Section 131.13 - Suspension and Reinstatement of Lifetime Income Benefits(a) An insurance carrier may suspend the payment of lifetime income benefits to a first responder during and for a period in which: (1) The first responder fails to complete the annual certification as required by §408.1615(e). (2) The first responder, without good cause, fails to attend a designated doctor examination as required by §408.0041(j). (3) The first responder is employed in any capacity. (4) A designated doctor's report indicates that the first responder is no longer entitled to lifetime income benefits as provided in §408.0041(k-1). (b) Before an insurance carrier may suspend lifetime income benefits under this section, the insurance carrier must send a plain-language notice to the first responder that explains the basis for the suspension. (1) Within 20 days of receiving this notice, the first responder must respond to the insurance carrier's notice by: (A) submitting the annual certification to the insurance carrier; (B) notifying the insurance carrier of an examination under § 127.25 of this title (relating to Failure to Attend a Designated Doctor Examination); or (C) requesting dispute resolution under Chapters 140 - 144 and 147 of this title (relating to Dispute Resolution). (2) If the first responder does not respond within 20 days of receiving this notice, the insurance carrier may suspend the first responder's benefits. (c) If an insurance carrier suspends benefits under subsection (a)(1) of this section, the insurance carrier must reinstate benefits effective on the date the insurance carrier receives the first responder's annual certification. The reinstatement of benefits must occur no later than the seventh day following the date the insurance carrier receives the annual certification. (d) If an insurance carrier suspends benefits under subsection (a)(2) of this section (failure to attend a designated doctor examination), the insurance carrier must follow § 127.25 of this title for suspension and reinstatement of the first responder's benefits. (e) If an insurance carrier suspends benefits under subsection (a)(3) of this section (employment in any capacity), the first responder must submit a new request for lifetime income benefits under § 131.1 of this chapter (relating to Initiation of Lifetime Income Benefits; Notice of Denial). (f) If the insurance carrier suspends or reinstates benefits under this section, the insurance carrier must also comply with the electronic notification requirements to DWC in §124.2 and Chapter 124, Subchapter B (relating to Insurance Carrier Claim Electronic Data Interchange Reporting to the Division).28 Tex. Admin. Code § 131.13
Adopted by Texas Register, Volume 49, Number 46, November 15, 2024, TexReg 9326, eff. 11/21/2024