than is seen in workers’ compensation systems.
If employers are more involved, how do we know they will do the right thing for injured workers?
- First, Social Responsibility: Most Texas injury benefit employers take social responsibility very seriously. They commonly compete to be recognized locally and nationally as a “Best Place to Work.”
- Second, Productivity and Profits: This is not the Industrial Age when workers were abundant and untrained. Employers today are highly incentivized to retain trained workers within a shrinking labor force and return injured employees to their pre-injury status and a productive job.
- Third, Fiduciary Responsibility: The law requires it. Under Texas injury benefit programs, the claims administrator has fiduciary responsibility to act in the best interest of employees, and is personally liable if he/she fails to do so. No such employee protections exist within workers’ compensation programs.
- Fourth, Negligence Liability Exposure. Stripped of the tradition and common law defenses, Texas employers without Workers’ Compensation have paid over 100 settlements and judgments of $1 million or more. This risk is real and a powerful force for good.
Why do Texas injury benefit programs require faster injury reporting than workers' compensation?
- This is an advantage for everyone, not a penalty.
- More immediate notice of injury has several important advantages for workers and employers.
- Prompt injury reporting leads to:
- Early medical diagnosis
- Faster, more effective medical treatment
- Better medical outcomes
- These are simple facts supported by American Medical Association guidelines and numerous medical studies.
- Prompt injury reporting also supports:
- Timely investigation of the claim and availability of witnesses
- Timely post-accident drug/alcohol testing, where desired
- Coworkers exposed to unsafe conditions for shorter periods of time
- Employers emphasize the reporting timeframe to their employees through multiple communication methods, including Summary Plan Description booklets required by law, highlights brochures, computer-based learning modules, wallet cards, posters in the workplace, communication from supervisors and periodic retraining. To paraphrase the U.S. Homeland Security mantra: “If you experience something, say something.”
- Immediate notice of injury requirements must be subject to a “good cause” exception to handle unique situations. This good cause exception, coupled with the claim administrator’s duty to act as a fiduciary in application of the benefit plan’s terms, is an important “check and balance.”
- In view of the above advantages to immediate reporting, why does Texas workers’ compensation allow 30 days (plus a good cause exception) to report injuries that the employee knows about? That works well for no one.
- Prompt injury reporting also supports:
- Prompt injury reporting leads to:
How has the Texas injury benefit program impacted Texas workers' compensation over the past 12 years?
- Texas has dropped from the 10th most expensive workers’ compensation system in the U.S. (in 2003) to ranking 43rd in terms of expense (in 2018) AND achieved better medical outcomes for injured workers.
- These dramatic improvements in injured worker outcomes and employer costs are due to a combination of legal reforms and competition with the Texas injury benefit program. Insurance companies must work harder to implement reforms faster and maximize the results when competing with an alternative (Texas injury benefit program) product.
Do Texas injury benefit programs or workers' compensation programs pay better benefits?
- The vast majority of workers’ compensation and Texas injury benefit program claims do not involve catastrophic injury. For these typical claims, all reasonable and necessary medical expenses are paid in full. However, most employees covered by Texas injury benefit programs are eligible for wage replacement benefits that are higher than workers’ compensation benefits (even after adjusting for any applicable taxes). Texas injury benefit wage replacement benefits commonly start sooner, are paid at a higher percentage and with a higher (or no) weekly dollar cap.
- Texas injury benefit programs often pay more defined levels of compensation faster in catastrophic claims. For example, death and dismemberment benefits in Texas injury benefit programs are typically paid in a lump sum or installments over three years instead of weekly payments strung out over many more years.
- In some cases, Texas injury benefit programs may pay fewer benefits for catastrophic injury claims because of the opportunity for additional recoveries due to any employer negligence that caused the injury. This Texas negligence liability exposure is very real, with over 100 identified settlements or judgments of $1 million or more involving employers that do not provide workers’ compensation insurance coverage.
What about tragic injury cases?
- The sad truth is there are tragic stories under both workers’ compensation and Texas injury benefit programs. The questions everyone should be asking are: Which system has fewer claims go awry? Which system brings injured workers back to their jobs and supporting their families faster? Which system has fewer disputes? Those are true measures of employee satisfaction and tragedy.
- Texas injury benefit programs have outperformed workers’ compensation by those standards (and, at the same time, cost employers that regularly experience occupational injuries less money) for decades.
What would you want for yourself or a family member if hurt at work?
- Better understanding of injury benefit rights and responsibilities?
- Immediate medical diagnosis and treatment by the best available physician?
- Payment of higher wage replacement benefits on the employer’s normal payroll system?
- Faster return to work?
- Fewer disputes?
- Less red tape, resulting in a smoother process and lower taxpayer expense?