Tex.
Labor Code 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 (Initiation of Benefits; Insurance Carrier’s Refusal; Administrative Violation) 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.(d)
In this subsection, the terms “custodial officer,” “detention officer,” “emergency medical technician,” “firefighter,” and “peace officer” have the meanings assigned by Section 607.051 (Definitions), Government Code. In addition to the other requirements of this section, if an insurance carrier’s notice of refusal to pay benefits under Section 409.021 (Initiation of Benefits; Insurance Carrier’s Refusal; Administrative Violation) is sent in response to a claim for compensation resulting from a custodial officer’s, a detention officer’s, an emergency medical technician’s, a firefighter’s, or a peace officer’s disability or death for which a presumption is claimed to be applicable under Subchapter B (Definitions), Chapter 607 (Benefits Relating to Certain Diseases and Illnesses), Government Code, the notice must include a statement by the carrier that:(1)
explains why the carrier determined a presumption under that subchapter does not apply to the claim for compensation; and(2)
describes the evidence that the carrier reviewed in making the determination described by Subdivision (1).(d-1)
An insurance carrier has not committed an administrative violation under Section 409.021 (Initiation of Benefits; Insurance Carrier’s Refusal; Administrative Violation) if the carrier has sent notice to the employee as required by Subsection (d) of this section or Section 409.021 (Initiation of Benefits; Insurance Carrier’s Refusal; Administrative Violation)(a-3).
Source:
Section 409.022 — Refusal to Pay Benefits; Notice; Administrative Violation, https://statutes.capitol.texas.gov/Docs/LA/htm/LA.409.htm#409.022 (accessed Jun. 5, 2024).
