Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 65 - UNETHICAL OR FRAUDULENT CLAIMS PRACTICES › Section 65.10 - Actions by Carrier, Claimant's Attorney, and/or Agent

Current through Reg. 49, No. 28; July 12, 2024
The following willful acts shall be deemed unethical or
				  fraudulent conduct by the board.
(1)
				Carrier representatives:
(A) misrepresenting
				to claimants, employers, or health providers the provisions of the Workers'
				Compensation Law of Texas;
(B)
				failing to submit to the board any settlement agreement executed by the
				parties;
(C) failing to immediately
				notify the board of the suspension or stopping of compensation and the reason
				for such suspension or stopping of compensation;
(D) stopping or suspending compensation
				without substantiating evidence that such action is authorized by
				law;
(E) misrepresenting that one
				is employed by the State of Texas or any agency thereof;
(F) instructing employers not to file
				Employer's First Reports of Injury with the board when such filing is required
				by statute;
(G) instructing
				employers to violate the claimant's rights guaranteed by Texas Civil Statutes,
				Article 8306, §7;
(H) failing
				to promptly tender full death benefits where no bona fide dispute exists as to
				the liability of the carrier;
(I)
				allowing an employer to dictate the methods by which and the terms on which a
				claim is handled and settled. Nothing in the foregoing shall prohibit the free
				discussion of a claim prior to prehearing conference, prohibit the employer's
				assistance in the investigation and evaluation of a claim prior to pre-hearing
				conference, or prohibit the employer's attendance at a pre-hearing conference
				and participation therein as a witness/observer;
(J) failing to confirm medical benefits
				coverage to any persons or facility providing medical treatment to a claimant
				where no bona fide dispute exists as to the liability of the carrier;
(K) failing, without good cause, to attend a
				pre-hearing conference;
(L)
				attending a pre-hearing conference without complete authority or failing to
				exercise authority to effectuate settlement;
(M) adjusting workers' compensation claims in
				any manner contrary to the provisions of the Adjusters Licensing Act or the
				rules and regulations of the State Board of Insurance;
(N) failing to promptly process claims in a
				reasonable and prudent manner;
(O)
				failing to initiate or reinstate compensation when due where no bona fide
				dispute exists as to the liability of the carrier;
(P) misrepresenting the reason for not paying
				compensation or for the suspension of compensation;
(Q) misdating the Form A-1 so as to distort
				the true date of the initial payment of compensation;
(R) making notations on drafts or other
				instruments so as to indicate that the draft or instrument represents a final
				settlement of a claim when in fact the claim is still open and pending before
				the board;
(S) failing and refusing
				to pay compensation from week to week as and when the same matures and accrues
				directly to the person entitled thereto;
(T) failing to pay an award of the board as
				directed by the board when no appeal is perfected;
(U) violating any rule of the
				board;
(V) controverting claims
				when evidence clearly indicates compensability;
(W) failing to file with the board,
				immediately upon receipt, originals of the E-1, Employer's First Report of
				Injury or Illness; E-2, Employer's Supplemental Report of Injury; and IAB-150,
				Employer's Wage Statement.