Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 131 - BENEFITS-LIFETIME INCOME BENEFITS › Section 131.1 - Initiation of Lifetime Income Benefits; Notice of Denial

Current through Reg. 49, No. 28; July 12, 2024
(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.