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Notice Of Disputed Issues And Refusal To Pay Beneifts PLN-11 - Texas
| Notice Of Disputed Issues And Refusal To Pay Beneifts Form. This is a Texas form and can be used in Plain Language Notices Workers Compensation . |
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NOTICE OF DISPUTED ISSUE(s) AND REFUSAL TO PAY BENEFITS DATE: TO: [NAME OF INJURED EMPLOYEE] [ADDRESS] [CITY, STATE, ZIP] RE: [DATE OF INJURY] [NATURE OF INJURY] [PART OF BODY INJURED] [EMPLOYEE SSN] [TWCC #] [CARRIER NAME/TPA NAME] [CARRIER CLAIM #] [EMPLOYER NAME] [EMPLOYER ADDRESS] [EMPLOYER CITY, STATE, ZIP] We are disputing entitlement of (***type of benefit/service/bod ypart/condition***) because: (***Provide full and complete statement explaining the action taken_________________ ________________________________________________________________________ ____________________________________________________________________***) If you do not agree with the dispute and rfuse al to pay benefits, please contact me: Adjusters Name: _____________________________________________ Toll Free Telephone #: _____________________________________________ Fax #/E-mail Address: _____________________________________________ If we are unable to resolve the issue to your satisfaction, you have the right to file a dispute with the Texas Workers Compensation Commission and request a Benefit Review Conference. For assistance or to request a Benefit Review Conference, contact the Commission office handling your claim at 1-800-252-7031. If you would like to receive notices such as this by facsimor electronic ile transmission such as 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: American LegalNet, Inc. www.USCourtForms.comTWCC PLN-11 (Rev. 1/05) Page 1 *N11P1-0105* TEXAS WORKERS COMPENSATION COMMISSION <<<<<<<<<********>>>>>>>>>>>>> 2 INSTRUCTIONS: Notification of Disputed Issue(s) and Refusal to Pay Benefits (Form PLN11) Rule 124. 2(h) This letter will be used to notify the employee and the Commission of the carriers dispute of an issue dealing with the administration of a claim (disability, extent of injury, etc). This letter does not constitute a request for a Benefit Review Conference. This letter should be used iden to tify the existence of a benefit disputed issue to include, but not limited to, disability, extent of injury, or the eligibility to Death Bene ofifts a beneficiary or potential beneficiary and should be idperodv to the employee/beneficiary/representative. If the initial determination is that the entire claim is not compensable, see PLN 1. Provide a full and complete statement of te facts shurrounding the claim that justify and serve as the grounds for the disput e. EXAMPLES: Your entitlement (***medical treatment for the neck, shoulder and arm***) is being disputed and benefits are not being paid for the following reason(s): We have received notice of an injury to additional body parts. dWeispute the additional body parts of neck, shoulder and arm as not related to the compensable injury sustained 5/1/02. The employee has not previously mentioned these body parts as part of the injury and there is no medical evidence to support a causal relationship to the compensable injury. NOTE: A statement that simply states a conclusion such as dability inis question, carrier disputes extent or under investigation is insufficient grounds fothr e information required per Rule 124.2(h). Disputes should be based upon information a carrier has obtained or verified. MAIL THIS LETTER TO THE TEXAS WORKERS COMPENSATION COMMISSION IN LIEU OF A TWCC 21 American LegalNet, Inc. www.USCourtForms.comTWCC PLN-11 (Rev. 1/05) Page 2 *N11P2-0105* TEXAS WORKERS COMPENSATION COMMISSION
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