10.1 General Definitions Copy

GENERAL DEFINITIONS

Adjuster means a person licensed under Chapter 407 of the Texas Labor Code.

Administrative violation means a violation of workers’ compensation laws or an adopted rule that is subject to penalties and sanctions as provided by the Department of Insurance.

Agreement means the resolution by the parties to a dispute of one or more issues regarding an injury, death, coverage, compensability, or compensation. The term does not include a settlement.

Alien means a person who is not a citizen of the United States.

Benefit means a medical benefit, an income benefit, a death benefit, or a burial benefit based on a compensable injury.

Certified self-insurer means a private employer granted a certificate of authority to self-insure, as authorized by the Texas Department of Insurance, for the payment of compensation.

Child means a son or daughter. The term includes an adopted child or a stepchild who is a dependent of the employee.

Commute means to pay in a lump sum.

Compensable Injury means an injury that arises out of and in the course and scope of employment for which compensation is payable.

Compensation means payment of a benefit

Course and scope of employment means an activity of any kind or character that has to do with and originates in the work, business, trade, or profession of the employer and that is performed by an employee while engaged in or about the furtherance of the affairs or business of the employer. The term includes an activity conducted on the premises of the employer or at other locations

The term does not include:
Transportation to and from the place of employment unless

• The transportation is furnished as a part of the contract of employment or is paid for by the employer;
• The means of transportation are under the control of the employer; or
• The employee is directed in the employee’s employment to proceed from one place to another place;

Death benefit means a payment made under this subtitle to a legal beneficiary because of the death of an employee.

Dependent means an individual who receives a regular or recurring economic benefit that contributes substantially to the individual’s welfare and livelihood if the individual is eligible for distribution of benefits.

Designated Doctor means a doctor appointed by mutual agreement of the parties or by the Department of Insurance to recommend a resolution of a dispute as to the medical condition of an injured employee.

Disability means the inability because of a compensable injury to obtain and retain employment at wages equivalent to the pre-injury wage.

Doctor means a doctor of medicine, osteopathic medicine, optometry, dentistry, podiatry, or chiropractic who is licensed and authorized to practice.

Employer means, unless otherwise specified, a person who makes a contract of hire, employs one or more employees, and has workers’ compensation insurance coverage. The term includes a governmental entity that self-insures, either individually or collectively.

Health Care includes all reasonable and necessary medical aid, medical examinations, medical treatments, medical diagnoses, medical evaluations, and medical services. The term does not include vocational rehabilitation. The term includes:

• Medical, surgical, chiropractic, podiatric, optometric, dental, nursing, and physical therapy
• Services provided by or at the direction of a doctor;
• Physical rehabilitation services performed by a licensed occupational therapist provided by or at the direction of a doctor;
• Psychological services prescribed by a doctor;
• The services of a hospital or other health care facility;
• A prescription drug, medicine, or other remedies; and
• A medical or surgical supply, appliance, brace, artificial member, or prosthesis, including training in the use of the appliance, brace, member, or prosthesis.

Health Care Facility means a hospital, emergency clinic, outpatient clinic, or other facility providing health care.

Health Care Practitioner means an individual who is licensed to provide or render and provides or renders health care; or A non-licensed individual who provides or renders health care under the direction or supervision of a doctor.

Health Care Provider means a health care facility or health care practitioner

Impairment means any anatomic or functional abnormality or loss existing after maximum medical improvement that results from a compensable injury and is reasonably presumed to be permanent.

Impairment Rating means the percentage of permanent impairment of the whole body resulting from a compensable injury.

Income benefit means a payment made to an employee for a compensable injury. The term does not include a medical benefit, death benefit, or burial benefit.

Injury means damage or harm to the physical structure of the body and a disease or infection naturally resulting from the damage or harm. The term includes an occupational disease.

Maximum medical improvement means the earlier of:

• The earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated;
• The expiration of 104 weeks from the date on which income benefits begin to accrue; or
• The date determined as provided Texas Labor Code.

Medical benefit means payment for health care reasonably required by the nature of a compensable injury and intended to:

• Cure or relieve the effects naturally resulting from the compensable injury, including reasonable expenses incurred by the employee for necessary treatment to cure and relieve the employee from the effects of an occupational disease before and after the employee knew or should have known the nature of the disability and its relationship to the employment;
• Promote recovery; or
• Enhance the ability of the employee to return to or retain employment.

Objective means independently verifiable or confirmable results that are based on recognized laboratory or diagnostic tests, or signs confirmable by physical examination.

Objective clinical or laboratory finding means a medical finding of impairment resulting from a compensable injury, based on competent objective medical evidence that is independently confirmable by a doctor, including a designated doctor, without reliance on the subjective symptoms perceived by the employee.

Occupational Disease means a disease arising out of and in the course of employment that causes damage or harm to the physical structure of the body, including a repetitive trauma injury. The term includes a disease or infection that naturally results from the work-related disease. The term does not include an ordinary disease of life to which the general public is exposed outside of employment unless that disease is an incident to a compensable injury or occupational disease.

Repetitive Trauma Injury means damage or harm to the physical structure of the body occurring as the result of repetitious, physically traumatic activities that occur over time and arise out of and in the course and scope of employment.

Representative means a person, including an attorney, authorized by the commission to assist or represent an employee, a person claiming a death benefit, or an insurance carrier in a matter arising that relates to the payment of compensation.

Sanction means a penalty or other punitive action or remedy imposed by the commission on an insurance carrier, representative, employee, employer, or health care provider for an act or omission in violation of a regulation, rule or order of the Department of Insurance.

Settlement means a final resolution of all the issues in a workers’ compensation claim that are permitted to be resolved.

Subjective means perceivable only by an employee and not independently verifiable or confirmable by recognized laboratory or diagnostic tests or signs observable by physical examination.

Treating Doctor means the doctor who is primarily responsible for the employee’s health care for an injury.

Wages includes all forms of remuneration payable for a given period to an employee for personal services. The term includes the market value of board, lodging, laundry, fuel, and any other advantage that can be estimated in money that the employee receives from the employer as part of the employee’s remuneration.