Texas Workers' Compensation

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§ 131.1. Initiation of Lifetime Income Benefits; Notice of Denial

(a) The insurance carrier shall 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 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 shall 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 within 60 days from the receipt of 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 shall 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 in accordance with 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 shall 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 receipt of the written request. The notice of denial of eligibility shall 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 a benefit review conference as provided by Chapter 141 of this title (relating to Dispute Resolution–Benefit Review Conference).

(f) Nothing in this section is intended to limit any insurance carrier’s duty to initiate payment of lifetime income benefits before the time limit established in subsection (c) of this section.

(g) Effective date. This section is effective on June 1, 2015.

The provisions of this §131.1 adopted to be effective June 1, 2015, 40 TexReg 929.

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At a Glance:

Title:

§ 131.1. Initiation of Lifetime Income Benefits; Notice of Denial

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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