| (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.
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| Source Note: The provisions of this §124.3 adopted to be effective March 13, 2000, 25 TexReg 2096; amended to be effective March 14, 2004, 29 TexReg 2322; amended to be effective January 12, 2020, 45 TexReg 348 |
