June 16, 2018

Texas allows an employer to opt out of the state-run Workers’ Compensation program. Companies who opt out are called Non-Subscribers Employers and any workplace injury occurring falls within the requirements and regulations for a Texas Non-Subscriber Employers Accidents and Claims plan or policy.

The Non-Subscriber employer contracts with a neutral Third Party Administrator to handle their Texas Non-Workers’ Comp insurance claims. A Plan Document is a result of this contract. One of the stipulations listed in the plan document is an agreement that the employer must provide a Summary Plan Description to every employee. Meant to be a condensed interpretation of the plan document, the summary description should contain terms most people can easily understand.

Admittedly, confusion regarding the Summary Plan Description and the Plan Document occurs frequently. Here are some common questions and answers about your benefits and documents.

What is it?

ERISA information explaining employee benefits usually includes the Summary Plan Description, also known as an Occupational Injury Benefit Plan. The summary plan description lists your responsibilities in case of an injury on the job and tells you what benefits the plan provides to take care of as you recover from your injury.

Read More: Workplace Injuries at a Non-Subscriber Employer

The summary plan of the occupational injury benefit plan comes from your employer. Usually, you receive this plan when hired. If you misplaced it, ask your human resources coordinator for another copy and you must receive one. The law requires your employer to provide this to you if you request it.

Occasionally, there may be an insurer who has this information. As most Non-Subscriber Employers are not self-insured, usually there is no traditional insurance company in the background who can provide that information.

Why do I need it?

Without the summary plan description, you will not know what rights and responsibilities you have in case of an injury on the job. No one plans an injury, therefore reading and understanding this information before an injury occurs is very important.

The Plan Document is the legal contract between your employer and the plan administrator. As a legally binding contract, both parties must follow it precisely. The intent is to protect the employee as well as the employer when there is a workplace injury resulting in a Texas Non Subscriber Workers Comp insurance claim.

As the plan document itself is the legal contract between your employer and the company administering your claim, it is not usually part of your employment packet. Regardless, you are entitled to view the plan document and receive a copy of it. Your employer or ERISA plan administrator must respond to your written request for plan documents by providing them within 30 days.

Which one controls my rights?

There “should” be no substantial difference between the plan document and your summary of that plan. Appropriate claims administration requires honesty and transparency from the plan administrator and your employer. Non-Subscriber claims examiners are encouraged to interact often with the injured worker in a non-adversarial role. This is different than the traditional claims adjuster vs the world attitude.

In the event there is any conflict between what is stated in the Summary Plan description, (information provided to the employee), and the Plan document, (information given to the employer), resolution may be in the favor of the Plan document. Nevertheless, any significant difference could be cause for concern and further discussion at the very least.

Does the Arbitration agreement apply to both?

If you signed an arbitration agreement when you received a copy of your Plan, benefits or any time thereafter, the arbitration agreement will apply. Overturning that agreement is highly unlikely.

Nonetheless, an employee does not have to accept the plan agreement. While unlikely to occur with new employees, if a plan begins during your employment it is your choice to sign or reject it.

Where could I find copies of them?

As mentioned above, your human resource department has copies of all insurance related documents and will provide a copy upon your request. It is your right to know and understand your coverage and summary plan description.

Do not hesitate to request copies or ask for clarification on any benefit information from your Non-Subscriber employer. No reputable employer will hesitate to provide you with all the help you need. In the event that you do not receive documentation or help, report it to the ERISA administrator, as this is a federally mandated issue. Your employer or plan administrator has 30 days to comply with your written request, best sent by certified mail, or potentially face penalties of $110.00 for each day delayed in providing you with the requested documents. 29 U.S.C. 1132 (c).

Speak with a work injury attorney that you can trust and one who can understand your needs. There’s no doubt that you will eventually hit a wall or a disagreement with your company’s insurance company so, you would be in a much better position being well represented when that time comes.