La. Admin. Code tit. 40 § I-6631

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-6631 - Notice of Payment, Modification, Suspension, Termination or Controversion of Compensation or Medical Benefits

EMPLOYER/PAYOR MAIL TO:

1. Employee Social Security No. ______-_____-_______

OFFICE OF WORKERS' COMPENSATION

2. Payor Claim No.: _____________________________

POST OFFICE BOX 94040

3. Date of Injury/Illness _________________________

BATON ROUGE, LA 70804-9040

4. Date of Notice: ______________________________

NOTICE OF PAYMENT, MODIFICATION, SUSPENSION, TERMINATION OR CONTROVERSION

OF COMPENSATION OR MEDICAL BENEFITS

5. Purpose of Form (check one):

Initial Payment ____ Modification ____ Suspension ____ Termination____ Controversion ____

(a) Employee Name:

Address: ______________________________________________

Telephone: ______________________________________________

(b) Employee Representative Name (if known)

Address: ______________________________________________

Telephone: ______________________________________________

Facsimile: ______________________________________________

(c) Employer Name: ______________________________________________

Address: ______________________________________________

______________________________________________

Telephone: ______________________________________________

Facsimile: ______________________________________________

7. Effective Date of Initial Payment, Modification, Suspension, Termination or Controversion:______/______/20_____

8. Description of Injury/Occupational Disease: ______________________________________________________________________________________

9. Average Weekly Wage: $__________________

10. Payment/Modification (check one): Initial Payment ____ Modification____

Indemnity Benefits are to be paid as follows:

A. Permanent Total Disability (PTD)___ Temporary Total Disability (TTD)___ (check one) benefits at the rate of $_____________ per week;

B. Supplemental Earnings Benefits (SEB) paid at the rate of $__________________per ________________ based on a wage earning capacity of $________________________; OR

SEB paid at the rate of $ _______________ per ________________ dependent on wages as reflected in LWC-WC-1020's to be submitted by

employee each month;

C. Reduced PTD___ TTD____ SEB_____ (check one) at the rate of $___________ due to employee's receipt of (check applicable item):

_____ Social Security Benefits at the rate of $______________ per _____________;

_____ Other Workers' Compensation Benefits at the rate of $__________ per _________'

_____ Employer Funded Disability Benefits at the rate of $___________ per __________;

_____ Unemployment Insurance Benefits

_____ Third Party Recovery in the amount of $_______________

_____ 50% reduction of compensation based on Employee's refusal to cooperate with Vocational Rehabilitation

_____ Reduction due to child support order

_____ Other (Describe): _____________________________________________________________________________________________________

D. Permanent Partial Disability (PPD) Benefits of $______________ per week payable for ____________ weeks.

E. Death Benefits have begun in the amount of $ _________ per week, representing ______% of AWW.

Employee Name __________________

Date of injury/illness________________

11. Suspension/Termination

Indemnity and/or Medical Benefits have been suspended/terminated due to:

_____ Employee's refusal to submit to a medical examination;

_____ Employee's refusal to execute a Choice of Physician form;

_____ Fraud

_____ Dispute over Compensability (Describe):

________________________________________________________

|_________________________________________________________

_______________________

_____ Employee's refusal to return the form LWC-WC-1025 or LWC-WC-1020;

_____ Released to return to work full duty;

_____ Employee able to earn 90% of pre-accident average weekly wage; or

____ Other (Describe):

________________________________________________________

|_________________________________________________________

_______________________

12. Controversion

Employee's rights to Indemnity and/or Medical Benefits are disputed and have been denied because Employer/Payor disputes:

_____ Compensable Work Accident;

_____ Compensable Injury;

_____ Employment Relationship;

_____ Causation;

_____ Disability;

_____ Fraud;

_____ Jurisdiction; or

____ Other (Describe):

________________________________________________________

|_________________________________________________________

_______________________

13. Notice Submitted By:______________________

Signature of Preparer:________________________

Printed name:_______________________

Position/Affiliation: ______________________

Telephone: _____________________

Facsimile: _____________________

Address: _________________

________________________________________________________

|_________________________________________________________

14. Please provide the following information:

Payor/Self Insured Employer Name:____________________________________________

Telephone: ___________________________

Facsimile: _______________________________

Address: ___________________________________

NOTICE OF DISAGREEMENT

(to be completed by Employee/Employee Representative)

MAIL TO: Employee Social Security No.: _______-____-________

The preparer for Employer/Payor Payor Claim No. (if known): _______________________________

at the address listed in Section 13 Date of Injury/Illness: _______________________________

of the LWC-WC-1002. Date of Notice of Disagreement:

BASIS OF DISAGREEMENT

1. Average Weekly Wage is incorrect. The correct AWW amount is $______________.

2. The type of workers' compensation indemnity benefits is incorrect. The correct type is PTD/TTD/SEB/PPD (circle one).

3. The amount/rate of workers' compensation indemnity benefits is incorrect. The correct amount is $_________ per __________.

4. The basis for Employer/Payor's suspension/termination/controversion of benefits is incorrect because (describe):

______________________________________________________________________________________________________________________________

5. Other (describe): ________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

6. Notice Submitted By:

Employee Name:__________________________

Telephone _________________________

Address: ____________________________

____________________________

Employee Representative ____________________________

La. Bar Roll No.____________________________

Address:____________________________

____________________________

Telephone: ____________________________

Facsimile:____________________________

Signature ____________________________

Printed name: ____________________________

La. Admin. Code tit. 40, § I-6631

Promulgated by the Department of Labor, Office of Workers' Compensation Administration, LR 25:286 (February 1999), amended by the Workforce Commission, Office of Workers Compensation, LR 40:387 (February 2014).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1310.1.