| (a) The insurance carrier shall initiate the payment
of lifetime income benefits without a final decision, order, or other
action of the commissioner if an injured employee meets the eligibility
criteria for lifetime income benefits listed under Labor Code §408.161
as a result of the compensable injury.
(b) An injured employee may submit a written request
for lifetime income benefits to the insurance carrier. The insurance
carrier shall either initiate lifetime income benefits or deny the
injured employee's eligibility for lifetime income benefits considering
all of the eligibility criteria listed under Labor Code §408.161
within 60 days from the receipt of the injured employee's written
request. An insurance carrier's failure to respond to the request
for lifetime income benefits within the timeframes described in this
subsection does not constitute a waiver of the insurance carrier's
right to dispute the injured employee's eligibility for lifetime income
benefits.
(c) The insurance carrier shall make the first payment
of lifetime income benefits on or before the 15th day after the date
the insurance carrier reasonably believes that the injured employee
is eligible for lifetime income benefits as a result of the compensable
injury. The initiation of lifetime income benefits without a final
decision, order, or other action of the commissioner does not waive
the insurance carrier's right to contest the compensability of the
injury in accordance with Labor Code §409.021(c).
(d) If the injured employee submits a written request
for lifetime income benefits and the insurance carrier denies that
the injured employee is eligible for lifetime income benefits, the
insurance carrier shall deny eligibility by sending a plain language
notice of denial of eligibility to the division, the injured employee,
and the injured employee's representative, if any, in the form and
manner prescribed by the division up to the 60th day after receipt
of the written request. The notice of denial of eligibility shall
include:
(1) a full and complete statement describing the insurance
carrier's reasons for denial. The statement must contain sufficient
claim-specific substantive information to enable the injured employee
to understand the insurance carrier's position or action taken under
the claim. A generic statement that simply states the insurance carrier's
position with phrases such as "not part of compensable injury," "not
meeting criteria," "liability is in question," "under investigation,"
"eligibility questioned," or other similar phrases with no further
description of the factual basis for the denial does not satisfy the
requirements of paragraph (1) of this subsection;
(2) contact information including the adjuster's name,
toll-free telephone and fax numbers, and email address; and
(3) a statement informing the injured employee of his
or her right to request a benefit review conference to resolve the
dispute.
(e) An injured employee may contest the insurance carrier's
denial of eligibility for lifetime income benefits or failure to respond
to the written request for lifetime income benefits by requesting
a benefit review conference as provided by Chapter 141 of this title
(relating to Dispute Resolution--Benefit Review Conference).
(f) Nothing in this section is intended to limit any
insurance carrier's duty to initiate payment of lifetime income benefits
before the time limit established in subsection (c) of this section.
(g) Effective date. This section is effective on June
1, 2015.
|
