TX Lab Code § 415.002 (2021)
2021 Texas Statutes|Labor Code|Title 5 - Workers' Compensation|Subtitle A - Texas Workers' Compensation Act|Chapter 415 - Administrative Violations|Subchapter A. Prohibited Acts|Section 415.002. Administrative Violation by Insurance Carrier

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.|Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.  Amended by Acts 1995, 74th Leg., ch. 980, Sec. 1.45, eff. Sept. 1, 1995.Amended by: Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.266, eff. September 1, 2005.|