Texas Labor Codes 415.002 pre 9/1/95

(a) An insurance carrier or its representative commits an administrative violation if that person wilfully or intentionally:

(1) misrepresents a provision of this subtitle to an employee, an employer, a health care provider, or a legal beneficiary;

(2) fails to submit to the commission a settlement or agreement of the parties;

(3) fails to timely notify the commission of the termination or reduction of benefits and the reason for that action;

(4) terminates or reduces benefits without substantiating evidence that the action is reasonable and authorized by law;

(5) instructs an employer not to file a document required to be filed with the commission;

(6) instructs or encourages an employer to violate a claimant's right to medical benefits under this subtitle;

(7) fails to tender promptly full death benefits if a legitimate dispute does not exist as to the liability of the insurance carrier;

(8) 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;

(9) 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;

(10) fails, without good cause, to attend a dispute resolution proceeding within the commission;

(11) attends a dispute resolution proceeding within the commission without complete authority or fails to exercise authority to effectuate agreement or settlement;

(12) adjusts a workers' compensation claim in a manner contrary to license requirements for an insurance adjuster, including the requirements of Chapter 407, Acts of the 63rd Legislature, Regular Session, 1973 (Article 21.07-4, Vernon's Texas Insurance Code), or the rules of the State Board of Insurance;

(13) fails to process claims promptly in a reasonable and prudent manner;

(14) fails to initiate or reinstate benefits when due if a legitimate dispute does not exist as to the liability of the insurance carrier;

(15) misrepresents the reason for not paying benefits or terminating or reducing the payment of benefits;

(16) dates documents to misrepresent the actual date of the initiation of benefits;

(17) 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 commission;

(18) fails or refuses to pay benefits from week to week as and when due directly to the person entitled to the benefits;

(19) fails to pay an order awarding benefits;

(20) controverts a claim if the evidence clearly indicates liability;

(21) unreasonably denies preauthorization required under Section 413.014 or unreasonably disputes the reasonableness and necessity of health care;

(22) violates a commission rule; or

(23) 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)(8) 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 commission and participate at the proceeding in accordance with this subtitle.

Acts 1993, 73rd Leg., ch. 269, section 1, eff. Sept. 1, 1993.