(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, § 1, eff. Sept. 1, 1993. Amended by Acts 1995, 74th Leg., ch. 980, § 1.45, eff. Sept. 1, 1995.
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), § 3.266, eff. September 1, 2005.