Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 130 - IMPAIRMENT AND SUPPLEMENTAL INCOME BENEFITS › Subchapter B - SUPPLEMENTAL INCOME BENEFITS › Section 130.108 - Contesting Entitlement or Amount of Supplemental Income Benefits; Attorney Fees

Current through Reg. 49, No. 28; July 12, 2024
(a) Injured
				  Employee Disputes. An injured employee may contest the determination by the
				  Division or the insurance carrier regarding non-entitlement to, or the amount
				  of, supplemental income benefits by requesting a benefit review conference as
				  provided by Chapter 141 of this title (relating to Dispute Resolution--Benefit
				  Review Conference).
(b) Insurance
				  Carrier Dispute; First Quarter. If an insurance carrier disputes a Division
				  finding of entitlement to, or amount of, supplemental income benefits for the
				  first quarter, the insurance carrier shall request a benefit review conference
				  as provided by Chapter 141 of this title (relating to Dispute
				  Resolution--Benefit Review Conference) within 10 days after receiving the
				  Division determination of entitlement. An insurance carrier waives the right to
				  contest the Division determination of entitlement to, or amount of,
				  supplemental income benefits for the first quarter if the request is not
				  received by the Division within 10 days after the date the insurance carrier
				  received the determination.
(c)
				  Insurance Carrier Dispute; Subsequent Quarter With Prior Payment. If an
				  insurance carrier disputes entitlement to a subsequent quarter and the
				  insurance carrier has paid supplemental income benefits during the quarter
				  immediately preceding the quarter for which the Application for Supplemental
				  Income Benefits is filed, the insurance carrier shall dispute entitlement to
				  the subsequent quarter by requesting a benefit review conference as provided by
				  Chapter 141 of this title (relating to Dispute Resolution--Benefit Review
				  Conference) within 10 days after receiving the Application for Supplemental
				  Income Benefits. An insurance carrier waives the right to contest the
				  entitlement to supplemental income benefits for the subsequent quarter if the
				  request is not received by the Division within 10 days after the date the
				  insurance carrier received the Application for Supplemental Income Benefits.
				  The insurance carrier does not waive the right to contest entitlement to
				  supplemental income benefits if the insurance carrier has returned the injured
				  employee's Application for Supplemental Income Benefits pursuant to §
										130.104(c)
				  of this title (relating to Determination of Entitlement or Non-entitlement for
				  Subsequent Quarters).
(d) Insurance
				  Carrier Disputes; Subsequent Quarter Without Prior Payment. If an insurance
				  carrier disputes entitlement to a subsequent quarter and the insurance carrier
				  did not pay supplemental income benefits during the quarter immediately
				  preceding the quarter for which the Application for Supplemental Income
				  Benefits is filed, the insurance carrier shall send the determination to the
				  injured employee within 10 days of the date the form was filed with the
				  insurance carrier and include the reasons for the insurance carrier's finding
				  of non-entitlement and instructions about the procedures for contesting the
				  insurance carrier's determination as provided by subsection (a) of this
				  section.
(e) Liability. An
				  insurance carrier who unsuccessfully contests a Division determination of
				  entitlement to supplemental income benefits is liable for:
(1) all accrued, unpaid supplemental income
				  benefits, and interest on that amount; and
(2) reasonable and necessary attorney's fees
				  incurred by the injured employee as a result of the insurance carrier's dispute
				  which have been ordered by the Division or court.