Finalized DWC Form PLN-11, Notice of Disputed Issue(s)

Texas Department of Insurance
Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 • Austin, Texas 78744-1645
512-804-4000 telephone • 512-804-4001 fax • www.tdi.texas.gov
Memorandum
To:
Workers’ Compensation System Participants
From: Tracey Beaver, Director of the Office of Workers’ Compensation Counsel
Date:
December 5, 2014
Subject: Finalized DWC Form PLN-11, Notice of Disputed Issue(s) and Refusal to
Pay Benefits
The Division of Workers’ Compensation (DWC) has finalized its revisions to the DWC
Form PLN-11, Notice of Disputed Issue(s) and Refusal to Pay Benefits (PLN-11). The
PLN-11 is a plain language notice sent by the insurance carrier to the injured
employee and DWC to clearly explain that the insurance carrier is disputing the
injured employee’s workers’ compensation claim and to provide the factual basis of
the dispute.
The revisions aim to assist injured employees, as well as DWC, in understanding and
navigating the disputed claim by clarifying whether the insurance carrier is disputing
the extent of injury, disability, and/or the claimant’s eligibility to receive death benefits.
The revised PLN-11 uses checkboxes to clearly list the issues the insurance carrier is
disputing in the claim. There are also minor revisions to clarify the instructions.
An informal draft of the PLN-11 was posted on the Texas Department of Insurance
website on September 9, 2014, with an informal comment period ending on October
1, 2014. Based upon comments, DWC made minor revisions to clarify that an
insurance carrier should check all boxes that apply when disputing a claim.
DWC also clarifies that the PLN-11 must only be used as provided under 28 TAC
§124.2(h), for disputing the extent of injury, disability, and/or the claimant’s eligibility
to receive death benefits. DWC encourages an insurance carrier to utilize other
modes of plain language communication with an injured employee for issues outside
the scope of the PLN-11.
The finalized PLN-11 is available on the Texas Department of Insurance website at
http://www.tdi.texas.gov/forms/form20numeric.html, and is effective June 1, 2015.
Insurance carriers may continue to use the existing PLN-11, available on the Texas
Department of Insurance website at http://www.tdi.texas.gov/forms/form20plain.html,
until the effective date of the revised PLN-11.

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