Texas 2009 - 81st Regular

Texas Senate Bill SB1696 Compare Versions

Only one version of the bill is available at this time.

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1	1	By: Ogden S.B. No. 1696
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to workers' compensation compensability disputes,
7	7	examinations to define the compensable injury and notifications to
8	8	health care providers regarding compensability disputes.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 408.0042, Labor Code is amended by
11	11	amending Subsection (a) to read as follows:
12	12	(a) The division shall require an injured employee to submit
13	13	to a single medical examination to define the compensable injury on
14	14	request by the insurance carrier or injured employee.
15	15	SECTION 2. Section 408.027, Labor Code is amended by adding
16	16	Subsection (c-1) to read as follows:
17	17	(c-1) An insurance carrier shall notify a health care
18	18	provider in writing if the carrier contests the compensability of
19	19	the injury for which the provider provides health care services. A
20	20	carrier may not deny payment for health care services provided by
21	21	the health care provider or preauthorized by the carrier before the
22	22	written notification on the grounds that the injury was not
23	23	compensable. An explanation of benefits or a notice of
24	24	determination under Chapter 4202, Insurance Code, does not
25	25	constitute written notice under this subsection. Payment for
26	26	medically necessary health care services provided or preauthorized
27	27	prior to the written notification of a compensability denial is not
28	28	subject to denial, recoupment, or refund from a health care
29	29	provider based on compensability. If the insurance carrier
30	30	successfully contests compensability, the insurance carrier is
31	31	liable for all health care provided prior to the issuance of the
32	32	notification required by this subsection, up to a maximum of
33	33	$7,000. The commissioner may adopt rules as necessary to implement
34	34	the provisions of this subsection.
35	35	SECTION 3. Section 409.021, Labor Code, is amended by
36	36	amending Subsections (a), (a-1) and (e) and adding Subsection (c-1)
37	37	to read as follows to read as follows:
38	38	Section 409.021. INITIATION OF BENEFITS; INSURANCE
39	39	CARRIER'S REFUSAL; ADMINISTRATIVE VIOLATION. (a) An insurance
40	40	carrier shall initiate compensation under this subtitle promptly.
41	41	Not later than the 15th day after the date on which an insurance
42	42	carrier receives written notice of an injury, the insurance carrier
43	43	shall:
44	44	(1) begin the payment of income or death benefits as
45	45	required by this subtitle; or
46	46	(2) notify the division and the employee in writing of
47	47	its refusal to pay and advise the employee of:
48	48	(A) the right to request a benefit review
49	49	conference; and
50	50	(B) the means to obtain additional information
51	51	from the division.
52	52	(a-1) An insurance carrier that fails to comply with
53	53	Subsection (a) or Section 408.027, Subsection (c-1) does not waive
54	54	the carrier's right to contest the compensability of the injury as
55	55	provided by Subsection (c) or (c-1) but commits an administrative
56	56	violation subject to Subsection (e).
57	57	(a-2) An insurance carrier is not required to comply with
58	58	Subsections (a) if the insurance carrier has accepted the claim as a
59	59	compensable injury and income or death benefits have not yet
60	60	accrued but will be paid by the insurance carrier when the benefits
61	61	accrue and are due.
62	62	(b) An insurance carrier shall notify the division in
63	63	writing of the initiation of income or death benefit payments in the
64	64	manner prescribed by commissioner rules.
65	65	(c) If an insurance carrier does not contest the
66	66	compensability of an injury on or before the 60th day after the date
67	67	on which the insurance carrier is notified of the injury, the
68	68	insurance carrier waives its right to contest compensability. The
69	69	initiation of payments by an insurance carrier does not affect the
70	70	right of the insurance carrier to continue to investigate or deny
71	71	the compensability of an injury during the 60-day period.
72	72	(c-1) Notwithstanding Subsection (c), if the insurance
73	73	carrier receives written notice from the injured employee's
74	74	treating doctor, which clearly describes the injury or clearly
75	75	describes how a new manifestation of the original injury,
76	76	additional injury, or additional diagnosis is related to the
77	77	compensable injury and the insurance carrier does not contest the
78	78	compensability of the injury or diagnosis on or before the 60th day
79	79	after the date on which it receives the notice described by this
80	80	subsection, the insurance carrier waives its right to contest
81	81	compensability of the injury or diagnosis described in the written
82	82	notice under this subsection. Submission of a medical bill,
83	83	medical documentation, or a request for preauthorization does not
84	84	constitute written notice under this subsection. The commissioner
85	85	may adopt rules as necessary to implement the provisions of this
86	86	subsection. This subsection cannot be construed as limiting:
87	87	(1) an injured employee's entitlement to medical
88	88	benefits in accordance with Section 408.021;
89	89	(2) an insurance carrier's or an injured employee's
90	90	ability to request a medical examination by the treating doctor to
91	91	define the compensable injury under Section 408.0042; or
92	92	(3) an insurance carrier's or an injured employee's
93	93	ability to request a designated doctor examination under Section
94	94	408.0041.
95	95	(d) An insurance carrier may reopen the issue of the
96	96	compensability of an injury if there is a finding of evidence that
97	97	could not reasonably have been discovered earlier.
98	98	(e) An insurance carrier commits a violation if the
99	99	insurance carrier does not initiate income or death benefit
100	100	payments or file a notice of refusal as required by this section or
101	101	Section 408.027 (c-1). A violation under this subsection shall be
102	102	assessed in accordance with Chapter 415 of this subtitle[at $500 if
103	103	the carrier initiates compensation or files a notice of refusal
104	104	within five working days of the date required by Subsection (a),
105	105	$1,500 if the carrier initiates compensation or files a notice of
106	106	refusal more than five and less than 16 working days of the date
107	107	required by Subsection (a), $2,500 if the carrier initiates
108	108	compensation or files a notice of refusal more than 15 and less than
109	109	31 working days of the date required by Subsection (a), or $5,000 if
110	110	the carrier initiates compensation or files a notice of refusal
111	111	more than 30 days after the date required by Subsection (a). The
112	112	administrative penalties are not cumulative].
113	113	SECTION 4. Section 409.022, Labor Code, is amended by
114	114	amending Subsections (a) to read as follows to read as follows:
115	115	Section 409.022. REFUSAL TO PAY BENEFITS; NOTICE;
116	116	ADMINISTRATIVE VIOLATION. (a) An insurance carrier's notice of
117	117	refusal to pay benefits under Section 409.021 or Section 408.027
118	118	(c-1) must specify the grounds for the refusal.
119	119	(b) The grounds for the refusal specified in the notice
120	120	constitute the only basis for the insurance carrier's defense on
121	121	the issue of compensability in a subsequent proceeding, unless the
122	122	defense is based on newly discovered evidence that could not
123	123	reasonably have been discovered at an earlier date.
124	124	(c) An insurance carrier commits an administrative
125	125	violation if the insurance carrier does not have reasonable grounds
126	126	for a refusal to pay benefits, as determined by the commissioner.
127	127	SECTION 5. Section 410.209, Labor Code is amended to read as
128	128	follows:
129	129	Section 410.209. REIMBURSEMENT FOR OVERPAYMENT. The
130	130	subsequent injury fund shall reimburse an insurance carrier for any
131	131	overpayments of benefits made under an interlocutory order or
132	132	decision if that order or decision is reversed or modified by final
133	133	arbitration, order, or decision of the commissioner or court. The
134	134	commissioner shall adopt rules to provide for a periodic
135	135	reimbursement schedule, providing for reimbursement at least
136	136	annually. Notwithstanding this section, payment of medical
137	137	benefits in accordance with Section 408.027 (c-1) of this subtitle
138	138	and Section 1305.153 (e), Insurance Code is not reimburseable from
139	139	the subsequent injury fund.
140	140	SECTION 6. EFFECTIVE DATE. This Act takes effect
141	141	September 1, 2009.