28 Tex. Admin. Code § 124.3 - Investigation of an Injury and Notice of Denial or Dispute
(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.
(b) Except as
provided by subsection (c), the insurance carrier waives the right to contest
compensability of or liability for the injury, if it does not contest
compensability on or before the 60th day after the date on which the insurance
carrier receives written notice of the injury.
(c) If the insurance carrier wants to deny
compensability of or liability for the injury after the 60th day after it
received written notice of the injury:
(1)
the insurance carrier must establish that it is basing its denial on evidence
that could not have reasonably been discovered earlier; and
(2) the insurance carrier is liable for and
shall pay all benefits that were payable prior to and after filing the Notice
of Denial until the division has made a finding that the evidence could not
have been reasonably discovered earlier.
(d) If the claim involves the death of an
injured employee, investigations, denials of compensability or liability, and
disputes of the eligibility of a potential beneficiary to receive death
benefits are governed by §
132.17 of this title (concerning
Denial, Dispute, and Payment of Death Benefits). Notwithstanding §
132.17(f)(1) and
(2) of this title, the insurance carrier may
issue a Notice of Continuing Investigation in accordance with the provisions of
§124.2(f) and this section.
(e)
Notwithstanding §
132.13 of this title (concerning
Burial Benefits), if an insurance carrier has issued a Notice of Continuing
Investigation in accordance with the provisions of §124.2(f) and this section,
the insurance carrier shall either pay or deny a claim for burial benefits
within seven days from the date the insurance carrier either initiated benefits
or filed a notice of denial in accordance with §
124.2(f) of this
title.
(f) Labor Code §
409.021 and subsection (a)
of this section do not apply to disputes of extent of injury. If an insurance
carrier receives a medical bill that involves treatment(s) or service(s) that
the insurance carrier believes is not related to the compensable injury, the
insurance carrier shall file a notice of dispute of extent of injury (notice of
dispute). The notice of dispute shall be filed in accordance with §
124.2 of this title and be filed
not later than the earlier of:
(1) the date
the insurance carrier denied the medical bill; or
(2) the due date for the insurance carrier to
pay or deny the medical bill as provided in Chapter 133 of this title
(concerning General Medical Provisions).
(g) If the insurance carrier receives a
written notice of injury for a disease or illness identified by Texas
Government Code, Chapter 607, Subchapter B (relating to Diseases or Illnesses
Suffered by Firefighters, Peace Officers, and Emergency Medical Technicians),
it shall investigate the applicability of the statutory presumption as well as
compensability of the injury, liability for the injury, and the accrual of
benefits.
(1) A claimant is not required to
expressly claim the applicability of a statutory presumption in order for the
statutory presumption to apply.
(2)
A presumption under Government Code, Chapter 607, Subchapter B, is claimed upon
an insurance carrier's receipt of a written notice of injury which identifies:
(A) the injured or deceased employee's
occupation as a firefighter, peace officer, or emergency medical technician,
and
(B) the injured or deceased
employee's disease or illness is a medical condition identified by Subchapter
B.
(3) A determination
that the statutory presumption does not apply does not relieve the insurance
carrier of its continuing obligation to conduct a reasonable investigation
relating to the compensability of the injury, liability for the injury, and
accrual of benefits.
Notes
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