Texas Workers' Compensation

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§ 140.6. Subclaimant Status: Establishment, Rights, and Procedures

(a) Applicability. This section is applicable to a subclaim pursued under Labor Code § 409.009, including a subclaim pursued by a health care insurer.

(b) Party status. A subclaimant as described in § 409.009 is a party to a claim concerning workers’ compensation benefits.

(c) Rights in Relation to the Injured Employee.

(1) A subclaimant may file and pursue a claim for reimbursement of a benefit that has been provided to an injured employee, and is entitled to appropriate dispute resolution in accordance with the Texas Workers’ Compensation Act (Act) and Division of Workers’ Compensation (Division) rules.

(2) A subclaimant may pursue a claim for reimbursement of a benefit that has been provided to an injured employee and participate in the dispute resolution process without the participation of the injured employee if:

(A) there is no prior written agreement between the injured employee and the workers’ compensation insurance carrier or no final decision by the Division on the issue in dispute;

(B) the workers’ compensation insurance carrier has denied the entitlement to benefits under the Act and Division rules;

(C) the injured employee is not pursuing dispute resolution to establish the injured employee’s entitlement to benefits with reasonable diligence; and

(D) the subclaimant has provided the injured employee with written notice of:

(i) subclaimant’s intent to pursue a claim for reimbursement of a benefit;

(ii) warning that a decision rendered may be binding against the injured employee; and

(iii) contact information for the Office of the Injured Employee Counsel.

(3) At a contested case hearing without the participation of the injured employee, the subclaimant must show, in addition to other facts:

(A) subclaimant provided written notice to the injured employee as specified in paragraph (2)(D) of this subsection;

(B) it has contacted the injured employee and the injured employee is not pursuing the dispute with reasonable diligence; or

(C) it has been unable to contact the injured employee through the exercise of reasonable diligence.

(d) Claims for Reimbursement of Medical Benefits.

(1) Subclaimants, other than subclaimants described in § 409.0091, must pursue a claim for reimbursement of medical benefits and participate in medical dispute resolution in the same manner as an injured employee or in the same manner as a health care provider, as appropriate, under Chapters 133 and 134 of this title (relating to General Medical Provisions and Benefits–Guidelines for Medical Services, Charges, and Payments).

(2) A health care insurer subclaimant must submit a reimbursement request in the form/format and manner prescribed by the Division and must contain all the required elements listed on the form.

(3) Workers’ compensation insurance carriers must process reimbursement requests from subclaimants pursuant to Chapters 133 and 134 of this title.

(e) Contested Case Hearing. A subclaimant may pursue a contested case hearing under the provisions of Chapters 140-143 of this title (relating to Dispute Resolution).

The provisions of this § 140.6 adopted to be effective September 23, 2008, 33 TexReg 8002.

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At a Glance:

Title:

§ 140.6. Subclaimant Status: Establishment, Rights, and Procedures

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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