GQ Corner

Q. The claimant filed a DWC-52 application for supplemental income benefits (SIBS) after the filing deadline for the relevant quarter and indeed most of the way through the compensable quarter. Given this timeframe, can I deny entitlement for the entire quarter at issue?

A. Not on this basis alone. An application that is untimely in relation to the filing deadline but still filed during the compensable quarter only relieves the Carrier of liability for the portion of the quarter preceding the date the application was filed. If the claimant establishes entitlement to SIBS on the merits, the carrier retains liability for SIBS beginning on the date the application was filed and lasting through the end of the quarter.

Q. The carrier received notice of a claimed work-related injury just recently, several months after it was reported to have occurred. It appears the claimant timely reported the claimed incident to the employer but the employer failed to timely report the claim to the carrier. Under these circumstances, will the carrier be found to have waived its right to timely contest the compensability of the claimed injury or does it still have 60 days to deny the claim?

A. The carrier still has 60 days to deny the claim if its investigation supports a dispute of compensability, if a liability defense applies, etc. The action or inaction of the employer cannot cause the carrier to waive this right. Specifically, the ability of the carrier to investigate and timely deny a claim is tied to the date it received written notice. The carrier always has 15 days after receiving notice to investigate the claim before it is liable for accrued benefits, and 60 days after receiving notice to deny the claim. See Texas Labor Code Section 409.021; see also Rule 124.3.

Q. The claimant sustained a compensable injury but ultimately returned to full duty work (earning full pre-injury wages) before retiring on a voluntary basis. However, the claimant subsequently underwent surgery for the compensable injury. Should the carrier re-initiate temporary income benefits (TIBS) in light of evidence suggesting that the surgery has caused an inability to work? 

A. Maybe, depending on the specific circumstances. Essentially, this presents a fact question as to whether or not the claimant removed himself from the work force for reasons unrelated to the compensable injury with no intention to return to work thereafter. The Appeals Panel established in APD 021818 that voluntary retirement furnishes evidence that disability has ended with the caveat that retirement is merely a factor to be considered in determining whether the claimant is disabled. In other words, the mere fact of retirement does not automatically preclude a determination of disability after the retirement date. The Appeals Panel clarified in APD 022499 that the claimant may be able to prove that the compensable injury is still a producing cause of an inability to obtain and retain employment at the pre-injury wage after retirement, thereby entitling him to TIBS.