| # |
Date Received |
Question /
Problem |
Date Answered |
Resolution |
06-02 |
01-12-06 |
Section 415.002(a) of the Act states, "An insurance carrier or its representative commits an administrative violation if that person: (21) makes a statement denying ALL future medical care for a compensable injury; or..."
Please define "ALL" medical care.
Does this section allow a carrier to deny medical care for a particular body part or condition without being in violation of this section of the Act?
Example: An injured worker injures his back and arm. The carrier denies additional medical care for the arm only.
Is the denial of additional medical care for the arm only, not the back, considered a denial of ALL medical treatment under this section? |
02-21-06 |
Section 408.021 of the Act provides that an injured employee is entitled to all health care reasonably required by the nature of the injury as and when needed.
Once the carrier has accepted compensability of an injury, the carrier may not prospectively deny ALL future medical care for that injury.
The denial of ALL future medical care for any individual compensable body part or condition or the denial of ALL future medical care for all of the compensable body parts or conditions would not be in compliance with Section 415.002(a) of the Act. |
| 06-04 |
2-14-06 |
What, if any, interest is due after an insurance carrier receives form DWC-3, Employer’s Wage Statement, that indicates a higher TIB rate is owed; therefore, the carrier must adjust the TIB rate?
Rule 128.1(e) requires the carrier to begin payment of benefits based on the new AWW no later than the first payment due at least seven days following the date the carrier receives the new AWW information.
Rule 126.12(a) defines accrued but unpaid income benefits as:
(1) benefits that accrued during a period of dispute over liability or entitlement to benefits; or
(2) benefits that have not been paid by the date the carrier was required to pay them.
Rule 126.12(b) provides that carriers shall include simple interest in all payments for accrued but unpaid income benefits. |
2-22-06 |
Interest is due on the amount of the difference owed from the date benefits were paid at the wrong rate to the date the correct rate is paid.
Interested should be calculated separately for each week from the date a payment was made at the wrong rate to the date payment is made at the correct rate.
The interest rate table to calculate the correct interest rate is on our website:
www.tdi.state.tx.us.
Click on Division of Workers’ Comp home
Click on Public Information
Click on Discount Rates/Interest Rates |
06-04 |
2-14-06 |
**READDRESS***
What, if any, interest is due after an insurance carrier receives form DWC-3, Employer’s Wage Statement, that indicates a higher TIB rate is owed; therefore, the carrier must adjust the TIB rate?
Rule 128.1(e). |
Readdress
11-2-06 |
Rule 126.12 requires carriers to pay simple interest on accrued but unpaid income benefits. Accrued but unpaid income benefits are those that have accrued during a period of dispute over liability or entitlement to benefits or that have not been paid by the date the carrier was required to pay them.
Per Rule 128.1(e) "If a carrier determines or is notified that the employee’s AWW is different than what the carrier had previously determined (either as a result of subsection (c)(2) of this section, receipt of an updated wage statement, or by operation of other adjustments permitted/required under this title), the carrier shall adjust the AWW and begin payment of benefits based upon the adjusted AWW no later than the first payment due at least seven days following the date the carrier receives the new information regarding the AWW."
If a carrier makes a timely payment in accordance with §128.1, no interest would be due. |
| 06-05 |
2-15-06 |
1. Can the AWW for computing TIBs for a school district employee be adjusted to zero during Christmas break and other such breaks (such as spring break) under Rule 128.7(d) if the employee would not have earned wages during the break for dates of injury on or after 12-1-01?
2. Can the AWW for computing IIBs, LIBs or SIBs for a school district employee be adjusted to zero during this type of break? |
2-23-06 |
This answer applies to date of injury on or after 12-1-01
1. Yes, Rule 128.7(d) (3) allows the average weekly wage for TIBs be adjusted to zero for a period a school district employee would not have earned wages and no minimum benefit payment may be required.
2. No, the AWW cannot be reduced to zero for IIBs, LIBS, or SIBs for a school district employee according to Rule 128.7(e). |
| 06-06 |
2-22-06 |
Section 408.027 of the Act provides that a health care provider (HCP) shall “submit” a claim for payment to the insurance carrier not later than the 95th day after the date on which the health care services are provided to the injured employee.
Please define “submit”.
Is the submission date under this section the date the HCP SENDS the medical bill or the date the carrier RECEIVES the bill? |
2-22-06 |
The term “submit” is used in the same manner as the term “sent”.
Rule 102.4(h) provides the following instructions to determine when documents are sent:
(h) Unless the great weight of evidence indicates otherwise, written communications shall be deemed to have been sent on:
(1) the date received, if sent by fax, personal delivery or electronic transmission or,
(2) the date postmarked if sent by mail via United States Postal Service regular mail, or, if the postmark date is unavailable, the later of the signature date on the written communication or the date it was received minus five days. If the date received minus five days is a Sunday or legal holiday, the date deemed sent shall be the next previous day which is not a Sunday or legal holiday. |
| 06-07 |
6-01-06 |
If an injured worker does not have transportation to medical appointments, is the insurance carrier required to provide transportation to the appointments? |
6/15/06 |
No. There is nothing in the law or rules that requires an insurance carrier to provide transportation for medical appointments. The injured employee should arrange for transportation by personal or commercial resources.If the distance traveled to secure medical treatment is greater than 30 miles one-way, the injured employee may request reimbursement for travel expenses from the insurance carrier in accordance with rule 134.110. |
| 06-08 |
6-01-06 |
If a health care provider has a passenger van that is used to pick up patients who do not have transportation to their doctor’s appointment, is there anything in the law or rules that states that the health care provider cannot charge a fee (such as $5) to cover the cost of gas? |
6-15-06 |
Under Section 401.011(19) of the Act, transportation to a doctor appointment is not considered health care. Therefore, a health care provider cannot bill the insurance carrier for transportation to the appointment. If the distance traveled to secure medical treatment is greater than 30 miles one-way, the injured employee may request reimbursement for travel expense from the insurance carrier in accordance with rule 134.110. |
Texas Department of Insurance
