Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 124 - INSURANCE CARRIERS: NOTICES, PAYMENTS, AND REPORTING › Subchapter A - INSURANCE CARRIERS: REQUIRED NOTICES AND MODES OF PAYMENT › Section 124.3 - Investigation of an Injury and Notice of Denial or Dispute

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as provided in subsection (b) of
				  this section, upon receipt of written notice of injury as provided in §
										124.1
				  of this title (relating to Notice of Injury) the insurance carrier shall
				  conduct an investigation relating to the compensability of the injury, the
				  insurance carrier's liability for the injury, and the accrual of benefits. If
				  the insurance carrier believes that it is not liable for the injury or that the
				  injury was not compensable, the insurance carrier shall file the notice of
				  denial of a claim (Notice of Denial) in the form and manner required by Labor
				  Code §
										409.022
				  (relating to Refusal to Pay Benefits; Notice; Administrative Violation) and
				  §
										124.2
				  of this title (concerning Insurance Carrier Reporting and Notification
				  Requirements).
(1) If the insurance carrier
				  does not file a Notice of Denial by the 15th day after receipt of the written
				  notice of injury or does not file a Notice of Continuing Investigation as
				  described under Labor Code §
											409.021(a-3)
				  (relating to Initiation of Benefits; Insurance Carrier's Refusal;
				  Administrative Violation), the insurance carrier is liable for any benefits
				  that accrue and shall initiate benefits in accordance with this
				  section.
(2) If the insurance
				  carrier files a Notice of Denial after the 15th day but on or before the 60th
				  day after receipt of written notice of the injury:
(A) The insurance carrier is liable for and
				  shall pay all income benefits that had accrued and were payable prior to the
				  date the insurance carrier filed the Notice of Denial and only then is it
				  permitted to suspend payment of benefits; and
(B) The insurance carrier is liable for and
				  shall pay for all medical services, in accordance with the Act and rules,
				  provided prior to the filing of the Notice of Denial.
(3) The insurance carrier shall not file
				  notice with the division that benefits will be paid as and when they accrue
				  with the division.
(4) An insurance
				  carrier's failure to file a Notice of Denial or a Notice of Continuing
				  Investigation by the 15th day after it receives written notice of an injury
				  constitutes the insurance carrier's acceptance of the claim as a compensable
				  injury, subject to the insurance carrier's ability to contest compensability on
				  or before the 60th day after receipt of written notice of the injury. In the
				  event of such a failure, the insurance carrier is liable for and shall pay all
				  income and medical benefits that have accrued or become payable, subject to the
				  insurance carrier's right to contest compensability on or before the 60th
				  day.
(5) The insurance carrier
				  commits an administrative violation if, not later than the 15th day after it
				  receives written notice of the injury, it does not begin to pay benefits as
				  required, file a Notice of Denial of the compensability of a claim, or file a
				  Notice of Continuing Investigation in the form and manner required by §
											124.2
				  of this title. The division will send periodic notifications to all insurance
				  carriers regarding the amount of penalties owed and the proper way to submit
				  and document the payments.