reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 150 - REPRESENTATION OF PARTIES BEFORE THE AGENCY - QUALIFICATIONS FOR REPRESENTATIVES › Section 150.2 - Qualification and Authorization of Attorney To Practice before the Commission

Current through Reg. 49, No. 28; July 12, 2024
(a) An attorney who represents any party
				before the commission shall be licensed to practice law by the State Bar of
				Texas in order to receive an attorney's fee.
(b) An attorney who represents a claimant for
				benefits shall notify the commission in writing within 10 days of undertaking
				the representation of the party. The written notice shall identify the attorney
				and the claimant and the injured employee (if different from the
				claimant).
(c) An attorney may be
				disqualified, after a hearing under the Texas Workers' Compensation Act (the
				Act), §10.33, from representing any party before the commission for the
				following activities:
(1) knowingly charging
				a claimant a fee in excess of that allowed by the commission;
(2) knowingly assisting any person in making
				a false or misleading statement, misrepresenting or concealing a material fact,
				and/or fabricating, altering, concealing, or destroying a document, in order to
				claim benefits;
(3) knowingly
				assisting any person in making a false or misleading statement, misrepresenting
				or concealing a material fact, and/or fabricating, altering, concealing, or
				destroying a document, in order to defeat a claim for benefits;
(4) for engaging in conduct described in the
				Act, §10.07(a)(1)-(10) or (b)(1)-(23), whether or not an administrative
				violation is assessed; or
(5) being
				suspended or disbarred by the State Bar of Texas.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 150 - REPRESENTATION OF PARTIES BEFORE THE AGENCY - QUALIFICATIONS FOR REPRESENTATIVES › Section 150.3 - Representatives: Written Authorization Required

Current through Reg. 49, No. 28; July 12, 2024
(a) A representative, as that term is defined
				in the Texas Workers' Compensation Act (the Act), §1.03(40), is authorized
				under the Act, §2.09(e), to provide services in workers' compensation
				matters if:
(1) the person is an insurance
				adjuster holding a State Board of Insurance license to adjust workers'
				compensation claims, if the adjuster provides, to the commission, a written
				authorization from an insurance carrier to adjust claims. Written authorization
				is not required from an adjuster who is an employee of the insurance
				carrier;
(2) the person is an
				attorney and complies with the requirements of §
										150.2(a)
				of this title (relating to Qualification and Authorization of Attorney To
				Practice before the Commission); or
(3) the person who is not either an adjuster
				or attorney files with the commission a written power of attorney, or written
				authorization from the claimant, allowing that person access to confidential
				records. No fee or remuneration shall be received either directly or indirectly
				from a claimant.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 152 - ATTORNEY FEES › Section 152.1 - Attorney Fees: General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) To be
				eligible to earn a fee, an attorney representing any party shall hold an active
				license to practice law in Texas and not be currently under suspension for any
				reason.
(b) An attorney may receive
				a fee for representation of any party before the commission only after the
				commission approves the amount of the fee. An attorney shall not receive an
				amount greater than the fee approved by the commission, notwithstanding any
				agreements between the parties, including retainer fee agreements.
(c) The fee approved by the commission shall
				be limited to 25% of each weekly income benefit payment to the employee, up to
				25% of the total income benefits allowed and shall also be based on the
				attorney's time and expenses, subject to the guidelines and standards set forth
				in the Texas Workers' Compensation Act (the Act) and commission rules. An
				attorney's fee for representing an injured employee becomes a lien against any
				unpaid income benefits due the injured employee once the carrier receives the
				commission order approving the fee. The carrier must begin payment out of the
				approved income benefits by mailing a check to the attorney within seven days
				after receiving the commission order and thereafter whenever income benefits
				are paid until the fee has been paid or income benefits cease.
(d) An attorney's fee for representing a
				claimant may upon request by the attorney or carrier and approval by the
				commission be commuted to a lump sum only out of a sum certain award or order
				to pay benefits. This commuted fee may be discounted for present payment at the
				rate provided under the Act, §401.023, and shall not exceed 25% of the
				unpaid sum certain. A commuted fee shall be recouped by the carrier out of the
				future income benefits paid to the represented claimant, not to exceed more
				than 25% out of any single payment. The fee for representing a claimant for
				death benefits cannot be commuted where the only dispute involves
				identification of the proper beneficiaries.
(e) A client who discharges an attorney does
				not, by that action, defeat the attorney's right to claim a fee for services
				performed by that attorney prior to discharge.
(f) An attorney for an employee who prevails
				when a carrier contests a commission determination of eligibility for
				supplemental income benefits shall be eligible to receive a reasonable and
				necessary attorney's fee, including expenses. This fee is payable by the
				carrier, not out of the employee's benefits, and the fee shall not be limited
				to a maximum of 25% of the employee's recovery. All provisions of these rules,
				except §
									152.4
				of this title (relating to Guidelines for Legal Services Provided to Claimants
				and Carriers), apply.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 152 - ATTORNEY FEES › Section 152.2 - Attorney Fees: Representation of Claimants

Current through Reg. 49, No. 28; July 12, 2024
(a) An attorney who represents a claimant
				shall notify the commission in writing within 10 days of undertaking
				representation, and shall provide a copy of the contract of employment if
				requested by the commission.
(b)
				For purposes of computing the maximum amount of a fee that may be fixed and
				approved for a claimant's attorney, "claimant's recovery" shall not include:
(1) the amount of benefits paid to the
				claimant prior to hiring the attorney;
(2) benefits initiated or offered by an
				insurance carrier when the initiation or offer is based upon documentation in a
				claimant's file, and has not been the subject of a dispute with the
				carrier;
(3) any undisputed portion
				of impairment benefits paid or offered to the claimant based upon an impairment
				rating that is assessed by the carrier, under the Texas Workers' Compensation
				Act (the Act), §4.26(f);
(4)
				the value of medical and hospital benefits provided to the claimant;
				or
(5) lifetime income or death
				benefits when the carrier admits liability on all issues involved, and when the
				maximum benefit is tendered in writing by a carrier, no later than the date on
				which the carrier is required to contest the claim.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 152 - ATTORNEY FEES › Section 152.3 - Approval or Denial of Fee by the Division

Current through Reg. 49, No. 28; July 12, 2024
(a)
				To claim a fee, an attorney representing any party must submit to the division
				a complete and accurate application for attorney fees in the form and manner
				prescribed by the division.
(b) An
				application for attorney fees must include:
(1) each attorney's name and bar card
				number;
(2) the law firm name,
				phone number, and mailing address;
(3) the injured employee's name, date of
				injury, and DWC claim number;
(4)
				the beneficiary's name, type, contact information, and social security number,
				if applicable;
(5) the dates of
				legal service;
(6) the hourly rate
				and number of hours for each attorney and legal assistant providing legal
				services;
(7) an itemized list of
				each legal service performed and expense incurred representing the claimant or
				insurance carrier that identifies the attorney or legal assistant who provided
				the service, the date the service was provided, and the hours or amount
				requested;
(8) a certification that
				every statement, numerical figure, and calculation in the application for
				attorney fees submitted to the division is within the attorney's personal
				knowledge, is true and correct, and represents services, charges, and expenses
				provided by the attorney or a legal assistant under the attorney's supervision;
				and
(9) additional case-specific
				justification for any fee that exceeds the guidelines for legal
				services.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 152 - ATTORNEY FEES › Section 152.4 - Guidelines for Legal Services Provided to Claimants and Insurance Carriers

Current through Reg. 49, No. 28; July 12, 2024
(a) The division will consider the guidelines
				for legal services outlined in subsection (c), the maximum hourly rate for
				legal services in subsection (d), Labor Code, §
									408.221
				and §
									408.222,
				and written evidence presented to the division, when approving, partially
				approving, or denying an application for attorney fees.
(b) An attorney may request, and the division
				may approve, a number of hours greater than those allowed by the guidelines for
				legal services if the attorney demonstrates to the satisfaction of the division
				that the higher fee was justified based on the circumstances of the specific
				claim and Labor Code, §
									408.221
				and §
									408.222.
(c) The guidelines for legal services
				provided to claimants and insurance carriers are as follows:
Attached
				  Graphic
(d) The
				maximum hourly rate for legal services shall be as follows. Hourly rate:
(1) attorney--$200; and
(2) legal assistant (not to include hours for
				general office staff)--$65.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 152 - ATTORNEY FEES › Section 152.5 - Allowable Expenses

Current through Reg. 49, No. 28; July 12, 2024
(a) As part of the
				application for attorney fees, an attorney shall submit an itemized list of
				expenses incurred for the preparation and presentation of the client's case.
				The date, nature, and amount of the expense shall be clearly
				identified.
(b) The commission
				shall allow those expenses necessary for the preparation and presentation of a
				person's claim or a carrier's defense before the commission, including:
(1) travel expenses, at the rate set for
				state employees by the legislature for state employees in the General
				Appropriation Act, if the attorney is required to attend a benefit review
				conference or hearing more than 25 miles from the attorney's office nearest to
				the location of the conference or hearing;
(2) expenses necessary to present a case at a
				hearing including subpoena costs, court reporter's fee, per diem witness fees
				incurred, and translator's fee;
(3)
				the costs of records necessary to prepare or present a claim or defense
				including copies of commission files, a record check performed by the
				commission, medical reports (except medical reports required to be provided by
				commission rule), and copies of certificates, licenses, and decrees necessary
				for perfecting a claim for death benefits;
(4) costs of long distance telephone calls
				to: the client, an attorney or other representative of the other party, health
				care providers, or others necessary to prepare the claim or defense;
(5) costs of collect long distance telephone
				calls from the client; and
(6)
				investigative services necessary to establish or dispute a claim.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 152 - ATTORNEY FEES › Section 152.6 - Attorney Withdrawal

Current through Reg. 49, No. 28; July 12, 2024
(a) An attorney
				withdrawing representation must submit a notice of withdrawal under subsection
				(b) of this section or a motion to withdraw under subsection (d) of this
				section and comply with the Texas Disciplinary Rules of Professional Conduct of
				the State Bar of Texas, including surrendering papers and property to the
				client as required.
(b) An attorney
				must submit a notice of withdrawal in the form and manner prescribed by the
				division when:
(1) the attorney withdraws
				representation and a motion to withdraw under subsection (d) of this section is
				not required; or
(2) the attorney's
				representation is terminated by the attorney's client.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 156 - REPRESENTATION OF PARTIES BEFORE THE AGENCY - CARRIER'S AUSTIN REPRESENTATIVE › Section 156.1 - Carrier's Austin Representative

Current through Reg. 49, No. 28; July 12, 2024
(a) Each
				insurance carrier shall designate a person in Austin, Travis County, Texas as
				its representative to the Commission, to act as agent for receiving notice from
				the Commission.
(b) The designation
				required by this section shall be made in the form and manner prescribed by the
				Commission and contain the representative's name, address, telephone number,
				facsimile number and e- mail address.
(c) Any notice from the Commission, sent to
				the designated representative's Austin address, is notice from the Commission
				to the insurance carrier.
(d) A
				person designated under this rule continues as agent for the insurance carrier
				until 30 days after the Commission receives notice that the insurance carrier
				designates another representative.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 160 - REPORTS OF INJURY AND OCCUPATIONAL DISEASE - GENERAL PROVISIONS › Section 160.1 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) This chapter applies to an employer as
				defined by Labor Code §
									411.001(2)
				and that is subject to Labor Code Chapter 411, Subchapter C.
(b) This section is effective January 1,
				2013.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 160 - REPORTS OF INJURY AND OCCUPATIONAL DISEASE - GENERAL PROVISIONS › Section 160.2 - Non-Subscribing Employer's Report of Injury

Current through Reg. 49, No. 28; July 12, 2024
(a) An employer that does not have workers'
				compensation insurance coverage (non-subscriber) and employs five or more
				employees not exempt from workers' compensation insurance coverage shall file
				with the division a report of each:
(1)
				death;
(2) on-the-job injury that
				results in more than one day's absence from work for the injured employee;
				and
(3) occupational disease of
				which the employer has knowledge.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 160 - REPORTS OF INJURY AND OCCUPATIONAL DISEASE - GENERAL PROVISIONS › Section 160.3 - Subscribing Employer's Report of Injury

Current through Reg. 49, No. 28; July 12, 2024
(a) An employer that has workers'
				compensation insurance coverage (subscriber) shall file a report of injury with
				the division pursuant to Labor Code §
									411.032.
				A subscribing employer's report of injury filed in accordance with Labor Code
				§
									409.005
				and applicable division rules satisfies that employer's requirement to file a
				report of injury under Labor Code §
									411.032,
				unless the division requests that the employer file a report with the division
				for a specific injury.
(b) For an
				employee who has waived workers' compensation insurance coverage in accordance
				with Labor Code §
									406.034, an
				employer covered by workers' compensation insurance, whether by commercial
				insurance or through self-insurance as provided by the Texas Workers'
				Compensation Act, shall file with the division a report of each:
(1) death;
(2) on-the-job injury that results in more
				than one day's absence from work for the injured employee; and
(3) occupational disease of which the
				employer has knowledge.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 165 - REJECTED RISK: INJURY PREVENTION SERVICES › Section 165.1 - Identification and Notification of Certain Policyholders Insured by the Texas Mutual Insurance Company Acting as the Insurer of Last Resort

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas
				Mutual Insurance Company must provide the division a list of the policyholders
				requiring accident prevention services (rejected risk employers) . This list
				must include rejected risk employers that meet the criteria in Texas Insurance
				Code Chapter 2054, Subchapters H and K.
(b) A policyholder subject to Texas Insurance
				Code §
									2054.504, whose
				corporate office is located outside of Texas must, on receipt of notification
				by the Texas Mutual Insurance Company of the requirement to get a safety
				consultation as a condition of insurance, provide the Texas Mutual Insurance
				Company the following information:
(1) the
				name and title of the senior official in Texas with the authority to commit
				funds and to establish policy, procedures, and actions required to implement
				the accident prevention plan and address the exposures identified in the hazard
				exposure survey;
(2) the official's
				mailing address; and
(3) the
				official's business telephone number.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 165 - REJECTED RISK: INJURY PREVENTION SERVICES › Section 165.2 - Safety Consultation

Current through Reg. 49, No. 28; July 12, 2024
(a)
				Policyholders who have not had an accident prevention plan developed and
				implemented in the last six months prior to notification shall, not later than
				30 days following the effective date of the policy, or receipt of notice of
				identification as a Rejected Risk employer, whichever occurs later, complete a
				safety consultation using a source approved by the division pursuant to §
				164.9 and § 164.10 of this title (relating to Approval of Professional
				Sources for Safety Consultations; and Removal From the List of Approved
				Sources). The consultation may be provided by:
(1) the Texas Workers' Compensation
				Commission's Division of Workers' Health and Safety (the division);
(2) the Texas Mutual Insurance Company;
				or
(3) another professional
				source.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 165 - REJECTED RISK: INJURY PREVENTION SERVICES › Section 165.3 - Formulation and Components of Accident Prevention Plan

Current through Reg. 49, No. 28; July 12, 2024
(a) Policyholders who have not had an
				accident prevention plan developed in the last six months prior to notification
				will, within 30 days of the date of the safety consultant's initial report,
				develop an accident prevention plan. This plan will be consistent with
				established state safety and health codes and with accepted industry practices.
				The accident prevention plan shall be developed with the assistance of an
				Approved Professional Source as defined in § 164.9 of this title (relating
				to Approval of Professional Sources for Safety Consultations), and shall be in
				the format prescribed by the commission. The policyholder shall submit the
				completed accident prevention plan, developed and signed by the policyholder
				and the Approved Professional Source, to the division. The Approved
				Professional Source's signature on the accident prevention plan cover sheet
				certifies that the accident prevention plan meets the format prescribed by the
				commission. The format shall include the following components and specify the
				individual responsible for each, by position or title:
(1) a management component with a written
				safety policy statement and assignment of responsibilities and
				authority;
(2) analysis component
				which includes a review of safety program documentation, existing operations,
				and injury trends. The analysis will be used to evaluate the effectiveness of
				the existing programs and to detect existing or potential trends. The analysis
				component will contain a statement as to the interval between the
				accomplishment of the analyses;
(3)
				a safety program recordkeeping system component;
(4) a safety and health education and
				training component with a statement as to the interval between training
				sessions;
(5) a safety
				audit/inspection component with a statement as to the interval between safety
				audits/inspections;
(6) an accident
				investigation component to identify the cause factors of injuries, and plan and
				record corrective actions; and
(7)
				a component to ensure review and revision of the safety program when changes in
				operations, equipment, or employee activities are determined or anticipated, to
				ensure continued effectiveness of the program requirements. This component also
				includes the periodic review and revisions of the safety program including a
				statement as to the interval (minimum of annually) between reviews.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 165 - REJECTED RISK: INJURY PREVENTION SERVICES › Section 165.4 - Request for Safety Consultation From the Division

Current through Reg. 49, No. 28; July 12, 2024
(a) A policyholder notified as a Rejected
				Risk employer may request that the division perform the safety
				consultation.
(b) The request shall
				be in writing on the form prescribed by the commission and may be delivered to
				the Texas Workers' Compensation Commission's Division of Workers' Health and
				Safety (the division) by mail, in person, by facsimile, or by electronic
				transmission. The form shall include:
(1) the
				policyholder's name, address, and telephone number;
(2) the name of the contact person at the
				policyholder's place of business; and
(3) the date the policyholder received notice
				of identification as a Rejected Risk employer.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 165 - REJECTED RISK: INJURY PREVENTION SERVICES › Section 165.5 - Reimbursement of Division for Services Provided to Rejected Risk Employers

Current through Reg. 49, No. 28; July 12, 2024
(a) A policyholder shall be required to
				reimburse the Texas Workers' Compensation Commission's Division of Workers'
				Health and Safety (the division) for the services the division renders when:
(1) the policyholder requested services under
				§
										165.4
				of this title (relating to Request for Safety Consultation from the Division)
				and the division provides the consultation and formulates an accident
				prevention plan for the policyholder;
(2) the division conducts a follow-up
				inspection of the policyholder's premises under §
										165.6
				of this title (relating to Follow-up Inspection by the Division); or
(3) the division investigates accidents at
				the policyholder's worksite(s) while the policyholder is in the rejected risk
				program.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 165 - REJECTED RISK: INJURY PREVENTION SERVICES › Section 165.6 - Follow-Up Inspection of the Policyholder's Premises by the Division

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas Workers' Compensation
				Commission's Division of Workers' Health and Safety (the division) shall
				conduct a follow-up inspection to ensure compliance with, and effectiveness of,
				the accident prevention plan developed in response to a safety consultation
				required by the Texas Insurance Code, Article 5.76-3, §8(c). This
				inspection shall be conducted at the policyholder's premises. The inspection
				shall be conducted not earlier than 90 days or later than six months after the
				date the accident prevention plan is submitted to the division.
(b) The inspection shall be conducted and
				completed during normal work hours.
(c) The policyholder shall allow the division
				access to the policyholder's premises, including remote job sites, and
				employees during normal work hours to conduct the follow-up inspection. A
				policyholder who without good cause refuses to allow the division access to the
				policyholder's premises may be served with an order of the commission demanding
				such access. Failure to comply with the commission order will subject the
				policyholder to penalties and sanctions as provided in the Texas Insurance Code
				and the Texas Labor Code.
(d) The
				division may require the presence of the professional source consultant that
				conducted the hazard survey or assisted with the accident prevention plan
				development during the follow-up inspection. If the professional source is
				required during the inspection, the division will coordinate that requirement
				with the policyholder and the professional source, at the policyholder's
				expense.
(e) At the time of the
				inspection, the division may consider as evidence of compliance information
				which includes, but is not limited to, visual verification, written policies
				and procedures, attendance rosters for training programs, employee interviews,
				and purchase orders or receipts for equipment or services necessary to support
				the accident prevention plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 165 - REJECTED RISK: INJURY PREVENTION SERVICES › Section 165.7 - Report of Follow-Up Inspection

Current through Reg. 49, No. 28; July 12, 2024
(a) As
				soon as practical, but not later than 30 days from the date of the follow-up
				inspection, the policyholder, the safety consultant, and the Texas Mutual
				Insurance Company, shall be provided copies of the follow-up inspection report
				by the division.
(b) The report
				shall be in writing and shall specify whether the policyholder has, or has not,
				implemented the accident prevention plan or other acceptable corrective
				measures approved by the division.
(c) If the policyholder is found not to have
				implemented the accident prevention plan, the report shall also contain a list
				of the specific areas of the accident prevention plan which have not been
				implemented.
(d) Failure or refusal
				to implement the accident prevention plan is an administrative violation with
				penalty not to exceed $5,000 for each day of non-compliance. The Texas Workers'
				Compensation Commission's Division of Workers' Health and Safety (the division)
				shall refer the matter to the Commission's Division of Compliance and Practices
				to pursue the administrative violation if:
(1)
				the policyholder fails or refuses to implement the accident prevention plan or
				approved alternative measures;
(2)
				the policyholder does not cancel coverage within 30 days after the date of the
				division's determination of such failure or refusal; and
(3) the Texas Mutual Insurance Company
				notifies the division that it will not cancel the coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 166 - ACCIDENT PREVENTION SERVICES › Section 166.1 - Definition of Terms

Current through Reg. 49, No. 28; July 12, 2024
(a) The following
				words and terms, when used in this chapter, have the following meanings, unless
				the context clearly indicates otherwise.
(1)
				Accident prevention facilities--All personnel, procedures, equipment,
				materials, documents, buildings, programs, and information necessary to
				maintain or provide accident prevention services to the policyholder.
(2) Nature of the policyholders'
				operations--Type of business or industry with specific reference to potential
				for accident, injury, or disease determined by the standard hazards associated
				with the most hazardous industrial operations in which the policyholder is
				engaged.
(3) Premium--The amount
				charged for a workers' compensation insurance policy, including any
				endorsements, after the application of individual risk variations based on loss
				or expense considerations as defined by Insurance Code §
										2053.001
				(2-a).
(4) Survey--An on-site visit
				to a policyholder's worksite in Texas where the risk exists or the loss
				occurred and during which the insurance company's accident prevention personnel
				performs a hazard assessment of the worksite, reviews safety and health
				programs, and makes recommendations to assist in mitigating risks and
				preventing injuries and illnesses.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 166 - ACCIDENT PREVENTION SERVICES › Section 166.2 - Adequacy of Accident Prevention Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Under Labor
				Code §§
									411.061,
				411.063, and
				411.068(a)(1),
				an insurance company writing workers' compensation insurance in Texas must
				maintain or provide accident prevention facilities that are adequate to provide
				accident prevention services required by the nature of its policyholders'
				operations, and must include:
(1)
				surveys;
(2)
				recommendations;
(3) training
				programs;
(4)
				consultations;
(5) analyses of
				accident causes;
(6) industrial
				hygiene;
(7) industrial health
				services;
(8) qualified accident
				prevention personnel. To provide qualified accident prevention personnel and
				services, an insurance company may:
(A) employ
				qualified personnel;
(B) retain
				qualified independent contractors;
(C) contract with the policyholder to provide
				personnel and services; or
(D) use
				a combination of the methods provided in this paragraph; and
(9) written records, reports, and
				evidence of all accident prevention services provided to each
				policyholder.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 166 - ACCIDENT PREVENTION SERVICES › Section 166.3 - Annual Information Submitted by Insurance Companies

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				insurance company writing workers' compensation insurance in Texas must file
				with the division an annual report on its accident prevention services no later
				than April 1 of each calendar year.
(b) An annual report required by this section
				must be filed with the division in the format and manner prescribed by the
				division.
(c) The annual reports
				must not include the expenses or the costs of underwriting visits to a
				policyholder's premises unless accident prevention services are provided during
				the visit. In that case, the proportionate costs of the accident prevention
				services may be included in the report.
(d) Insurance companies are responsible for
				timely and accurate reporting under this section. A report required by this
				section is considered filed with the division only when it accurately contains
				all of the required data elements and is received by the division.
(e) This section is effective July 1,
				2024.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 166 - ACCIDENT PREVENTION SERVICES › Section 166.5 - Inspections of Adequacy of Accident Prevention Facilities and Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Inspections. The division may conduct
				inspections to determine the adequacy of an insurance company's accident
				prevention services.
(1) Affiliated companies
				of an insurer may be inspected together if the same facilities, programs, and
				personnel are used by each of the companies.
(2) At least 90 days before an inspection,
				the division must notify the insurance company in writing of the inspection.
				The notice must specify the location and date of the inspection.
(3) The division may conduct unannounced
				on-site visits to determine compliance with the Labor Code and division rules
				in accordance with the procedures governing on-site visits in Chapter 180 of
				this title (relating to Monitoring and Enforcement) regardless of the
				provisions of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter A - GENERAL RULES FOR ENFORCEMENT › Section 180.1 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
					 will have the following meanings:
(1)
				  Act--The Texas Workers' Compensation Act, Labor Code, Title 5, Subtitle
				  A.
(2) Administrative violation--A
				  violation, failure to comply with, or refusal to comply with the Act, or a
				  rule, order, or decision of the commissioner. This term is synonymous with the
				  terms "violation" or "violate."
(3)
				  Agent--A person who a system participant uses or contracts with for the purpose
				  of providing claims service or fulfilling duties under the Labor Code Title 5
				  and rules. The system participant who uses or contracts with the agent may also
				  be responsible for the administrative violations of that agent.
(4) Appropriate credentials--The
				  certifications, education, training, and experience to provide the health care
				  that an injured employee is receiving or is requesting to receive. Under Texas
				  Labor Code §
										408.0043, a physician who
				  performs a peer review, utilization review, or independent review of health
				  care services requested, ordered, provided, or to be provided by a physician
				  must be of the same or similar specialty as the physician who requested,
				  ordered, provided, or will provide the health care service. A dentist must meet
				  the requirements of Texas Labor Code §
										408.0044. A chiropractor
				  must meet the requirements of Texas Labor Code §
										408.0045.
(5) Commissioner--The commissioner of
				  workers' compensation.
(6)
				  Complaint--A written submission to the division alleging a violation of the Act
				  or rules by a system participant.
(7) Compliance Audit (also Performance
				  Review)--An official examination of compliance with one or more duties under
				  the Act and rules. A compliance audit does not include monitoring or review
				  activities involving the Medical Advisor or the Medical Quality Review
				  Panel.
(8) Conviction or
				  convicted--
(A) A system participant is
				  considered to have been convicted when:
(i) a
				  judgment of conviction has been entered against the system participant in a
				  federal, state, or local court;
(ii) the system participant has been found
				  guilty in a federal, state, or local court;
(iii) the system participant has entered a
				  plea of guilty or nolo contendere (no contest) that has been accepted by a
				  federal, state, or local court;
(iv) the system participant has entered a
				  first offender or other program and judgment of conviction has been withheld;
				  or
(v) the system participant has
				  received probation or community supervision, including deferred
				  adjudication.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter A - GENERAL RULES FOR ENFORCEMENT › Section 180.2 - Filing a Complaint

Current through Reg. 49, No. 28; July 12, 2024
(a) Any person may
				  submit a complaint to the division for alleged administrative violations, except
				  as provided in subsection (b) of this section.
(b) A health care provider cannot submit a
				  complaint about a medical billing issue if the date of service for the medical
				  billing issue was more than 12 months before the date of the complaint, unless
				  the issue qualifies for an exception to the filing deadline under §
										133.307(c)(1)(B) of
				  this title, concerning medical fee dispute resolution. If the issue qualifies for
				  an exception to the medical fee dispute resolution filing deadline under
				  §133.307(c)(1)(B), then a health care provider cannot submit a complaint
				  about that issue if the medical fee dispute resolution filing deadline in
				  §133.307(c)(1)(B) has passed. This subsection does not apply to a health
				  care provider submitting a complaint under Insurance Code Chapter 1305.
(c) A person may submit a complaint to the
				  division:
(1) through the division's
				  website;
(2) by email;
(3) through written correspondence;
(4) by fax; or
(5) in person. The division will help a person
				  submitting an in-person complaint reduce the complaint to writing.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter A - GENERAL RULES FOR ENFORCEMENT › Section 180.3 - Compliance Audits

Current through Reg. 49, No. 28; July 12, 2024
(a) The division
				  shall conduct Compliance Audits of the workers' compensation records of system
				  participants and their agents for compliance with the Act and division
				  rules.
(b) The division may conduct
				  a compliance audit at the offices of a system participant or at any location
				  the division deems appropriate. During a compliance audit, the division may, at
				  its discretion, utilize persons in addition to division staff to provide
				  additional expertise.
(c) The
				  division shall provide reasonable notice in advance of a compliance audit. That
				  notice shall:
(1) be in writing;
(2) be sent at least 10 days before the
				  compliance audit is to be performed;
(3) specify the information that must be made
				  available;
(4) list the name and
				  telephone number of the audit coordinator; and
(5) specify the date, time, location, and
				  conditions of the compliance audit.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter A - GENERAL RULES FOR ENFORCEMENT › Section 180.4 - On-Site Visits

Current through Reg. 49, No. 28; July 12, 2024
(a) As often as it
				  considers necessary, the division may review the operations of a system
				  participant to determine compliance with the Act or division rules.
(b) When reviewing the operations of a system
				  participant to determine compliance with the Act or division rules, the
				  division may conduct on-site visits to the system participant's premises.
				  On-site visits may be announced or unannounced.
(c) The on-site visit will occur during the
				  system participant's normal business hours.
(d) An on-site visit must not disturb a
				  health care provider's actual provision of health care to a patient.
(e) The division shall provide written notice
				  of each announced and unannounced on-site visit. This notice shall:
(1) be sent at least 10 days before the
				  on-site visit unless the on-site visit is unannounced in which case the notice
				  will be provided at the time of the on-site visit;
(2) specify the alleged violation(s) that is
				  the subject of the on-site visit;
(3) specify the types of records that must be
				  made available during the on-site visit;
(4) list the name and telephone number of the
				  division staff representative; and
(5) specify the date, time, location, and
				  conditions of the on-site visit.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter A - GENERAL RULES FOR ENFORCEMENT › Section 180.5 - Access to Workers' Compensation Related Records and Information

Current through Reg. 49, No. 28; July 12, 2024
(a) Upon written request from the division
				  any system participant shall provide copies of or access to all records and
				  information held by that system participant related to issues being reviewed or
				  investigated in the format and manner specified by the division.
(b) The request will identify the records and
				  information to be produced and will provide a specific, reasonable date to
				  produce the information.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter A - GENERAL RULES FOR ENFORCEMENT › Section 180.8 - Notices of Violation; Notices of Hearing; Default Judgments

Current through Reg. 49, No. 28; July 12, 2024
(a) A notice of violation (NOV) is a notice
				  issued to a system participant when the division finds that the system
				  participant has committed an administrative violation and the division seeks to
				  impose a sanction under the Act or division rules. An NOV is not required to be
				  issued before or after the issuance of an ex parte emergency cease and desist
				  order.
(b) An NOV shall be in
				  writing and include:
(1) the provision(s) of
				  the Act, rule, order, or decision of the commissioner that the system
				  participant violated;
(2) a summary
				  of the facts that establish that the violation(s) occurred;
(3) a description of the proposed sanction
				  that the division intends to impose;
(4) a statement of the basis for the proposed
				  sanction including:
(A) a description of the
				  underlying facts considered by the division for each of the factors listed in
				  Labor Code §
												415.021(c)
				  and (c-2), if applicable, (relating to
				  Assessment of Administrative Penalties) and §
												180.26
				  of this title (relating to Criteria for Proposing, Recommending and Determining
				  Sanctions; Other Remedies) in determining the appropriateness of the division's
				  proposed sanction;
(B) a
				  description of which factors under Labor Code §
												415.021(c)
				  and (c-2), if applicable, and §
												180.26
				  of this title had a mitigating or aggravating effect on the division's proposed
				  sanctions; and
(C) a description of
				  the division's proposed sanction for each violation or violation type in the
				  case of repeated administrative violations. This requirement does not prohibit
				  the division from considering the aggregate impact of all administrative
				  violations described in the NOV when proposing a sanction if justice requires
				  such consideration;
(5)
				  the right to consent to the charge and the proposed sanction(s);
(6) the right to request a hearing;
				  and
(7) other information about the
				  rights, obligations, and procedures for requesting a hearing.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter A - GENERAL RULES FOR ENFORCEMENT › Section 180.9 - Proposals for Decision

Current through Reg. 49, No. 28; July 12, 2024
(a) If a hearing
				  was conducted in conjunction with Labor Code §§
										407.046,
				  408.023,
				  415.0215, or
				  415.034, or in
				  another case under the Act that is not subject to Labor Code §
										402.073(b),
				  the commissioner shall review the proposed decision of the administrative law
				  judge. If the commissioner modifies, amends, or changes a recommended finding
				  of fact or conclusion of law, or order of the administrative law judge, the
				  commissioner's final order shall state the legal basis and the specific reasons
				  for the change.
(b) The division
				  shall notify the person by issuing an order that describes the effects of the
				  sanction. This order shall be delivered by verifiable means with a copy to the
				  appropriate licensing or certification authority.
(c) Failure to comply with the sanction may
				  result in additional administrative violations.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter A - GENERAL RULES FOR ENFORCEMENT › Section 180.10 - Ex Parte Emergency Cease and Desist Orders

Current through Reg. 49, No. 28; July 12, 2024
(a) The commissioner ex parte may issue an
				  emergency cease and desist order upon application by division staff if:
(1) the commissioner believes a person
				  regulated by the division under Labor Code, Title 5 is engaging in conduct
				  violating a law, rule or order; and
(2) the commissioner believes that the
				  alleged conduct under paragraph (1) of this subsection will result in harm to
				  the health, safety, or welfare of another person.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter A - GENERAL RULES FOR ENFORCEMENT › Section 180.19 - Incentives

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this section is to develop
				  incentives and emphasize performance-based oversight to regulatory outcomes.
				  Regulatory outcomes are assessed for the following key regulatory goals:
(1) provide timely and accurate income and
				  medical benefits;
(2) increase
				  timely and accurate communications among system participants;
(3) encourage safe and timely return of
				  injured employees to productive roles;
(4) promote safe and healthy
				  workplaces;
(5) ensure each injured
				  employee shall have access to prompt, high-quality, cost-effective medical
				  care; and
(6) limit disputes to
				  those appropriate and necessary.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 180 - MONITORING AND ENFORCEMENT › Subchapter B - MEDICAL BENEFIT REGULATION › Section 180.22 - Health Care Provider Roles and Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
(a) Health care providers as defined in
				  subsections (c) - (e) of this section shall provide all health care reasonably
				  required by the nature of the injury as and when needed to:
(1) cure or relieve the effects naturally
				  resulting from the compensable injury;
(2) promote recovery; or
(3) enhance the ability of the injured
				  employee to return to or retain employment.