Presented by: The Law Office of Ricky D. Green 9600 Escarpment Blvd, Ste 745-52 Austin, Texas 78749 512 280-0055 Phone 8

1. Presented by: The Law Office of Ricky D. Green 9600 Escarpment Blvd, Ste 745-52 Austin, Texas 78749 (512) 280-0055 Phone (866) 853-9407 Toll Free (512) 280-0071Fax www.rickydgreen.com

2. WHAT FORM DO YOU FILE? In order to dispute a claim based on compensability and/or extent of the injury, the claims adjuster must file a PLN-1 and/or a PLN-11. The PLN-1 and PLN-11 defines and shapes the basis for your dispute and gives notice to system participants why you disputed the claim.

3. WHAT ARE THE LAWS?

4. Texas Labor Code �409.022 An insurance carrier's notice of refusal to pay benefits under Section 409.021 must specify the grounds for the refusal. The grounds for the refusal specified in the notice constitutes the only basis for the insurance carrier's defense on the issue of compensability in a subsequent proceeding, unless the defense is based on newly discovered evidence that could not have been reasonably discovered at an earlier date.

5. DWC Rules Rule 124.2(d) The carrier shall notify the Commission and the claimant of a denial of a claim (Denial) based on non-compensability or lack of coverage� Rule 124.2(h) Notification to the Commission and the claimant of a dispute of disability, extent of injury, or eligibility of a claimant to receive death benefits requires the carrier to use plain language notices with language and content prescribed by the Commission. Notices shall provide a full and complete statement describing the carrier's action and its reason(s) for such action. The statement must contain sufficient claim-specific substantive information to enable the employee/legal beneficiary to understand the carrier's position or action taken on the claim. A generic statement that simply states the carrier's position with phrases such as "no medical evidence to support disability," "not part of compensable injury," "liability is in question," "under investigation," "eligibility questioned" or other similar phrases does not satisfy the requirements of this section.

6. DWC Rules DWC Rule 124.3(a) Except as provided in subsection (b), upon receipt of written notice of injury, the carrier shall conduct an investigation relating to the compensability of the injury, the carrier's liability for the injury, and the accrual of benefits. DWC Rule 124.3(e) Texas Labor Code, �409.021 and subsection (a) of this section do not apply to disputes of extent of injury.

7. Failure to Investigate Bad faith lawsuits Waiver Administrative violations Increased costs/added reserves

8. Bad Faith Cases Snyder v. Christus Health Gulf Coast d/b/a Christus St. Joseph Hospital, No. 2004-53229, in the 215th Judicial District Court in Harris County, Texas. $4,218,799 (plus $114,000 in attorney fees contingent upon appeal) jury verdict awarded on October 26, 2006. Ruttiger v. Texas Mut. Ins. Co., No. 05-CV-0796, in the 122nd Judicial District Court, Galveston County, Texas. $385,000 jury verdict awarded. Affirmed by the Houston Court of Appeals, 1st District, on January 17, 2008.

9. Can Public Entities Be Sued for Bad Faith? No. Public entities have governmental immunity under the Texas Tort Claims Act, Texas Civil Practice & Remedies Code Chapter 101.

10. How To Investigate Employer Contact Claimant Contact Health Care Provider Contact Other Investigative Techniques

11. Roadmap to Perfecting the Denial Receive notice of injury Deadline claim Investigate claim (talk with the employer, the claimant, and doctors) Send out the HIPAA release for medical records, follow up on witnesses Review all medicals to determine if mechanism of injury is correct, look for pre-existing injuries, determine the extent of the injury for filing of the PLN-11 Timely dispute the claim by PLN-1 and/or PLN-11 (file your PLN-11 toward the end of the 60-day waiver period) Base your denials on medical opinions, witness statements, employer insight, to avoid possible breach of good faith and fair dealing Document your file