Factors That Affect a Disability Determination
Whether a Texas workers' comp claimant has disability is decided on evidence: medical restrictions, wage records, and the employer's response to both. This page lists the factors that carry the decision.
What the decision is actually weighing
Disability in Texas workers' comp means the compensable injury keeps a worker from earning the pre-injury wage. Every disability determination, whether made by an adjuster reviewing a file or a judge after a hearing, weighs the same two questions: is there an earnings loss, and did the injury cause it? The factors below are the evidence each side brings to those questions. How Disability Is Determined explains who makes the decision; this page covers what the decision turns on.
The medical factors
The work status report, form DWC073, is the single most important document. It is the form on which a doctor states whether the worker can return to work, with what restrictions, for what period. Restrictions on a DWC073 are the medical backbone of a disability claim. A full-duty release on one, even a release buried in emergency-room discharge paperwork the worker barely read, is the most common reason checks never start or suddenly stop. Workers should read every work status report and every discharge document, and should know at all times what the most recent one says.
Beyond the DWC073, the determination weighs:
- Whether the restrictions match the treatment records. Restrictions a doctor cannot tie to examination findings are easy for a carrier to attack.
- Which conditions the restrictions come from. If restrictions rest on a body part or condition the carrier has not accepted, the carrier will argue the wage loss comes from a non-compensable condition. That dispute is covered at Extent-of-Injury Denials: When the Carrier Accepts Only Part of Your Injury.
- Gaps in treatment. A long stretch without medical visits invites the argument that the injury resolved. Why Missing Medical Appointments Hurts Your Claim explains this factor in detail.
The wage factors
Disability is measured against the average weekly wage, called the AWW, so the accuracy of that number is itself a factor. An AWW set too low understates the earnings gap (Average Weekly Wage in Texas Workers' Compensation Claims covers how to check it). From there, the determination weighs actual post-injury earnings: pay stubs, hours worked, and any second job the injury cost the worker. Documented earnings are hard to argue with in either direction, which is why workers should keep every pay record from the injury forward.
The employer factors
What the employer does after receiving the restrictions matters as much as the restrictions themselves.
- Whether light duty was offered, and in what form. A proper written offer meeting the state's requirements, called a bona fide offer of employment, can reduce or end benefits if refused. A vague verbal suggestion does not carry the same weight. When Your Employer Offers Light Duty: The Bona Fide Offer (BFOE) explains the requirements.
- Whether the employer can accommodate the restrictions. A documented "we have no work within those restrictions" supports disability plainly. Employer silence, documented over days, is treated the same way, as covered at When Your Employer Cannot Accommodate Your Work Restrictions.
- Why employment ended. A firing or resignation during the claim invites the carrier to argue the wage loss comes from the separation, not the injury. Those disputes are covered at Termination for Cause and Voluntary Resignation.
The carrier's counter-evidence
Carriers do not rely only on the treating doctor's paperwork. Expect some or all of the following in a contested disability period: an opinion from a required medical exam (RME) doctor, an examination the carrier arranges; a peer review, a records-only opinion from a doctor who never examines the worker; surveillance and social media review, looking for activity inconsistent with the claimed restrictions; and wage or employment records subpoenaed from any post-injury employer. None of these is automatically decisive. Each is a factor a judge weighs against the treating records, and a neutral opinion can be obtained through a designated doctor exam, requested on form DWC032, when the dispute needs breaking.
Finally, the worker's own conduct during the claim is a factor large enough to have its own page: How Your Actions Can Affect a Disability Determination.
Attorney notes regarding income benefits
Income benefits can become one of the most confusing parts of a Texas workers’ compensation claim. Even when the insurance carrier is sending checks, that does not necessarily mean the right benefits are being paid, in the right amount, or for the right length of time.
A few warning signs deserve attention:
- Your checks suddenly stop or decrease: There should be a reason, and that reason may be disputed.
- Your wages look wrong: An incorrect Average Weekly Wage can affect the amount of benefits you receive.
- You return to work for less money: You may still have rights to income benefits in some situations.
- Your impairment rating seems too low: A lower rating can mean fewer weeks of Impairment Income Benefits.
- You receive a denial: Eligibility for SIBs, LIBs, or other income benefits can involve detailed rules that are easy to misunderstand.
- The carrier claims it overpaid you: Do not assume that a demand for repayment is automatically correct.
At Abbott, Clay & Bedoy, we review benefit payments, wage calculations, medical evidence, work status, impairment ratings, and carrier decisions to determine whether our clients are receiving the income benefits Texas law provides.
Workers’ compensation checks can affect your ability to pay the mortgage, buy groceries, and support your family while you recover. Getting the amount wrong matters.
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