Instructions to the insurance carrier:

Notice Regarding First Payment of Lifetime Income Benefits 28 Texas Administrative Code (TAC) §124.2

If the carrier has approved the injured employee’s request for lifetime income benefits (LIBs), follow these instructions:

This notice must be used to report to the injured employee/representative the approval of LIBs.

The insurance carrier must:

• Provide this notice to the injured employee and the injured employee’s representative (if applicable).
• Provide the following information as requested on the notice:
• date lifetime income benefits began to accrue;
• average weekly wage that income benefits are based on;
• accrual anniversary date;
• annual certification period, if applicable; and
• any explanatory comments that are needed.

File the appropriate electronic data interchange (EDI) transaction with DWC.
Do not send this notice to DWC.

Notice Regarding Denial of Lifetime Income Benefits Texas Labor Code Sections 408.161 and 408.1615 and 28 Texas Administrative Code (TAC) §131.1

If the insurance carrier has denied the injured employee’s request for LIBs, follow these instructions:

This notice must be used by an insurance carrier to notify an injured employee/representative and the Texas Department of Insurance, Division of Workers’ Compensation (DWC) of the insurance carrier’s denial of eligibility regarding LIBs. This notice does not constitute a request for a benefit review conference. The insurance carrier must provide a full and complete statement describing the insurance carrier’s reasons for denial. Denials should be based on the information the insurance carrier has obtained or verified. The statement must contain sufficient claim-specific substantive information to enable the injured employee to understand the insurance carrier’s position or action taken on the claim.

If the initial determination is that the entire claim is not compensable, use the PLN-1.

The insurance carrier must:

• Provide this notice to the injured employee, DWC, and the injured employee’s representative (if applicable).
• Provide a full and complete statement describing the factual basis and the reasons for the action taken. A generic statement such as “not part of the compensable injury,” “not meeting criteria,” “liability in question,” “under investigation,” “eligibility questioned,” or similar phrases with no further description of the factual basis for the action taken does not satisfy the requirements of 28 TAC §131.1. Explain the reasons for disputing the issues in plain language without unnecessary use of technical terms, acronyms, and abbreviations.

File the appropriate EDI transaction with DWC and send this notice to DWC.

Format requirements

• Must use font size of 12-point or larger (28 TAC §124.2(s)).

Format recommendations

Information sent to injured employees must be written in plain language. Along with clear writing, it is helpful to the reader when information is in a clean, easy-to-read format. Using easy-to-understand words and clean formatting might increase the length of your letter, but it also might greatly reduce customer service calls. Here are recommendations for formatting letters to injured employees:

• Print only information that applies to the reader: (1) Remove the section “Instructions to the insurance carrier,” and (2) if this letter has more than one option, remove the option that doesn’t apply to the injured employee.
• Choose a clean font style: Avoid highly stylized fonts. Fonts like Segoe, Verdana, and Times New Roman are known to be the easiest to read.
• Avoid italics and underlines: If you want to emphasize text, it’s often better to use bold or a bigger font size.
• Use sufficient and consistent spacing: DWC suggests using 6 pts between paragraphs and bullets and 12 pts between sections.