GQ Corner
Q: I have an injury date of October 13, 2014. Claimant refused medical treatment and employer was not aware of any treatment until December of 2014. Carrier received notice of the claim on December 5, 2014 and disputed the claim on December 12, 2014. A network provider has submitted a bill for date of service November 6, 2014 in the amount of $22,000. Do we pay $7,000 since it is a network claim or nothing?
A: Under Section 1305.153(e), on a network claim a Carrier that successfully disputes compensability remains liable to a network provider for up to $7,000 for services rendered prior to the PLN 1 being filed and notice to that provider of the dispute.
Q: I have a question on subsequent injury fund recovery. Claimant was assigned a 6% IR from the treating doctor, but a DD was already requested. The DD gave her a 1% so we have an overpayment. Is that something that SIF refunds or is it only if we had an order to pay?
A: Unfortunately, this is not an overpayment the SIF will reimburse. The overpayment of benefits was not made under an order or decision that was subsequently reversed or modified by adjudication or judicial order, nor was payment made pursuant to a designated doctor’s opinion that was later overturned by decision and order. Rule 116.11 outlines the categories for which reimbursement is possible. Those categories include:
(1) reimbursement from the Subsequent Injury Fund (SIF), pursuant to Labor Code §403.006(b)(2), for an overpayment of income, death, or medical benefits when the insurance carrier has made an unrecoupable overpayment pursuant to decision of a Hearing Officer or the Appeals Panel or an interlocutory order, and that decision or order is reversed or modified by final arbitration, order, or decision of the commissioner, State Office of Administrative Hearings, or a court of last resort;
(2) reimbursement from the SIF pursuant to Labor Code §403.007(d) for death benefits paid to the SIF before a legal beneficiary was determined to be entitled to receive death benefits;
(3) for a compensable injury that occurs on or after July 1, 2002, reimbursement from the SIF for the amount of income benefits paid to an injured employee attributable to multiple employment and paid pursuant to Labor Code §408.042;
(4) for a compensable injury that occurs on or after September 1, 2007, reimbursement from the SIF for the amount of income, death benefits, or a combination paid to an injured employee or a legal beneficiary attributable to multiple employment and paid pursuant to Labor Code §408.042;
(5) reimbursement from the SIF, pursuant to Labor Code §408.0041(f) and (f-1), for an overpayment of benefits made by the insurance carrier based on the opinion of the designated doctor if that opinion is reversed or modified by a final arbitration award or a final order or decision of the commissioner or a court; or
(6) reimbursement from the SIF made in accordance with rules adopted by the commissioner pursuant to Labor Code §413.0141
Q: I am paying death benefits on a claim. The decedent has one son that is receiving death benefits because he was enrolled in college. He took last semester off. I have attempted to reach him several times by phone and by email for a copy of this semester’s class schedule, and he has yet to provide me a copy. I contacted the college, but they will not release any information without a signed authorization form from the son. The beneficiary has emailed me a few times stating he would send his schedule, but has yet to send it.
Please advise if there is anything else I need to do or if I’m okay to terminate his death benefits..
A: Rule 132.8(c) states that “the insurance carrier may request proof that a child eligible for benefits is enrolled as a full-time student in an accredited educational institution; the child shall furnish such proof within 20 days of receiving such request.”
Unfortunately, the only manner of enforcement is per 132.8(g), which says “a person who knowingly or intentionally continues to receive benefits as an eligible child or on behalf of an eligible child when the person is no longer entitled to receive them, or who knowingly fails to disclose the facts of ineligibility to the carrier or the commission, may be assessed administrative penalties under the Texas Workers’ Compensation Act, §10.04.”
As a result, you can refer him to DWC for this failure to respond. You can’t, however, cut off his death benefits without affirmative evidence that his has ceased to be enrolled for two consecutive semesters. You should request dispute resolution on this issue by filing DWC-45 requesting a conference to review the child continuing entitlement to death benefits. There is a good chance that these two action will prompt the child to provide the information you need. If that information does show that he did not enroll for the second semester, you may then suspend death benefits to the child and redistribute benefits as required.
FOLIO
