GQ Corner
Q. If the claimant misses more than 8 days of work, does he/she not get paid benefits for the first 7 days? I thought once the employee missed over 15 days, then all days were paid. But in looking at the PLN-2 letter regarding first notice of TIBS payments, it says they begin on the 8th day.
A: TIBs accrue on the 8th day of disability. The first 7 days of disability constitute the waiting period. That period is paid only if the claimant has at least a certain period of lost time. That period is either 14 or 15 days. Texas Lab. Code Ann Sec. 408.082(c) provides : If disability continues for two weeks or longer after the date it begins, compensation shall be computed from the date disability begins. The construction of the statute depends upon the meaning of the word “ after “. The safe interpretation is to pay the waiting period upon the occurrence of 14 days of lost time.
Q: Can you please provide the rules that state an injured employee cannot be reimbursed for items purchased from Amazon or other facilities unless they provide a prescription from the provider? We have an injured employee buying items that she believes help her while she is out and feels that we should reimburse her. I explained that we must have a prescription from the provider to deem it medically necessary before reimbursing.
A: A claimant may request reimbursement for health care that he has paid. The procedures for doing so are set out in rule 133.270 and 134.504 ( for pharmaceuticals ). The claimant needs to follow those procedures. The carrier is required to treat the claimant’s request for reimbursement as it would treat a medical bill. The carrier has 45 days to take final action on the request. A clmt is entitled to all health care reasonably required by the nature of the injury. See Sec. 408.021 of the Texas Labor Code. “ Health care reasonably required “ means health care that is clinically appropriate and considered effective for the injury and provided in accordance with best practices consistent with evidence-based medicine or if that evidence is not available, then it is based on generally accepted standards of medical practice recognized in the medical community. If the clmt is seeking reimbursement of medications or of medical equipment, he should have a prescription. The lack of a prescription raises issues such as relatedness or medical necessity. If the request is going to be denied on the basis of lack of medical necessity, then that determination should be made by a URA. See rule 180.22(g).
Q: Claimant was fired. We still have to add the non-pecuniary wage information to AWW to determine new TIB/IIB rates now regardless of basis for termination, correct?
A: Correct. So long as the employer continues to provide non-pecuniary benefits to the claimant, those benefits are not included in the calculation of the AWW. However, once the employer discontinues the non-pecuniary benefits, the weekly value of those non-pecuniary benefits is included in the calculation of the AWW.
FOLIO
