Just for Injured Employees

Workers' compensation insurance is a way to pay for some of the costs for employees and their families when:

• An employee is injured on the job
• An employee has an occupational disease
• An employee is killed on the job

• If it's an emergency, get care at the nearest facility.
• Report the injury to your employer as soon as possible.
• Your employer must report the injury to Texas Mutual. The sooner it is reported, the sooner we can help.
• Your employer must give you a copy of the injury report and the Employee Rights and Responsibilities.
• If your employer is enrolled in our health care network, please read the Notice of Network Requirements PDF (767 KB).
• If you already have a claim with Texas Mutual, you can get more information by calling (800) 859-5995 and asking for your adjuster.

Once you report the injury, a specialized adjuster will work on gathering information and additional details needed to determine the eligibility of the claim and benefits. They will reach out to you and your employer to get this information. If your claim is accepted, the adjuster, who is your claim partner, will be assigned to help you through the process. Your adjuster will also contact you and let you know what to expect in the coming days and gather any additional information to make sure you get the medical care and benefits you need.

Once you have received medical care, your adjuster works with your doctor to find out what activities you can do while you're recovering. Your adjuster will continue to stay in touch with you during your recovery.

For a more in-depth look at the process, view our info sheet on the Steps of a Claim (PDF 0.98MB) with Texas Mutual.

As an injured employee you have rights and responsibilities under the Texas workers' compensation system. You can visit the Office of Injured Employee Council's site to see the full list of Injured Employee Rights and Responsibilities, offered in several different languages.

The assigned adjuster to your claim will let you know what information they may need from you. Generally, they will ask you incident details about your injury, explain how workers' compensation works, go over benefits and talk to you about getting medical care. Once a claim has been established on your behalf, you will receive a claim number specific to you, which is needed throughout the process.

Your adjuster will let you know what forms you need to sign. Depending on your communication preferences, your adjuster will send you the forms via email or mail.

If you already know what form you need, see the Forms section on the Just for Injured Employees page.

When your employer reports your injury to Texas Mutual, an adjuster is assigned to help you with everything from getting medical care to receiving benefits. It is important to communicate with them and stay in contact so they can answer any questions that may come up.

You can call (800) 859-5995 and ask for your assigned adjuster. Please be prepared to provide your claim number, date of injury or employer information.

Our Texas Mutual Network Provider Directory is optimized for desktop and mobile use and can help you:

• Locate an urgent care facility or treating doctor
• Find a specialist
• Locate pharmacies
• See injured employee articles and additional resources

Visit texasmutual.com/care to explore.

For injured employees who qualify, your adjuster will help you get set up with an account on Texas Mutual Online to help you stay up to date with your claim. In your Texas Mutual Online account, you will be able to view adjuster contact information, see income payments, save ID cards and more.

If you have more than one claim with Texas Mutual but don’t see them all when you log in, contact your adjuster or call us at (800) 859-5995 between 8 a.m. and 5:30 p.m. Central.

Your adjuster works with you to make sure you have access to all the resources you need. They will ask you if you prefer to receive forms and other necessary information through email or mail.

If your adjuster gets you set up with an account on Texas Mutual Online, your online experience will be desktop and mobile friendly.

Your adjuster is your claims partner and can help you every step of the way. If you need support outside of Texas Mutual, you can visit the Texas Department of Insurance, Division of Workers' Compensation to find more information and resources related to the workers' compensation system in Texas.

For resources related to recovery, visit our Injured Employees Resources page.

We have 15 days from the date your workplace injury or illness is reported to us to determine if it’s covered under your employer’s workers’ comp insurance policy. We need this time to contact you, your employer, your health care provider or any witnesses to:

• Better understand your injury or illness, including how it happened and the severity.
• Verify your job duties and personal information, like address, date of birth, etc.
• Learn if you will be out of work as a result of the injury or illness, and if so, gather wage information so you can be compensated if your injury or illness is covered.

By the 15th day, we will have enough information to be able to proceed. In the meantime, we will help you get any medical or prescription care you may need.

If your claim is accepted by Texas Mutual, that means it meets eligibility requirements and you are entitled to one or more benefits we offer, such as:

• We will pay for your prescription(s) and medical care during your recovery.
• We will pay for lost wages if you are unable to work for an extended period, or if you earn less than you did prior to your injury or illness. Depending on the nature of your injury or illness, lost wage payments could be for as little as a few days or for life.

Speak with your assigned adjuster to know exactly what benefits are covered for you.

If you feel your claim should be covered by workers’ comp, speak to your adjuster to see if any information was missing. If you are not in agreement with Texas Mutual's decision, you have the right to dispute and can contact the Division of Workers' Compensation Customer Line at (800) 252-7031 or visit their site to learn more.

For additional resources to help with your recovery, visit our Injured Employee Resources page.

An accepted claim means that your injury or illness was covered by Texas Mutual. You were entitled to benefits such as prescription and medical care, and possibly lost wages. Claims are usually closed after you return to work. Please contact your adjuster about your claim if:

• You have not returned to work.
• Your injury or illness requires more medical treatment.
• You receive a bill related to the treatment of your injury or illness.
• You have any questions.

Your claim was closed after a thorough review determined that your claim did not meet eligibility requirements. Your adjuster will contact you to discuss the specifics of your claim and why it was not accepted. If you feel your claim should be covered, please view “My claim was denied. How can I appeal or dispute my claim?”

If your employer does participate in the network, WorkWell TX, you are required to choose a network doctor for any regular and specialized treatment. If you see a doctor out of network immediately following any initial emergency procedures, you may be responsible for paying your medical bill from your visit.

If your employer does not participate in the network, you do not need to choose a network doctor.

A network is made up of doctors, specialists, health care professionals and hospitals who have agreed to accept insurance from an insurance company. We vet each one to ensure they provide high-quality care and share our goals and values to assist you in returning to a productive life. If your employer has signed up for our network, using a network provider will help you avoid any unnecessary costs.

Your employer will let you know if they are a network participant. You can also call (800) 859-5995 to find out.

You can find a medical provider using our online Network Provider Directory by visiting texasmutual.com/care.

Pre-authorization is a process insurance companies use to review the treatment or medication plan recommended by your doctor to make sure it’s covered by insurance. We can identify anything that isn’t covered and help find alternatives that are appropriate. If you’re waiting on an approval for a pre-authorization request, check with your health care provider first to make sure they’ve submitted their request to us. You can contact your adjuster, too, and we will work with your health care provider to ensure you get the necessary treatment for your work injury.

• If your employer does participate in our health care network, you are allowed to change your treating doctor once. After that, requested changes must be approved.
• If your employer does not participate in the health care network, you have to file a DWC-053 (PDF 256KB) with the Texas Department of Insurance, Division of Workers' Compensation.

Optum, our pharmacy provider, has many pharmacies, including Walgreens, CVS, Walmart, Kroger, Target, Costco, Sam's Club, Brookshire, HEB and Tom Thumb. You can find a network pharmacy near you using our online Network Provider Directory at texasmutual.com/care.

Medication and treatment related to your work injury are covered by workers' compensation. However, there are some prescriptions and procedures that are subject to pre-authorization. If your prescription is for a generic medication, but you prefer the brand name, you must pay the difference in price to get the brand name.

When you get care or medicine, you may be asked to show one of your ID cards so they can bill us. Sometimes this does not happen, so if you get a bill from anyone related to treatment for your workplace injury or illness, contact your adjuster.

To see a specialist, your treating doctor will need to make the referral. If your employer is part of our health care network, you are required to see a specialist that is also in-network.

Your treating doctor may refer you to a specialist for care or services, such as physical therapy or an MRI. If you’re waiting to schedule an appointment and have not been contacted after 3-5 business days, follow up with your treating doctor to make sure they submitted the referral. If they have, you can check with the provider they referred you to and check that they got everything they needed. If either office says they need something from Texas Mutual, let your adjuster know so we can take care of it as soon as possible.

The Division of Workers' Compensation selects a designated doctor to perform a maximum medical improvement (MMI) examination. A designated doctor resolves questions or issues related to an injured employee's medical condition or injury.

Maximum medical improvement (MMI) is a term to describe when an injured employee has completed and received all treatment necessary for their injury. MMI means the work injury has improved as much as it's going to improve.

Once an injured employee has reached MMI, a certified medical provider will give them an impairment rating (IR). An IR is a percentage that represents an injured employee's impairment. Based on that percentage, injured employees may be eligible to receive three weeks of impairment income benefits (IIBs) per percentage.

If your claim is accepted by Texas Mutual, you may receive two kinds of benefits:

• Medical benefits: These benefits pay for reasonably required medical treatment of your injury or occupational disease.
• Indemnity benefits: If you are off work because of your injury, these benefits may repay you for some lost wages. If a doctor determines that you have permanent impairment from your injury, indemnity benefits pay for this loss in accordance with the state law. There are four types of indemnity benefits, each with their own criteria for eligibility:

• Temporary income benefits (TIBs): You may be eligible for these benefits if you are off work for more than seven days.
• Impairment income benefits (IIBs): These benefits are paid after you reach maximum medical improvement (MMI) with an impairment rating (IR).
• Supplemental income benefits (SIBs): You are eligible for these benefits if you receive an impairment rating (IR) of 15% or above.
• Lifetime income benefits (LIBs): There are certain serious injuries that make you eligible to receive income benefits for your entire lifetime.

An injured employee must be off work for more than seven days to become eligible for income benefits, also known as, indemnity benefits. Your adjuster will let you know what to expect should you miss work for more than seven days.

You can call (800) 859-5995 and ask for your workers' compensation specialist.

We request your wage information from your employer in order to calculate your average weekly wage (AWW). This number reflects the average amount of wages you make per week. You are eligible to receive a percentage of your AWW depending on the type of indemnity benefits you are receiving. See the benefits question to learn about the four different types.

Texas law says that employers who provide workers’ comp coverage for their employees don’t pay settlements after an injury. However, if you have a permanent impairment as a result of your injury, you may be entitled to impairment benefits. Please contact your adjuster for more information.

Your workers’ comp income benefits are not taxable. We will not send you any tax documents since you do not need to claim them on your taxes.

You should notify us of any change of address as soon as possible. This will help ensure you receive your benefit checks and other important information about your claim in a timely manner.

To notify us of any address change, call (800) 859-5995, or write to:

Texas Mutual Insurance Company
P.O. Box 12029
Austin, Texas 78711-2029

We also suggest that you submit a change of address form with the U.S. Postal Service. Go to the U.S. Postal Service website for additional details about changing your address.

Please note: We only accept change of address calls or correspondence from the injured employees or the injured employee's legal representative.

Return-to-work programs help injured employees get back to work quickly and safely with job modifications or light duty work. With a return-to-work program, you are able to maintain your pre-injury income, steer clear of the disability mindset and heal sooner.

When you are released to return to work, your doctor will approve you for either light or full duty.

Light duty: This type of duty restricts you from performing certain activities, which your doctor will identify, and could be different than the work you were doing before.

Full duty: This type of duty means you may return to work in full capacity.

For further questions, contact your adjuster. 

Your doctor will let you know when you are able to return to work. Your doctor will also let you, your adjuster and employer know what you can safely do while you are recovering.

Contact your adjuster to discuss return-to-work opportunities and they will inform you of any next steps.

If you’ve returned to work after a workplace injury or illness and are making less money than you did before your incident, let your adjuster know. Even if you are on light duty or reduced hours, you are entitled to the same earnings as before, including pay for overtime.

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