Texas Workers' Compensation

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§ 180.2. Filing a Complaint

(a) Any person may submit a complaint to the division for alleged administrative violations.

(b) A person may submit a complaint to the division:

(1) through the division’s website;

(2) through electronic correspondence;

(3) through written correspondence;

(4) through facsimile correspondence; or

(5) in person and the complaint will be reduced to writing.

(c) A complaint submitted on the form provided by the division or in any other written format shall contain the following information as applicable:

(1) complainant’s name and contact information;

(2) name and contact information of the subject or parties of the complaint, if known;

(3) name and contact information of witnesses, if known;

(4) claim file information including, but, not limited to, the name, address, and date of injury of the injured employee, if known;

(5) the statement of the facts constituting the alleged violation including the dates or time period the alleged violation occurred;

(6) the nature of the alleged violation, including, the specific sections of the Act and division rules alleged to have been violated, if known;

(7) supporting documentation relevant to the allegation that may include, but, is not limited to, medical bills, Explanation of Benefits Statements, copy of payment invoices or checks, and medical reports as applicable;

(8) supporting documentation for alleged fraud may include photographs, video, audio, and surveillance recordings, and reports; and

(9) other sources of pertinent information, if known.

(d) Contact information may include, but, is not limited to, name, address, telephone number, facsimile number, email address, business name, business address, business telephone number, and websites.

(e) A complaint shall contain sufficient information for the division to investigate the complaint.

(f) Upon receipt of a complaint, the division will review, monitor and may investigate the allegation against a person or entity who may have violated the Act or division rules.

(g) The division will assign priorities to complaints being investigated based on a risk-based complaint investigation system that considers:

(1) the severity of the alleged violation;

(2) continued noncompliance of the alleged violation;

(3) whether a commissioner order has been violated; or

(4) other risk-based criteria the division determines necessary.

(h) A person commits an administrative violation if the person submits a complaint to the division that is:

(1) frivolous, as defined in § 180.1 of this title (relating to Definitions);

(2) groundless or made in bad faith; or

(3) done specifically for competitive or economic advantage.

The provisions of this §180.2 adopted to be effective March 14, 2002, 27 TexReg 1817; amended to be effective January 9, 2011, 35 TexReg 11873.

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At a Glance:

Title:

§ 180.2. Filing a Complaint

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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