28 Tex. Admin. Code § 132.17 - Denial, Dispute, and Payment of Death Benefits

(a) Upon being notified of a death resulting from an injury, the insurance carrier (carrier) shall: investigate whether the death was a result of the injury and, if the carrier has not already done so in compliance with § 124.3 of this title (relating to Investigation of an Injury and Notice of Denial/Dispute) due to the injury being reported separately, conduct an investigation relating to the compensability of the death, the carrier's liability for the death, and the accrual of benefits. The carrier shall have 60 days from notification of the death or from written notice of the injury that resulted in the death (whichever is greater) to conduct its investigation.

(b) If the carrier believes that it is not liable for the death or that the death was not compensable, the carrier shall file the notice of denial of a claim (notice of denial) in the form and manner required by § 124.2 of this title (relating to Carrier Reporting and Notification Requirements). If the notice of denial is not filed by the 60th day as required, the carrier may not raise an issue of compensability or liability and is liable for any benefits that accrued and shall initiate benefits in accordance with this section.

(c) A carrier that is made aware of a death under subsection (a) of this section shall attempt to identify all potential beneficiaries, other than the subsequent injury fund (SIF), and the carrier shall maintain documentation relating to its attempt to identify potential beneficiaries.

(d) A carrier that identifies or becomes aware of a potential beneficiary shall notify the potential beneficiary of potential entitlement to benefits, using a plain language notice containing language and content prescribed by the Commission. This notice shall be sent within seven days of the date the carrier identified or was otherwise made aware of the identity and means of contacting the potential beneficiary.

(e) If the carrier receives a claim for death benefits in accordance with § 122.100 of this title (relating to Claim for Death Benefits), the carrier shall review the evidence provided by the beneficiary to determine whether the person is entitled to death benefits as provided in §132.2 through § 132.6 of this title (relating to Determination of Facts of Dependent Status; Eligibility of Spouse to Receive Death Benefits; Eligibility of a Child to Receive Death Benefits; Eligibility of a Grandchild to Receive Death Benefits; Eligibility of Other Surviving Dependents to Receive Death Benefits).

(f) If the carrier believes the claimant is eligible to receive death benefits, the carrier shall begin payment of death benefits. If the carrier believes that the claimant is not eligible to receive death benefits, the carrier shall file the notice of dispute of eligibility (notice of dispute) in the form and manner required by § 124.2 of this title (relating to Carrier Reporting and Notification Requirements).

(1) The carrier shall either begin the payment of death benefits or file the notice of dispute not later than the 15th day after the latest of:

(A) receiving the claim for death benefits;

(B) final adjudication of the carrier's denial of compensability or liability under §124.2 and subsection (b) of this section; or

(C) the expiration of the carrier's right to deny compensability/liability under subsection (a) of this section.

(2) If the notice of dispute is not filed within 15 days as required, the carrier is liable for and shall pay all benefits that had accrued and were payable prior to the date the carrier files the notice of dispute and only then is the carrier permitted to suspend payment of benefits.

(g) If the carrier has filed a notice of denial prior to receipt of a claim for death benefits, the carrier shall provide a copy of the previously filed notice of denial to the claimant within seven days of receipt of the claim for death benefits.

(h) The 15-day timeframe provided for in subsection (f) of this section applies only to claims for benefits based on compensable injuries that occurred on or after September 1, 2003. For claims based on compensable injuries that occurred prior to September 1, 2003, the applicable timeframe in subsection (f) of this section is seven days.

Notes

28 Tex. Admin. Code § 132.17

The provisions of this §132.17 adopted to be effective March 13, 2000, 25 TexReg 2106; amended to be effective March 14, 2004, 29 TexReg 2345