28 Tex. Admin. Code § 131.1 - Initiation of Lifetime Income Benefits; Notice of Denial
(a) The insurance
carrier must initiate the payment of lifetime income benefits without a final
decision, order, or other action of the commissioner if an injured employee
meets the eligibility criteria for lifetime income benefits listed under Labor
Code §
408.161 or §
408.1615 as a result of
the compensable injury.
(b) An
injured employee may submit a written request for lifetime income benefits to
the insurance carrier. The insurance carrier must either initiate lifetime
income benefits or deny the injured employee's eligibility for lifetime income
benefits considering all of the eligibility criteria listed under Labor Code §
408.161 or §
408.1615 within 60 days of
receiving the injured employee's written request. An insurance carrier's
failure to respond to the request for lifetime income benefits within the
timeframes described in this subsection does not constitute a waiver of the
insurance carrier's right to dispute the injured employee's eligibility for
lifetime income benefits.
(c) The
insurance carrier must make the first payment of lifetime income benefits on or
before the 15th day after the date the insurance carrier reasonably believes
that the injured employee is eligible for lifetime income benefits as a result
of the compensable injury. The initiation of lifetime income benefits without a
final decision, order, or other action of the commissioner does not waive the
insurance carrier's right to contest the compensability of the injury under
Labor Code §
409.021(c).
(d) If the injured employee submits a written
request for lifetime income benefits, and the insurance carrier denies that the
injured employee is eligible for lifetime income benefits, the insurance
carrier must deny eligibility by sending a plain-language notice of denial of
eligibility to the division, the injured employee, and the injured employee's
representative, if any, in the form and manner prescribed by the division up to
the 60th day after it receives the written request. The notice of denial of
eligibility must include:
(1) a full and
complete statement describing the insurance carrier's reasons for denial. The
statement must contain sufficient claim-specific substantive information to
enable the injured employee to understand the insurance carrier's position or
action taken under the claim. A generic statement that simply states the
insurance carrier's position with phrases such as "not part of compensable
injury," "not meeting criteria," "liability is in question," "under
investigation," "eligibility questioned," or other similar phrases with no
further description of the factual basis for the denial does not satisfy the
requirements of paragraph (1) of this subsection;
(2) contact information, including the
adjuster's name, toll-free telephone and fax numbers, and email address;
and
(3) a statement informing the
injured employee of his or her right to request a benefit review conference to
resolve the dispute.
(e)
An injured employee may contest the insurance carrier's denial of eligibility
for lifetime income benefits or failure to respond to the written request for
lifetime income benefits by requesting dispute resolution as provided by
Chapters 141 - 144 and 147 of this title (relating to Dispute
Resolution).
(f) Nothing in this
section is intended to limit an insurance carrier's duty to initiate payment of
lifetime income benefits before the time limit established in subsection (c) of
this section.
Notes
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