NOTICE OF DISPUTED ISSUE(S) AND REFUSAL TO PAY BENEFITS DATE: TO: [NAME OF INJURED EMPLOYEE] [ADDRESS] [CITY, STATE, ZIP] [DATE OF INJURY] [NATURE OF INJURY] [PART OF BODY INJURED] [EMPLOYEE SSN] [CLAIM #] [CARRIER NAME/TPA NAME] [CARRIER CLAIM #] [EMPLOYER NAME] [EMPLOYER ADDRESS] [EMPLOYER CITY, STATE, ZIP] RE: We are disputing (check all that apply): the existence/duration/extent of your disability* the extent of your compensable injury your eligibility to receive death benefits *Disability means your work-related injury prevents you from getting or keeping employment at preinjury wage levels. (***Insurance carrier shall provide a full and complete statement explaining the action taken and the reason(s) for such action.***) _______________________________________________________________________________ _______________________________________________________________________________ If you do not agree with the dispute and refusal to pay benefits, please contact me: Adjuster's Name: Toll Free Telephone #: Fax #: E-mail Address: ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ If we are unable to resolve the issue to your satisfaction, you have the right to request a Benefit Review Conference (BRC) to resolve the dispute. Contact the Texas Department of Insurance, Division of Workers' Compensation (DWC) at 1-800-252-7031 for additional information or to request a BRC. If you would like to receive notices such as this by facsimile or e-mail, please contact me and provide your facsimile number or e-mail address. Please note that making a false or fraudulent workers' compensation claim is a crime that may result in fines and/or imprisonment. CC: DWC FORM PLN-11 (Rev. 06/15) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS Notice of Disputed Issue(s) and Refusal to Pay Benefits (DWC FORM PLN-11) 28 Texas Administrative Code (TAC) §124.2(h) This notice must be used by an insurance carrier to notify a claimant (injured employee/beneficiary) and DWC of the carrier's dispute of an issue or issues (disability, extent of injury, death benefits) dealing with the administration of a claim. This notice does not constitute a request for a Benefit Review Conference. If the initial determination is that the entire claim is not compensable, see DWC Form PLN-01. The insurance carrier must: · check the appropriate box(es) to indicate the issue(s) being disputed; and · provide a full and complete statement describing the factual basis and the reason(s) for the action taken. NOTE: A generic statement such as "employee returned to work," "adjusted for light duty," "liability in question," "compensability in dispute," "under investigation," or similar phrases with no further description of the factual basis for the action taken does not satisfy the requirements of 28 TAC §124.2(h). Take caution to explain the reason(s) for disputing the issue(s) in plain language without unnecessary use of technical terms, acronyms, and/or abbreviations. Disputes should be based on the information the carrier has obtained or verified. PROVIDE A COPY OF THIS NOTICE TO DWC, THE CLAIMANT, AND TO THE CLAIMANT'S REPRESENTATIVE (if applicable). DWC FORM PLN-11 (Rev. 06/15) Page 2 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com