GQ Corner
Q. The carrier accepted a compensable injury, but the claimant has not lost any time from work. Accordingly, benefits have not accrued. Is the carrier nonetheless required to file a PLN-11 disputing disability given its position that the claimant is not entitled to TIBS?
A. No. Texas Labor Code Section 409.021(a) provides as follows:
(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 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.
However, section 409.021(a-2) clarifies that a carrier is not required to comply with the dictates of subsection (a) if it has “accepted the claim as a compensable injury and income or death benefits have not yet accrued but will be paid when the benefits accrue and become due.” In the circumstances described above, income benefits have not yet accrued or become due, so the carrier does not have liability for indemnity benefits and it is not required to file a PLN-11 disputing disability.
Q. What is the maximum amount for which an insurance carrier may be liable for funeral expenses?
A. This inquiry is governed by Texas Labor Code Section 408.186 and Rule 132.13. Those provisions require that if the death of an employee results from a compensable injury, the carrier is required to pay the lesser of the actual costs incurred for reasonable burial expenses or up to maximum amounts as follows:
• $2,500 for injuries occurring prior to September 1, 1999
• $6,000 for injuries occurring from September 1, 1999 to August 31, 2015
• $10,000 for injuries on or after September 1, 2015
The legislature recently increased the cap to $10,000 with the passage of Senate Bill 653.
Q. The claimant recently filed a DWC-32 to request a designated doctor examination on the issues of MMI and impairment rating. However, the treating doctor previously issued a certification of MMI and impairment rating and more than 90 days have passed from the date on which the claimant received delivery of written notice of the certification by verifiable means. Can the carrier prevent the designated doctor examination from proceeding as requested?
A. Yes. Under these circumstances, it is appropriate to raise an objection to and request a stay of the requested examination along with a request for an expedited Contested Case Hearing (CCH) on the matter pursuant to Rule 127.1. See subsection (f) of that rule:
(f) A party may dispute the division’s approval or denial of a designated doctor request through the dispute resolution processes outlined in Chapters 140 – 144 and 147 of this title (relating to Dispute Resolution processes, proceedings, and procedures). Parties may not dispute a designated doctor examination request or any information on the request until the division has either approved or denied the request. Additionally, a party is entitled to seek an expedited contested case hearing under §140.3 of this title (relating to Expedited Proceedings) to dispute an approved or denied request for a designated doctor examination. The division, upon timely receipt and approval of the request for expedited proceedings, shall stay the disputed examination pending the decision and order of the expedited contested case hearing. Parties seeking expedited proceedings and the stay of an ordered examination must file their request for expedited proceedings with the division within three working days of receiving the order of designated doctor examination under §127.5(a) of this title (relating to Scheduling Designated Doctor Appointments).