Texas Labor Code - Section 415.002. Administrative Violation By Insurance Carrier
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Texas Laws > Labor Code > Texas Labor Code - Section 415.002. Administrative Violation By Insurance Carrier
§ 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 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.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 1995, 74th Leg., ch. 980, § 1.45, eff. Sept. 1, 1995;
Acts 2005, 79th Leg., ch. 265, § 3.266, eff. Sept. 1, 2005; Acts
2005, 79th Leg., ch. 728, § 11.144, eff. Sept. 1, 2005.
Section: 414.002 414.003 414.004 414.005 414.006 414.007 415.001 415.002 415.003 415.0035 415.004 415.005 415.006 415.007 415.008
Last modified: August 11, 2007
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