Section 131.1 - Initiation of Lifetime Income Benefits; Notice of Denial(a) The insurance carrier must 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 or §408.1615 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 must 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 or §408.1615 within 60 days of receiving 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 must 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 under 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 must 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 it receives the written request. The notice of denial of eligibility must 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 dispute resolution as provided by Chapters 141 - 144 and 147 of this title (relating to Dispute Resolution).(f) Nothing in this section is intended to limit an insurance carrier's duty to initiate payment of lifetime income benefits before the time limit established in subsection (c) of this section.28 Tex. Admin. Code § 131.1
Adopted by Texas Register, Volume 40, Number 09, February 27, 2015, TexReg 930, eff. 6/1/2015; Amended by Texas Register, Volume 49, Number 46, November 15, 2024, TexReg 9326, eff. 11/21/2024