NOTICE REGARDING ELIGIBILITY FOR LIFETIME INCOME 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] We are denying your request for lifetime income benefits (LIBs) because: (***Insurance carrier provide a full and complete statement explaining the action taken and the reason(s) for such action.***) _______________________________________________________________________________ _______________________________________________________________________________ B) Your first payment of workers' compensation benefits for the period of (***first day of period being paid***) is being issued. The benefit payment is called "Lifetime Income Benefits" (LIBs) and is paid weekly. The amount of your LIBs payment is based on 75% of the reported Average Weekly Wage of (***$$$***). Each year on (***accrual anniversary date***) the LIBs weekly benefit amount will increase by 3%. You may request that we make benefit payments by electronic funds transfer directly to your bank account. Also, you may request that we change your LIBs from a weekly payment to a monthly payment. (***Insurance carrier provide explanatory comments, if needed.***) _______________________________________________________________________________ _______________________________________________________________________________ If you do not agree with the denial and refusal to pay benefits in Box A or with the amount of weekly income benefits being paid in Box B, please contact me: Adjuster's Name: Toll Free Telephone #: Fax #: E-mail Address: ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ RE: A) 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 Division of Workers' Compensation (DWC) at 1-800252-7031 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: DIVISION OF WORKERS' COMPENSATION DWC FORM PLN-04 (Rev. 06/15) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS Notice regarding an insurance carrier's denial of the injured employee's request for LIBs and refusal to pay benefits 28 Texas Administrative Code (TAC) �131.1 If Box A is checked, the following instructions apply: This notice must be used by an insurance carrier to notify an injured employee/representative and DWC of the insurance carrier's denial of eligibility regarding LIBs. This notice does not constitute a request for a Benefit Review Conference. If the initial determination is that the entire claim is not compensable, also see DWC Form PLN-01. The insurance carrier must provide a full and complete statement describing the insurance carrier's reasons for denial. 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. NOTE: A generic statement such as "not part of 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 denial does not satisfy the requirements of 28 (TAC) �131.1. Take caution to explain the reasons for disputing the issue in plain language without unnecessary use of technical terms, acronyms, and/or abbreviations. Denials should be based on the information the insurance carrier has obtained or verified. SEND a copy of this notice to DWC, the injured employee, and the injured employee's representative, if any. Notice regarding first payment of LIBs 28 Texas Administrative Code (TAC) �124.2(e)(1) and (f) If Box B is checked, the following instructions apply: This notice must be used to report to the injured employee/representative the payment of LIBs when the payment is the initial payment of indemnity benefits on a claim. Only one notice of initial payment may be sent on a claim but the initial payment benefit type may be TIBs (PLN-02), IIBs (PLN-03), LIBs (PLN-04) or DBs (PLN-05). Provide the following information as requested on the form: � date Lifetime Income Benefits began to accrue; � Average Weekly Wage that income benefits are based on; � accrual anniversary date; and � any explanatory comments that are needed. DO NOT SEND this notice to DWC. DWC FORM PLN-04 (Rev. 06/15) Page 2 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com