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§ 142.7. Statement of Disputes

(a) Statement of disputes. The statement of disputes is a written description of the benefit dispute or disputes to be considered by the administrative law judge. A dispute not expressly included in the statement of disputes will not be considered by the administrative law judge.

(b) Statement of disputes after a benefit review conference. The statement of disputes for a hearing held after a benefit review conference includes:

(1) the benefit review officer’s report, identifying the disputes remaining unresolved at the close of the benefit review conference;

(2) the parties’ responses, if any;

(3) additional disputes by unanimous consent, as provided by subsection (c) of this section; and

(4) additional disputes presented by a party, as provided by subsections (d) and (e) of this section, if the administrative law judge determines that the party has good cause.

(c) Party response to the benefit review officer’s report. A party may submit a response to the disputes identified as unresolved in the benefit review officer’s report. The response shall:

(1) be in writing;

(2) describe and explain the party’s position on the unresolved dispute or disputes;

(3) be sent to the division no later than 20 days after receiving the benefit review officer’s report; and

(4) be delivered to all other parties, as provided by §142.4 of this title (relating to Delivery of Copies to All Parties).

(d) Additional disputes by unanimous consent. Parties may, by unanimous consent, submit for inclusion in the statement of disputes one or more disputes not identified as unresolved in the benefit review officer’s report. Additional disputes submitted by consent shall:

(1) be made in writing;

(2) identify the dispute and explain the party’s position on it;

(3) be signed by all parties;

(4) be sent to the division no later than 10 days before the hearing; and

(5) explain why the issue was not raised earlier.

(e) Additional disputes by permission of the administrative law judge. A party may request the administrative law judge to include in the statement of disputes one or more disputes not identified as unresolved in the benefit review officer’s report. The administrative law judge will allow such amendment only on a determination of good cause.

(1) If the requester is a carrier, carrier representative, claimant represented by an attorney, or claimant assisted by OIEC, the request shall:

(A) be made in writing;

(B) identify and describe the dispute or disputes;

(C) state the reason for the request;

(D) be sent to the division no later than 15 days before the hearing; and

(E) be delivered to all other parties, as provided by §142.4 of this title (relating to Delivery of Copies to All Parties).

(2) A claimant who is neither represented by an attorney nor assisted by OIEC may request additional disputes to be included in the statement of disputes by contacting the division in any manner no later than 15 days before the hearing.

(3) The administrative law judge will rule on the request, and notify the parties of the ruling.

(f) Statement of disputes without prior benefit review conference. The statement of disputes for a hearing held without a prior benefit review conference includes:

(1) the request for hearing, as described in §142.5(c) of this title (relating to Sequence of Proceedings To Resolve Benefit Disputes); and

(2) the other party’s response, as described in §142.5(e) of this title (relating to Sequence of Proceedings To Resolve Benefit Disputes), if any.

The provisions of this §142.7 adopted to be effective February 12, 1991, 16 TexReg 463; amended to be effective January 7, 2019, 44 TexReg 108.

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At a Glance:

Title:

§ 142.7. Statement of Disputes

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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