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TITLE 28INSURANCE
PART 2TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
CHAPTER 65UNETHICAL OR FRAUDULENT CLAIMS PRACTICES
RULE §65.10Actions by Carrier, Claimant's Attorney, and/or Agent

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.

  (2) Claimant's attorney and/or agents:

    (A) failing, without good cause, to attend a pre-hearing conference;

    (B) committing an act of barratry as defined by the laws of this state;

    (C) withholding sums not authorized by the board from claimant's weekly compensation or from advancements;

    (D) entering into a compromise settlement agreement without the knowledge, consent, and signature of the claimant or beneficiary;

    (E) taking a fee or withholding expenses in excess of such sums authorized by the board;

    (F) refusing or failing to make prompt delivery to claimant (client) of the funds belonging to claimant as a result of a compromise settlement agreement, A-2 payment or award;

    (G) violating the Code of Professional Responsibility of the State Bar of Texas;

    (H) violating any rule of the board. (Rev. 1979).


Source Note: The provisions of §65.10 adopted to be effective November 20, 1977, 2 TexReg 4324; amended to be effective September 25, 1979, 4 TexReg 3232; amended to be effective September 18, 1981, 6 TexReg 3274; amended to be effective October 26, 1981, 6 TexReg 3819; amended to be effective November 11, 1983, 8 TexReg 4499; amended to be effective October 1, 1985, 10 TexReg 3506; amended to be effective October 17, 1989, 14 TexReg 5260.

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