By: Ogden S.B. No. 1696
A BILL TO BE ENTITLED
AN ACT
relating to workers' compensation compensability disputes,
examinations to define the compensable injury and notifications to
health care providers regarding compensability disputes.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 408.0042, Labor Code is amended by
amending Subsection (a) to read as follows:
(a) The division shall require an injured employee to submit
to a single medical examination to define the compensable injury on
request by the insurance carrier or injured employee.
SECTION 2. Section 408.027, Labor Code is amended by adding
Subsection (c-1) to read as follows:
(c-1) An insurance carrier shall notify a health care
provider in writing if the carrier contests the compensability of
the injury for which the provider provides health care services. A
carrier may not deny payment for health care services provided by
the health care provider or preauthorized by the carrier before the
written notification on the grounds that the injury was not
compensable. An explanation of benefits or a notice of
determination under Chapter 4202, Insurance Code, does not
constitute written notice under this subsection. Payment for
medically necessary health care services provided or preauthorized
prior to the written notification of a compensability denial is not
subject to denial, recoupment, or refund from a health care
provider based on compensability. If the insurance carrier
successfully contests compensability, the insurance carrier is
liable for all health care provided prior to the issuance of the
notification required by this subsection, up to a maximum of
$7,000. The commissioner may adopt rules as necessary to implement
the provisions of this subsection.
SECTION 3. Section 409.021, Labor Code, is amended by
amending Subsections (a), (a-1) and (e) and adding Subsection (c-1)
to read as follows to read as follows:
Section 409.021. INITIATION OF BENEFITS; INSURANCE
CARRIER'S REFUSAL; ADMINISTRATIVE VIOLATION. (a) An insurance
carrier shall initiate compensation under this subtitle promptly.
Not later than the 15th day after the date on which an insurance
carrier receives written notice of an injury, the insurance carrier
shall:
(1) begin the payment of income or death benefits as
required by this subtitle; or
(2) notify the division and the employee in writing of
its refusal to pay and advise the employee of:
(A) the right to request a benefit review
conference; and
(B) the means to obtain additional information
from the division.
(a-1) An insurance carrier that fails to comply with
Subsection (a) or Section 408.027, Subsection (c-1) does not waive
the carrier's right to contest the compensability of the injury as
provided by Subsection (c) or (c-1) but commits an administrative
violation subject to Subsection (e).
(a-2) An insurance carrier is not required to comply with
Subsections (a) if the insurance carrier has accepted the claim as a
compensable injury and income or death benefits have not yet
accrued but will be paid by the insurance carrier when the benefits
accrue and are due.
(b) An insurance carrier shall notify the division in
writing of the initiation of income or death benefit payments in the
manner prescribed by commissioner rules.
(c) If an insurance carrier does not contest the
compensability of an injury on or before the 60th day after the date
on which the insurance carrier is notified of the injury, the
insurance carrier waives its right to contest compensability. The
initiation of payments by an insurance carrier does not affect the
right of the insurance carrier to continue to investigate or deny
the compensability of an injury during the 60-day period.
(c-1) Notwithstanding Subsection (c), if the insurance
carrier receives written notice from the injured employee's
treating doctor, which clearly describes the injury or clearly
describes how a new manifestation of the original injury,
additional injury, or additional diagnosis is related to the
compensable injury and the insurance carrier does not contest the
compensability of the injury or diagnosis on or before the 60th day
after the date on which it receives the notice described by this
subsection, the insurance carrier waives its right to contest
compensability of the injury or diagnosis described in the written
notice under this subsection. Submission of a medical bill,
medical documentation, or a request for preauthorization does not
constitute written notice under this subsection. The commissioner
may adopt rules as necessary to implement the provisions of this
subsection. This subsection cannot be construed as limiting:
(1) an injured employee's entitlement to medical
benefits in accordance with Section 408.021;
(2) an insurance carrier's or an injured employee's
ability to request a medical examination by the treating doctor to
define the compensable injury under Section 408.0042; or
(3) an insurance carrier's or an injured employee's
ability to request a designated doctor examination under Section
408.0041.
(d) An insurance carrier may reopen the issue of the
compensability of an injury if there is a finding of evidence that
could not reasonably have been discovered earlier.
(e) An insurance carrier commits a violation if the
insurance carrier does not initiate income or death benefit
payments or file a notice of refusal as required by this section or
Section 408.027 (c-1). A violation under this subsection shall be
assessed in accordance with Chapter 415 of this subtitle[at $500 if
the carrier initiates compensation or files a notice of refusal
within five working days of the date required by Subsection (a),
$1,500 if the carrier initiates compensation or files a notice of
refusal more than five and less than 16 working days of the date
required by Subsection (a), $2,500 if the carrier initiates
compensation or files a notice of refusal more than 15 and less than
31 working days of the date required by Subsection (a), or $5,000 if
the carrier initiates compensation or files a notice of refusal
more than 30 days after the date required by Subsection (a). The
administrative penalties are not cumulative].
SECTION 4. Section 409.022, Labor Code, is amended by
amending Subsections (a) to read as follows to read as follows:
Section 409.022. REFUSAL TO PAY BENEFITS; NOTICE;
ADMINISTRATIVE VIOLATION. (a) An insurance carrier's notice of
refusal to pay benefits under Section 409.021 or Section 408.027
(c-1) must specify the grounds for the refusal.
(b) The grounds for the refusal specified in the notice
constitute the only basis for the insurance carrier's defense on
the issue of compensability in a subsequent proceeding, unless the
defense is based on newly discovered evidence that could not
reasonably have been discovered at an earlier date.
(c) An insurance carrier commits an administrative
violation if the insurance carrier does not have reasonable grounds
for a refusal to pay benefits, as determined by the commissioner.
SECTION 5. Section 410.209, Labor Code is amended to read as
follows:
Section 410.209. REIMBURSEMENT FOR OVERPAYMENT. The
subsequent injury fund shall reimburse an insurance carrier for any
overpayments of benefits made under an interlocutory order or
decision if that order or decision is reversed or modified by final
arbitration, order, or decision of the commissioner or court. The
commissioner shall adopt rules to provide for a periodic
reimbursement schedule, providing for reimbursement at least
annually. Notwithstanding this section, payment of medical
benefits in accordance with Section 408.027 (c-1) of this subtitle
and Section 1305.153 (e), Insurance Code is not reimburseable from
the subsequent injury fund.
SECTION 6. EFFECTIVE DATE. This Act takes effect
September 1, 2009.