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The Collaborative Clearinghouse for Lawsuits and Other Claims Against ACE Group Insurance Companies

ACE American Insurance Company Disciplinary Action 091610 Part II

ATTENTION: It is possible that this information may no longer be current and therefore may be inaccurate. The index contains both open and closed cases and is not a complete list of cases in which an ACE Insurance Group company is involved. This information is provided to give interested persons an idea of the issues disputed in the indexed cases. For a full understanding of a case, one should read the rest of the court file, including the response. For the most up-to-date and complete information on a case, visit www.pacer.gov or contact the clerk of the relevant court.

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No. _________________
DWC-lO-0080
OFFICIAL ORDER of the COMMISSIONER OF WORKERS' COMPENSATION of the STATE OF TEXAS AUSTIN, TEXAS
SEP 16 2010
Date: ____________________ Subject Considered:
ACE AMERICAN INSURANCE COMPANY 436 Walnut Street Philadelphia, PA 19105 CONSENT ORDER DISCIPLINARY ACTION TDI ENFORCEMENT FILE NOS. 54941, 55675, 56349, 56732, 57105, 57135, 57618, 57106 General remarks and official action taken:
On this date came on for consideration by the Commissioner of Workers' Compensation, the matter of whether disciplinary action should be taken against Ace American Insurance Company ("Ace American"). The Texas Department of Insurance, Division of Workers' Compensation Staff ("Division Staff') alleges that Ace American violated the Texas Labor Code and that such conduct constitutes grounds for imposition of sanctions pursuant to TEX. LAB. CODE ANN. ch. 415. Division Staff and Ace American announce that they have compromised and settled all claims and agree to the entry of this Consent Order. The parties request that the Commissioner of Workers' Compensation informally dispose of this case pursuant to TEX. GOV'T CODE ANN. § 2001.056, TEX. LAB. CODE ANN. §§ 401.021 and 402.oo128(b)(7), and 28 TEX. ADMIN. CODE § 180.8(h). JURISD ICTIO N The Commissioner of Workers' Compensation has jurisdiction over this matter pursuant to TEX. LAB. CODE ANN. §§ 402.001, 402.00111, 402.00114, 402.00116, 402.00128, 408.0041,
COMMISSIONER'S ORDER
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408.027, 408.081, 408.101, 408.121, 408.125, 408.1225, 409.021, 409.023, 410.169, 410.208, 413.011, 415.002, 415.021, and 28 TEX. ADMIN. CODE ANN. §§ 129.3, 133.3,133.240, 134.204,134.402,134.1,142.16; and TEX. GOV'T CODE ANN. §§ 2001.051-2001.178. WAIVER Ace American Insurance Company acknowledges the existence of certain rights provided by the Texas Labor Code and other applicable law, including the right to receive a written notice of possible administrative violations as provided for by TEX. LAB. CODE ANN. § 415.032, the right to request a hearing as provided for by TEX. LAB. CODE ANN. § 415.034, and the right to judicial review of the decision as provided for by TEX. LAB. CODE ANN. § 415.035. Ace American Insurance Company waives all of these rights, as well as any other procedural rights that might otherwise apply, in consideration of the entry of this Consent Order. FINDINGS OF FACT The Commissioner makes the following fmdings of fact:
System Participant
1.
Ace American Insurance Company is a foreign property and casualty insurance company currently holding a certificate of authority issued by the Texas Department of Insurance on October 31, 1966, to transact the business of insurance pursuant to TEX. INS. CODE ANN. §§ 801.051-801.053, and is licensed to write multiple lines of insurance, including workers' compensation/employer's liability.
Responsibility to Comply with Commissioner Decisions or Orders
2.
In accordance with 28 TEX. LAB. CODE ANN. § 410.169, a decision of a hearing officer is final in the absence of timely appeal by a party and is binding pending appeal to the appeals panel. In accordance with 28 TEX. LAB. CODE ANN. § 41O.208(e), a person commits an administrative violation if the person fails or refuses to comply with an interlocutory order, final order, or decision of the commissioner within twenty days after the date the order or decision becomes final.
In accordance with 28 TEX. LAB. CODE ANN. § 415.002(a)(17), an insurance carrier or its representative commits an administrative violation if it fails to pay an order awarding benefits. In accordance with 28 TEX. LAB. CODE ANN. § 415.002(a)(20), an insurance carrier or its representative commits an administrative violation if it violates a commissioner rule.
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COMMISSIONER'S ORDER
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6.
In accordance with 28 TEX. LAB. CODE ANN. § 415.021(a), in addition to any other provisions in this subtitle relating to administrative violations, a person commits an administrative violation if the person fails to comply with an order or decision of the commissioner.
7.
In accordance with 28 TEX. ADMIN. CODE § 142.16(f), a decision regarding benefits not appealed to the appeals panel becomes final on the sixteenth day after the date received from the division of hearings. Parties shall comply with a final decision or order within 20 days from the date it becomes final. In accordance with 28 TEX. ADMIN. CODE § 142.16(g), a decision regarding benefits appealed to the appeals panel as provided by the Texas Lab. Code, §410.202 and Chapter 143 of this title, is binding on the parties and payable during an appeal to the appeals panel unless superseded by an interlocutory order contained in the decision, if any.
In accordance with 28 TEX. ADMIN. CODE § 142.16(h), parties shall comply with a decision regarding benefits appealed to the appeals panel that does not contain an interlocutory order by issuing and delivering payment of accrued and unpaid income benefits no later than the fifth day after filing a written request for appeal with the appeals panel as provided by the Texas Lab. Code §410.202, and Chapter 143 of this title.
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Failure to Timely Comply with Commissioner Decisions or Orders
10.
Ace American failed to comply with a contested case hearing decision and order (CCH D&O) for injured employee: N.W, Carrier No.YLLC28864, Division Claim No. XXXX3078, CIS No. 874188, and CTS No. 57135. a. On March 13,2009, a CCH D&O was issued ordering the carrier to pay benefits for disability period from August 16, 2006 through August 21, 2006, from August 24, 2006 until November 11, 2007 and December 14, 2007 until April 23, 2008. Ace American received the order on March 19, 2009. b. Ace American had fifteen working days from the date of receipt of the CCH D&O to appeal or the order would become final on the sixteenth day on April 10, 2009. The carrier had twenty days or until April 30, 2009 to pay the accrued benefits in addition to interest. c. Ace American did not comply with the CCH D&O until May 8, 2009, 8 days late.
11.
Ace American failed to comply with a CCH D&O for injured employee: L.H., Carrier No. YLLC56507, Division Claim No. XXXX2088, CIS No. 879738, and CTS No. 57135. a. On April 11, 2009, a CCH D&O was issued requiring the carrier to pay benefits in accordance with the decision that the injury was compensable.
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COMMISSIONER'S ORDER
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b. The order became final on the sixteenth day after receipt on May 13, 2009. Ace American was required to comply within twenty days of the order becoming final or by June 2, 2009. c. Ace American carrier did not comply with the CCH D&O until June 24,2009, 22 days late. Responsibility to Comply with a Medical Dispute Resolution Order (MDRO) 12. In accordance with 28 TEX. LAB. CODE ANN. § 415.002(a)(17), an insurance carrier or its representative commits an administrative violation if it fails to pay an order awarding benefits.
In accordance with 28 TEX. LAB. CODE ANN. § 415.021(a), in addition to any other provisions in this subtitle relating to administrative violations, a person commits an administrative violation if the person fails to comply with an order or decision of the commissioner.
13.
Failure to Comply with a MDRO 14. Ace American failed to comply with a MDRO for injured employee: A.c., Carrier No. C290C3489761, Division Claim No. XXXX6640, CIS No. 825170, and CTS No. 57106. a. On December 27, 2007, Ace American received MDRO M4-08-0349-01. Ace American was ordered to reimburse the health care provider (HCP) $732.20, plus interest within 30 days, or on January 26,2008. b. Ace American issued payment on April 18, 2008, in the amount of $780.20, 83 days late. Responsibility to Timely Pay Impairment Income Benefits (IIBs) 15. TEX. LAB. CODE ANN. § 408.121 requires a carrier to pay IIBs not later than the fifth day after the date on which the insurance carrier receives the doctor's report certifying maximum medical improvement. IIBs shall be paid for a period based on the impairment rating, unless that rating is disputed. TEX. LAB. CODE ANN §§408.1225(c) and 408.125(c) states the report of the designated doctor has presumptive weight, and the division shall base its determination of whether the employee has reached maximum medical improvement (MMI) on the report unless the preponderance of the other medical evidence it to the contrary.
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TEX. LAB. CODE ANN §408.0041 (£) states unless otherwise ordered by the commissioner, the carrier shall pay benefits based on the opinion of the designated doctor during the pendency of any dispute. TEX. LAB. CODE ANN. §408.081 requires a carrier to pay benefits weekly, as and when the benefits accrue without order from the commissioner. Weekly benefits are to be paid seven days after the first day of a pay period and monthly benefits are to be paid seven days after the end of the pay period.
Failure to Timely Pay IIBs
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Ace American failed to timely pay nBs within five days after receipt of the MMI report for injured employee: T.B., Carrier No. YLLC34954, Division Claim No. XXXX1458, CIS No. 871968, and CTS No. 57105. a. The injured employee reached MMI on December 9, 2008 with an impairment rating of 15%. b. On February 27, 2009, Ace American received a DWC Form-69 from the injured employee's certifying doctor. The carrier was required to issue nBs for twelve weeks within five days after of receipt of DWC Form-69 or by March 4, 2009. c. Ace American issued nBs in the amount of $3,375.82 on March 23, 2009, 19 days late.
20.
Ace American failed to timely pay nBs within five days after receipt of the MMI report for injured employee: A.C., Carrier No.YLLC60069, Division Claim No. XXXX7521, CIS No.867671, and CTS No.56732 a. The injured employee reached MMI on December 22, 2008 with an impairment rating of 7%. b. On March 6, 2009, Ace American received a DWC Form-69 from the injured employee's certifying doctor. Ace American was required to issue nBs for twentyone weeks within five days after receipt of DWC Form-69 of by March 11, 2009. c. Ace American issued IIBs in the amount of $4,135.60, on April 3, 2009, 23 days late.
21.
Ace American failed to timely pay nBs within five days after receipt of the MMI report for injured employee: I.M., Carrier No. YLLC32188, Division Claim No. XXXX4635, CIS No.872852, and CTS No.56732. a. The injured employee reached MMI on March 17, 2008 with an impairment rating of 10%.
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b. Ace American received a DWC Form-69 from the injured employee's certifying doctor on April 16, 2009. Ace American was required to issue IIBs benefits for 30 weeks within five days after receipt of DWC Form-69 or by April 21, 2009. c. Ace American issued IIBs benefits for 30 weeks in the amount of $10,098.80 on May 19,2009,28 days late.
Responsibility to Timely Pay Temporary Income Benefits (TIBs)
22.
TEX. LAB. CODE ANN. § 408.081 requires a carrier to pay benefits weekly, as and when the benefits accrue without order from the commissioner. Weekly benefits are to be paid seven days after the first day of a period and monthly benefits are to be paid seven days after the end of the pay period. TEX. LAB. CODE ANN §§ 408.1225(c) and 408.125(c) states the report of the designated doctor has presumptive weight, and the division shall base its determination of whether the employee has reached maximum medical improvement on the report unless the preponderance of the other medical evidence it to the contrary. TEX. LAB. CODE ANN § 409.021(a-e) states an insurance carrier shall initiate compensation under this subtitle promptly, not later than the 15 th day after the date on which an insurance carrier receives written notice of an injury, the insurance carrier shall (1) begin the payment of benefits as required by this subtitle; or (2) notify the division and the employee in writing of it refusal to pay and advise the employee of (a) the right to request a benefit review conference; and (b) the means to obtain additional information from the division. TEX. LAB. CODE ANN § 409.023(a) states an insurance carrier shall continue to pay benefits promptly as and when the benefits accrue without a final decision, order, or other action of the commissioner. TEX. LAB. CODE ANN. § 409.023(d) states an insurance carrier that commits multiple violations of this section commits an additional administrative violation.
Failure to Timely Pay Tills
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Ace American failed to timely pay Tills within seven days after the first day of a pay period or within seven days of a pay period ending for injured employee: J.G., Carrier No. 4650287529, Division Claim No. XXXX6703, CIS No. 873196, and CTS No. 56349. a. Ace American did not issue Tills for the weeks of April 8, 2009 through April 14, 2009 and April 15, 2009 through April 21, 2009.
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b. On April 24, 2009, the injured employee reported to TDI-DWC that he had not received a TIBs payment in two weeks. The TDI-DWC contacted the insurance carrier and the adjuster stated, "That somehow the injured employee was not in the system and that the payment would be issued and second day delivered". Ace American was required to continue to pay TIBs benefits weekly as and when the benefits accrue. c. Ace American issued a payment in the amount of $1,146.10 on April 24, 2009, 9 days late for benefit week of April 5, 2009 through April 14, 2009 and 2 days late for benefit week April 15,2009 through April 21, 2009. 28. Ace American failed to timely pay TIBs within seven days after the first day of a pay period or within seven days of a pay period ending for injured employee: J.P., Carrier No. C135C6835796, Division Claim No. XXXX0154, CIS No. 823066, and CTS No. 54941. a. Ace American did not issue TIBs for the week of April 23, 2007 through April 29, 2007 and subsequent weeks April 30, 2007 through September 9,2007. b. Ace American received notice of the employee's injury on April 23, 2007. The first day of TIBs eligibility was on April 23, 2007 and the due date to initiate TIBs was no later than May 8, 2007. Ace American was required to initiate compensation promptly, not later than the 15 th day after the date on which an insurance carrier receives written notice of an injury. Ace American was required to use wage information provided by the employee until the necessary information is provided by the employer. c. On December 28, 2007, Ace American issued payment in the amount of $9,104.17, 233 days late for benefit week of April 23, 2007 through April 29, 2007 and subsequent weeks April 30, 2007 through September 4,2007. 29. Ace American failed to timely pay TIBs within seven days after the first day of a pay period or within seven days of a pay period ending for injured employee: K.S., Carrier No.C494C0223443, Division Claim No. XXXX9364, CIS No.851827, and CTS No.55675. a. Ace American did not issue TIBs for the week of September 19, 2008 through September 25, 2008. In addition, Ace American did not issue subsequent benefits for weeks September 26, 2008 through December 18, 2008. Ace American was required to continue to pay TIBs benefits weekly as and when the benefits accrue. b. On December 19, 2008, Ace American issued TIBs benefits in the amount of $1,391.00 for the weeks of September 19, 2008 through September 25,2008,84 days late.
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30.
Ace American failed to timely pay TIBs within seven days after the first day of a pay period or within seven days of a pay period ending for injured employee: R.M., Carrier No.YLLC70158, Division Claim No. XXXXI085, CIS No.879207, and CTS No. 56732. a. The insurance carrier did not issue TIBs for the week of June 9, 2009 through June 15,2009 and subsequent week June 19,2009 through June 22, 2009. The carrier was required to continue to pay TIBs weekly as and when the benefits accrue. b. On June 24, 2009, the carrier issued TIBs benefits in the amount of $1,350.04 for the weeks of June 9, 2009 through June 15, eight days late.
31.
Ace American failed to timely pay TIBs within seven days after the first day of a pay period or within seven days of a pay period ending for injured employee: D.M., Carrier No. 4650284504, Division Claim No. XXXX6454, CIS No. 883108, and CTS No.57618. a. Ace American did not issue TIBs for the week of June 10, 2009 through June 16, 2009 and subsequent week June 19,2009 through June 22, 2009. Ace American was required to continue to pay TIBs benefits weekly as and when the benefits accrue. b. On July 21,2009, Ace American issued TIBs benefits in the amount of $1,099.44, 4 days late.
Responsibility to Take Final Action on a Medical Bill in a Timely Manner
32.
TEX. LAB. CODE ANN. § 408.027(b) states the insurance carrier must pay, reduce, or determine to audit the health care provider's claim not later than the 45 th day after the date of receipt by the carrier of the provider's claim.
In accordance with 28 TEX. ADMIN.CODE § 133.240(e), an insurance carrier shall take
33.
final action after conducting bill review on a complete medical bill, or determine to audit the medical bill not later than the 45 th day after the date the insurance carrier received a complete medical bill.
Failure to Take Timely Final Action on a Medical Bill
34.
Ace American failed to take timely action on a medical bill for injured employee: C.E., Carrier No. C135C6865232, Division Claim No. XXXX7619, CIS No. 879823, CTS No. 57618. a. The HCP provided medical services on August 28, 2008. Ace American received a properly completed medical bill from the HCP on September 8, 2008 in the amount of $847.25.
COMMISSIONER'S ORDER
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b. Ace American was required to take final action on the medical bill within 45 days of receipt on or before October 23,2008. c. Ace American issued final payment of $535.41 on July 23,2009,273 days late.
Responsibility to Provide Sufficient Reason for Reduction or Denial of a Payment for Medical Services
35. TEX. LAB. CODE ANN. § 408.027(e) states if an insurance carrier disputes the amount of payment or the health care provider's entitlement to payment, the insurance carrier shall send to the division, the health care provider, and the injured employee a report that sufficiently explains the reasons for the reduction or denial of payment for health care services provided to the employee.
In accordance with 28 TEX. ADMIN. CODE § 133.3(a), any communication between the health care provider and the insurance carrier related to medical bill processing shall be sufficient, specific detail to allow the responder to easily identify the information required to resolve the issue or question related to the medical bill.
36.
Failure to Provide Sufficient Reason for Reduction or Denial to Pay for Medical Services
37. Ace American failure to provide sufficient reason for reduction or denial to pay for medical services for injured employee: K.L., Carrier No.C135C7166698, and Division Claim No. XXXX8606, CIS No. 887317, CTS No. 57618. a. The HCP rendered services to the injured employee on April 13, 2009. b. On April 23, 2009, Ace American denied the services stating "Denied per insurance: coverage of the injury is disputed 100%". c. This was an insufficient reason for denial because a Contested Case Hearing decision and order issued on March 27, 2009 determined that the injured employee sustained a compensable injury. 38. Ace American failed to provide sufficient reason for reduction or denial to pay for medical services for injured employee M.C .. , Carrier No. C135C7153476, Division No. XXXX9824, CIS No. 895652, CTS No. 57618. a. The HCP provided medical services to the injured employee on April 24, 2009. The carrier received the medical bill on June 26, 2009. b. In response, on September 4, 2009 Ace American denied stating "29-The time limit for filing has expired".
COMMISSIONER'S ORDER
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c. This was an insufficient reason for the denial because the HCP provided a fax confirmation sheet that the carrier received the bill on June 26, 2009. 39. Ace American failed to provide sufficient reason for reduction or denial to pay for medical services for injured employee: R.S., Carrier No.027940000040760001, Division Claim No. XXXX1777, CIS No. 833833, CTS No. 57092. a. The HCP rendered one unit of physical therapy to the injured employee on May 14, 2008. The HCP submitted a complete medical bill for services on May 21, 2008 in the amount of $102.01. Ace American received the medical bill on May 23, 2008. b. In response, on June 20, 2008 Ace American denied stating reason code X9Y "Documentation to substantiate this charge was not submitted or is insufficient to accurately review this charge (X368 ANSI - 16)". c. This was an insufficient reason for the denial because the services rendered do not require documentation.
Responsibility to Pay Medical Bills in Accordance with Medical Fee Guidelines
40.
TEX. LAB. CODE ANN. § 413.011(a-d) states the commissioner shall adopt health care reimbursement policies and guidelines that reflect the standardized reimbursement structures found in other health care delivery systems with minimal modifications to those reimbursement methodologies as necessary to meet occupational injury requirements. To achieve standardization, the commissioner shall adopt the most current reimbursement methodologies, models, and values or weights used by the Federal Centers for Medicare and Medicaid Services, including applicable payment policies relating to coding, billing, and reporting, and may modify documentation requirements as necessary to meet the requirements of Section 413.053. 28 TEX. ADMIN. CODE § 134.402(e)(f) states regardless of billed amount, reimbursement shall be: (1) the amount for the service that is included in a specific fee schedule set in a contract that complies with the requirements of Labor Code §413.011; or (2) if no contracted fee schedule exists that complies with Labor Code §413.011, the maximum allowable reimbursement (MAR) amount under subsection (f) of this section, including any reimbursement for implantables. (3) If no contracted fee schedule exists that complies with Labor Code §413.011, and an amount cannot be determined by application of the formula to calculate the MAR as outlined in subsection (f) of this section, reimbursement shall be determined in accordance with § 134.1 of this title The reimbursement calculation used for (relating to Medical Reimbursement). establishing the MAR shall be the Medicare ASC reimbursement amount determined by applying the most recently adopted and effective Medicare Payment System Policies for Services Furnished in Ambulatory Surgical Centers and Outpatient Prospective Payment System reimbursement formula and factors as published annually in the Federal Register.
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Reimbursement shall be based on the fully implemented payment amount as in ADDENDUM AA, ASC COVERED SURGICAL PROCEDURES FOR CY 2008, published in the November 27, 2007 publication of the Federal Register, or its successor. Failure to Pay Medical Bills in Accordance with Medical Fee Guidelines 42. Ace American failed to pay the HCP that provided services for injured employee: G.Q., Carrier No. 0279000048190001, Division No. XXXX3176, CIS No. 888739, CTS No. 57618. a. The HCP provided medical services to the injured employee on September 8, 2008. The HCP submitted a bill for services code CPT 99456-W5, CPT 99456-W6, and CPT 99456-W7 on September 22, 2008 in the amount of $1,525.00. In response to the medical bill the Ace American paid a reduced amount of $350.00, stating code "WI Workers Compensation State Fee schedule Adjustment" and "Provider contracted/negotiated rate expired or not on file". b. The HCP submitted a request for reconsideration for the remaining balance of $1,175 on September 1, 2009, on the same day a complaint was filed with the Division. The carrier paid $1,215.22 on October 12,2009. Other Considerations 43. Ace American has agreed to submit to the Division a compliance plan to ensure timely initiation and continuation of indemnity benefit payments within 60 days of the date of the signing of this Order.
CONCLUSIONS OF LAW Based upon the foregoing findings of fact, the Commissioner of Workers' Compensation makes the following conclusions of law: 1. The Commissioner of Workers' Compensation has jurisdiction over this matter pursuant to TEX. LAB. CODE ANN. §§ 402.001, 402.00111, 402.00114, 402.00116, 402.00128, 408.027, 408.0041, 408.81, 408.101, 408.125, 408.1225, 409.21, 410.169, 413.31, 415.002, 415.021, and 28 TEX ADMIN. CODE ANN. §§ 133.3, 133.307, 133.308, 134.1, 134.204, 134.402, 142.16, 180.2, 180.10; and TEX. GOV'T CODE ANN. §§ 2001.051-2001.178. The Commissioner of Workers' Compensation has authority to informally dispose of this matter as set forth herein under TEX GOV'T CODE ANN. § 2001.056, TEX. LAB. CODE ANN. §§ 401.021 and 402.00 128(b)(7), and 28 TEX ADMIN. CODE § 180.8(h).
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3.
Ace American has knowingly and voluntarily waived all procedural rights to which they may have been entitled regarding the entry of this Order, including, but not limited to, written notice of possible administrative violations, a hearing, and judicial review.
In accordance with TEX. LAB. CODE ANN. § 415.021, the Commissioner of Workers' Compensation may assess an administrative penalty against a person who commits an administrative violation.
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In accordance with TEX. LAB. CODE ANN. § 415.021, in addition to any other provisions in this subtitle relating to violations, a person commits an administrative violation if the person violates, fails to comply with, or refuses to comply with this subtitle or a rule, order, or decision of the commissioner. Ace American violated TEX. LAB. CODE ANN §410.169 by its failure to comply with a decision or order of the commission. Ace American violated TEX. LAB. CODE ANN §41O.20S(e) by its failure or refusal to comply with an interlocutory order, final order, or decision of the commissioner within twenty days after the date of the order or decision. Ace American violated TEX. LAB. CODE ANN §415.002(a)(17) when it failed to pay an order awarding benefits. Ace American violated TEX. LAB. CODE ANN §415.002(a)(20) when it did not comply with a commissioner rule. Ace American violated TEX. LAB. CODE ANN §142.16(f) by its failure or refusal to comply with a final decision within twenty days. Ace American violated TEX. LAB. CODE ANN § 142.16(g) by its failure or refusal to comply with an appealed decision that is binding on appeal. Ace American violated TEX. LAB. CODE ANN § 142.16(h) by its failure or refusal to comply with a binding decision regarding benefits pending appeal within five days after the date of the appealed decision. Ace American violated TEX. LAB. CODE ANN § 40S.121 when it failed to pay benefits within five days after receipt of the MMI. Ace American violated TEX. LAB. CODE ANN §§ 40S.1225(c) and 40S.125(c) by failing to give the report of the designated doctor presumptive weight of whether the employee has reached MMI on the report.
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Ace American violated TEX. LAB. CODE ANN § 408.0041(f) when it failed to pay benefits based on the opinion of the designated doctor during the pendency of any dispute. Ace American violated TEX. LAB. CODE ANN § 409.021 (a-e) when it failed to initiate compensation benefits within fifteen days after it received written notice of an employee's injury. Ace American violated TEX. LAB. CODE ANN § 409.023(a) when it failed to pay benefits promptly when the benefits accrued. Ace American violated TEX. LAB. CODE ANN. § 408.027(b) by failing to pay, reduce, or determine to audit the HCP's claim not later than the 45 th day after the date of receipt by the carrier of the provider's claim. Ace American violated 28 TEX. ADMIN. CODE § 133.240(e) by failing to take final action after conducting bill review on a complete medical bill, or determine to audit the medical bill not later than the 45 th day after the date the insurance carrier received a complete medical bill. Ace American violated TEX. LAB. CODE ANN. § 408.027(e) by failing to send to the division, the HCP, and the injured employee a report that sufficiently explains the reasons for the reduction or denial of payment for health care services provided to the employee. Ace American violated 28 TEX. ADMIN. CODE § 133.3(a) by failing to communicate with the health care provider in a manner that was sufficient and with specific detail to allow the responder to easily identify the information required to resolve the issue or question related to the medical bill. Ace American violated TEX. LAB. CODE ANN. § 413.011 by failing to pay medical bills according to the Division Medical Fee Guidelines.
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Based on the Findings of Fact and Conclusions of Law above, the Commissioner of Workers' Compensation has determined that the appropriate disposition is to order payment of an administrative penalty and full compliance with the terms of this Order.
IT IS THEREFORE ORDERED that Ace American Insurance Company shall pay, and is hereby directed to pay, on or before thirty (30) days from the date of this Order, an administrative penalty in the amount of ONE HUNDRED FORTY SEVEN THOUSAND DOLLARS AND NO CENTS ($147,000.00). The payment must be paid by company check, cashier's check or money order made payable to the "State of Texas" and transmitted to the Texas Department of Insurance, Enforcement Division-DWC, Division 3721, MC-9999, P.O. Box 149104, Austin, Texas 78714-9104.
COMMISSIONER'S ORDER
Ace American Insurance Company CTS#54941,55675, 56349, 56732, 57105,57135, 57618,57106 Page 14 of 16
DWC- 1 0-0080
IT IS FURTHER ORDERED that Ace American shall submit to the Division, within 60 days of the date of the signing of this Order, a compliance plan to ensure timely initiation and continuation of indemnity benefit payments. IT IS ALSO ORDERED by the Commissioner of Workers' Compensation that if Ace American Insurance Company fails to comply with the terms of this Order that Ace American Insurance Company will have committed an additional administrative violation and it's failure to comply with the terms of this Order may subject Ace American Insurance Company to further penalties as authorized by the Texas Labor Code, which, pursuant to TEX. LAB. CODE ANN. § 415.021(a), includes the right to impose an administrative penalty of up to $25,000 per day per occurrence.
, COMPENSATION
COMMISSIONER'S ORDER
DWC- 1 0-0080
Ace American Insurance Company <:[S#54941,55675,56349,56732,57105,57135,57618,57106 Page 15 of 16
FOR THE STAFF:
::G~U(y
Staff Attorney, Enforcement Texas Department of Insurance Division of Workers' Compensation
Title
TypedlPrinted N arne
AUSTIN CEl\l'fRAL OFPIa
«&':fUVBD ifANDD~
AUG 24 2010
JIVlSION OFWORKBRs' COMPBNsAOO
TEXAs DEPAKfM£NT OF INSURANt::!
COMMISSIONER'S ORDER
Ace American Insurance Company CTS#54941,55675,56349,56732,57105,57135,57618,57106 Page 16 of 16
DWC-IO-0080
§ § §
STATEOF~~
COUNTYOF
'~~
BEFORE ME, h~ (?~ a notary public in and for the State of~~n this day pxrsonally appeared o.&1t.. LV·~ , known to me or proven to me through /fCe ?j511 lh....wj{" . 0..to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that (he/she) executed the same for the purposes and consideration therein expressed, who being by me duly sworn, deposed as follows:
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"My name is L1J. WA,J . I am of sound mind, capable of making this statement, and personally acquainted with the facts herein stated. I hold the office of ct... I am an authorized representative of Ace American Insurance Company, which holds a Certificate of Authority to transact the business of insurance in the State of Texas, and I am duly authorized by said company to execute this statement. Ace American Insurance Company has knowingly and voluntarily entered into this Consent Order and agrees with and consents to the issuance and service of the foregoing Consent Order by the Commissioner of Workers' Compensation in the State of Texas,"
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TypedlPrinted Name day of Q~
Given under my hand and seal of office this
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S ignawre of Notary Public
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NOTARY PUBLIC IN AND FOR THE STATE OF My Commission Expires: _ _ _ _ _ _ __
Bianca D. Penho/low
My Commission Expires 04/04/2013
New Castle County, State of De/aware
Notary Public

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