Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 116 - GENERAL PROVISIONS-SUBSEQUENT INJURY FUND › Section 116.11 - Request for Reimbursement from the Subsequent Injury Fund

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurance carrier may request:
(1) reimbursement from the Subsequent Injury
				Fund (SIF) under Labor Code §
										403.006(b)(2)
				for an overpayment of income, death, or medical benefits when the insurance
				carrier has made an unrecoupable overpayment pursuant to the decision of an
				administrative law judge, the Appeals Panel, or an interlocutory order, and
				that decision or order is reversed or modified by final arbitration, order, or
				decision of the commissioner, State Office of Administrative Hearings, or a
				court of last resort;
(2)
				reimbursement from the SIF under Labor Code §
										403.007(d)
				for death benefits paid to the SIF before a legal beneficiary was determined to
				be entitled to receive death benefits;
(3) for a compensable injury that occurs on
				or after July 1, 2002, reimbursement from the SIF for the amount of income
				benefits paid to an injured employee based on multiple employment and paid
				under Labor Code §
										408.042;
(4) for a compensable injury that occurs on
				or after September 1, 2007, reimbursement from the SIF for the amount of
				income, death benefits, or a combination paid to an injured employee or a legal
				beneficiary based on multiple employment and paid under Labor Code §
										408.042;
(5) reimbursement from the SIF, under Labor
				Code §
										408.0041(f) and
				(f-1), for an overpayment of benefits made by
				the insurance carrier based on the opinion of the designated doctor if that
				opinion is reversed or modified by a final arbitration award or a final order
				or decision of the commissioner or a court; or
(6) reimbursement from the SIF made in
				accordance with rules adopted by the commissioner under Labor Code §
										413.0141. For purposes of
				this subsection only, an injury is determined not to be compensable following:
(A) The final decision of the commissioner or
				the judgment of the court of last resort; or
(B) A claimant's failure to respond within
				one year of a timely dispute of compensability filed by an insurance carrier.
				In this instance only, the effective date of the determination of
				noncompensability is one year from the date the insurance carrier filed the
				dispute with the division.
(i) A
				determination under this paragraph does not constitute final adjudication. It
				does not preclude a party from pursuing their claim through the division's
				dispute resolution process, and it does not permit a health care provider to
				pursue a private claim against the claimant.
(ii) If the claim is later determined to be
				compensable, the insurance carrier must reimburse the SIF for any initial
				pharmaceutical payment that the SIF previously reimbursed to the insurance
				carrier. The insurance carrier's reimbursement of the SIF must be paid within
				the timeframe the insurance carrier has to comply with the agreement, decision
				and order, or other judgment that found the claim to be compensable.