Tex.
Labor Code Section 415.002
Administrative Violation by Insurance Carrier
(a)
An insurance carrier or its representative commits an administrative violation if that person:(1)
misrepresents a provision of this subtitle to an employee, an employer, a health care provider, or a legal beneficiary;(2)
terminates or reduces benefits without substantiating evidence that the action is reasonable and authorized by law;(3)
instructs an employer not to file a document required to be filed with the division;(4)
instructs or encourages an employer to violate a claimant’s right to medical benefits under this subtitle;(5)
fails to tender promptly full death benefits if a legitimate dispute does not exist as to the liability of the insurance carrier;(6)
allows an employer, other than a self-insured employer, to dictate the methods by which and the terms on which a claim is handled and settled;(7)
fails to confirm medical benefits coverage to a person or facility providing medical treatment to a claimant if a legitimate dispute does not exist as to the liability of the insurance carrier;(8)
fails, without good cause, to attend a dispute resolution proceeding within the division;(9)
attends a dispute resolution proceeding within the division without complete authority or fails to exercise authority to effectuate agreement or settlement;(10)
adjusts a workers’ compensation claim in a manner contrary to license requirements for an insurance adjuster, including the requirements of Chapter 4101 (Insurance Adjusters), Insurance Code, or the rules of the commissioner of insurance;(11)
fails to process claims promptly in a reasonable and prudent manner;(12)
fails to initiate or reinstate benefits when due if a legitimate dispute does not exist as to the liability of the insurance carrier;(13)
misrepresents the reason for not paying benefits or terminating or reducing the payment of benefits;(14)
dates documents to misrepresent the actual date of the initiation of benefits;(15)
makes a notation on a draft or other instrument indicating that the draft or instrument represents a final settlement of a claim if the claim is still open and pending before the division;(16)
fails or refuses to pay benefits from week to week as and when due directly to the person entitled to the benefits;(17)
fails to pay an order awarding benefits;(18)
controverts a claim if the evidence clearly indicates liability;(19)
unreasonably disputes the reasonableness and necessity of health care;(20)
violates a commissioner rule;(21)
makes a statement denying all future medical care for a compensable injury; or(22)
fails to comply with a provision of this subtitle.(b)
An insurance carrier or its representative does not commit an administrative violation under Subsection (a)(6) by allowing an employer to:(1)
freely discuss a claim;(2)
assist in the investigation and evaluation of a claim; or(3)
attend a proceeding of the division and participate at the proceeding in accordance with this subtitle.
Source:
Section 415.002 — Administrative Violation by Insurance Carrier, https://statutes.capitol.texas.gov/Docs/LA/htm/LA.415.htm#415.002 (accessed Apr. 20, 2024).
