Sec. 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.
‹ Prev All Texas sections Next ›
Lexace provides legal information, not legal advice, and no attorney–client relationship is created. Statute text is provided for general information and may not reflect the most recent amendments; verify against the official state code.