28 Tex. Admin. Code § 102.4 - General Rules for Non-Division Communications
(a) All written communications to a claimant
(who is either an employee, an employee's legal beneficiary, or a subclaimant)
must be sent to the most recent address or fax number supplied by the claimant.
If an address has not been supplied by the claimant, the most recent address
provided by the employer must be used.
(b) After an insurance carrier, employer, or
health care provider is notified in writing that a claimant is represented by
an attorney or other representative, copies of all written communications
related to the claim or to the claimant must be mailed or delivered to the
representative as well as the claimant, unless the claimant requests delivery
to the representative only.
(c)
Insurance carriers must provide a toll-free telephone number for receipt of
communication from claimants or their representatives with a sufficient
quantity of lines to service their volume of business.
(d) Insurance carriers and health care
providers must provide telephone numbers, fax numbers, and email addresses
sufficient to service the volume of business for receiving required verbal and
written communications on workers' compensation claims.
(e) Insurance carriers must ensure effective
and timely communication with claimants and other parties in the system. If a
claimant is unable to communicate with an insurance carrier due to a language
barrier, and the claimant is unable to provide a person that he or she trusts
to serve as a translator, the insurance carrier must provide a means to
translate except as needed for a division proceeding. The claimant must not be
required to contract with or otherwise employ a translator.
(f) When a claimant contacts an insurance
carrier and requests a response on their claim, the response must be verbally
provided or sent in writing by the insurance carrier within five working days
of receiving the request, unless the request is redundant or the response
duplicates information previously provided.
(g) Insurance carriers must employ or provide
a sufficient number of personnel, including adjusters appropriately licensed by
the Texas Department of Insurance, to meet their obligations under the Act and
this title.
(h) Unless the great
weight of evidence indicates otherwise, written communications will be deemed
to have been sent on:
(1) the date received if
sent by fax, personal delivery, or electronic transmission; or
(2) the date postmarked if sent by mail
through United States Postal Service regular mail, or, if the postmark date is
unavailable, the later of the signature date on the written communication or
the date it was received minus five days. If the date received minus five days
is a Sunday or legal holiday, the date deemed sent must be the next previous
day that is not a Sunday or legal holiday.
(i) An insurance carrier must maintain
adjuster's notes on activities and verbal communications involved with the
administration of a claim, with the exception of privileged attorney-client
communications. The adjuster's notes must, at a minimum, include the date of
the activity or communication, the identity of the insurance carrier staff
involved in the contact, the person contacted by or contacting the insurance
carrier, and a summary of the activity or communication.
(j) An insurance carrier, employer, or health
care provider that receives a written communication related to a workers'
compensation claim must date stamp or otherwise note on the document the date
the written communication was received.
(k) Written communications include all
records, reports, notices, filings, submissions, and other information
contained either on paper or in an electronic format.
(l) For purposes of this title, if a written
communication is required to be filed with both the division and another person
by the Act or division rules, the other person will be presumed to have
received the written communication on the date the division received its copy,
unless the other person noted the date of receipt as provided in subsection (j)
of this section, or the means of delivery of the communication was different.
In this situation, the other person has the burden of proving that they did not
receive or timely receive the written communication.
(m) Electronic transmission is defined as
transmission of information by fax, electronic mail, electronic data
interchange (EDI), or any other similar method and does not include telephonic
communication.
(n) If the division
receives an allegation that an insurance carrier or health care provider has
failed to provide sufficient toll-free telephone numbers, telephone numbers,
fax numbers, or email addresses, or that an insurance carrier has not provided
a sufficient number of adjusters as required by this section, unless the
violation appears to be willful or intentional, the division will not issue a
monetary penalty or other sanctions before:
(1) notifying the alleged violator of the
allegation;
(2) affording the
alleged violator the opportunity to either disprove the allegation or provide
mitigating information; and
(3) if
the violator is unable to disprove the allegation, issuing a written warning to
the violator allowing a reasonable grace period of not less than 30 days to
correct the noncompliance. The grace period may be less than 30 days if the
noncompliance prevents the violator from fulfilling other obligations under
this title.
(o) A
violation as described in subsection (n) will be considered willful or
intentional if the violator has been advised of complaints such that the
violator knew or should have known that the toll-free telephone numbers,
telephone numbers, fax numbers, email addresses, or number of adjusters was
insufficient, and the violator cannot establish that it made good faith efforts
to correct the deficiency or if the violator otherwise exhibited willful or
intentional conduct.
(p) For
purposes of determining the date of receipt for non-division written
communications, unless the great weight of evidence indicates otherwise, the
division will deem the received date to be five days after the date mailed
through United States Postal Service regular mail, or the date faxed or
electronically transmitted.
(q)
This section is effective on adoption.
Notes
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