ACE American Insurance Company Disciplinary Action 091610 Part II

8/8/2019 ACE American Insurance Company Disciplinary Action 091610 Part II

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DWC-lO-0080No. ________________ _

OFFICIAL ORDERof theCOMMISSIONER OFWORKERS' COMPENSATIONof the

Subject Considered:

STATE OF TEXASAUSTIN, TEXAS

SEP 16 2010Date: ____________________

ACE AMERICAN INSURANCE COMPANY436 Walnut StreetPhiladelphia, PA 19105CONSENT ORDERDISCIPLINARY ACTIONTDI 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, thematter of whether disciplinary action should be taken against Ace American Insurance Company("Ace American"). The Texas Department of Insurance, Division of Workers' CompensationStaff ("Division Staff') alleges that Ace American violated the Texas Labor Code and that suchconduct 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 claimsand agree to the entry of this Consent Order. The parties request that the Commissioner ofWorkers' 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 NThe 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,


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COMMISSIONER'S ORDER DWC-IO-0080Ace American Insurance CompanyCTS#54941, 55675,56349, 56732, 57105, 57135, 57618,57106Page 2 of 16408.027, 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.

WAIVERAce American Insurance Company acknowledges the existence of certain rights provided by theTexas Labor Code and other applicable law, including the right to receive a written notice ofpossible administrative violations as provided for by TEX. LAB. CODE ANN. 415.032, theright to request a hearing as provided for by TEX. LAB. CODE ANN. 415.034, and the right tojudicial review of the decision as provided for by TEX. LAB. CODE ANN. 415.035. AceAmerican Insurance Company waives all of these rights, as well as any other procedural rightsthat might otherwise apply, in consideration of the entry of this Consent Order.

FINDINGS OF FACTThe Commissioner makes the following fmdings of fact:

System Participant1. Ace American Insurance Company is a foreign property and casualty insurance companycurrently holding a certificate of authority issued by the Texas Department of Insurance onOctober 31, 1966, to transact the business of insurance pursuant to TEX. INS. CODEANN. 801.051-801.053, and is licensed to write multiple lines of insurance, includingworkers' compensation/employer's liability.

Responsibility to Comply with Commissioner Decisions or Orders2. In accordance with 28 TEX. LAB. CODE ANN. 410.169, a decision of a hearing officeris final in the absence of timely appeal by a party and is binding pending appeal to theappeals panel.3. In accordance with 28 TEX. LAB. CODE ANN. 41O.208(e), a person commits anadministrative violation if the person fails or refuses to comply with an interlocutoryorder, final order, or decision of the commissioner within twenty days after the date theorder or decision becomes final.4. In accordance with 28 TEX. LAB. CODE ANN. 415.002(a)(17), an insurance carrier orits representative commits an administrative violation if it fails to pay an order awardingbenefits.5. In accordance with 28 TEX. LAB. CODE ANN. 415.002(a)(20), an insurance carrier orits representative commits an administrative violation if it violates a commissioner rule.


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COMMISSIONER'S ORDER DWC .. 1 0-0080Ace American Insurance CompanyCTS#54941, 55675, 56349, 56732, 57105, 57135, 57618, 57106Page 3 of 166. In accordance with 28 TEX. LAB. CODE ANN. 415.021(a), in addition to any otherprovisions 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 thecommissioner.7. In accordance with 28 TEX. ADMIN. CODE 142.16(f), a decision regarding benefitsnot appealed to the appeals panel becomes final on the sixteenth day after the datereceived from the division of hearings. Parties shall comply with a final decision or orderwithin 20 days from the date it becomes final.8. In accordance with 28 TEX. ADMIN. CODE 142.16(g), a decision regarding benefitsappealed to the appeals panel as provided by the Texas Lab. Code, 410.202 and Chapter143 of this title, is binding on the parties and payable during an appeal to the appeals panelunless superseded by an interlocutory order contained in the decision, if any.9. In accordance with 28 TEX. ADMIN. CODE 142.16(h), parties shall comply with adecision regarding benefits appealed to the appeals panel that does not contain aninterlocutory order by issuing and delivering payment of accrued and unpaid incomebenefits no later than the fifth day after filing a written request for appeal with the appealspanel as provided by the Texas Lab. Code 410.202, and Chapter 143 of this title.

Failure to Timely Comply with Commissioner Decisions or Orders10. Ace American failed to comply with a contested case hearing decision and order (CCHD&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 fordisability 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. AceAmerican received the order on March 19, 2009.b. Ace American had fifteen working days from the date of receipt of the CCH D&O toappeal or the order would become final on the sixteenth day on April 10, 2009. Thecarrier had twenty days or until April 30, 2009 to pay the accrued benefits in additionto 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 inaccordance with the decision that the injury was compensable.


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COMMISSIONER'S ORDER DWC 1 0 008 0Ace American Insurance Company - -CTS#54941,55675, 56349, 56732, 57105, 57135, 57618, 57106Page 4 of 16b. The order became final on the sixteenth day after receipt on May 13, 2009. AceAmerican was required to comply within twenty days of the order becoming final orby 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 orits representative commits an administrative violation if it fails to pay an order awardingbenefits.13. In accordance with 28 TEX. LAB. CODE ANN. 415.021(a), in addition to any otherprovisions in this subtitle relating to administrative violations, a person commits anadministrative violation if the person fails to comply with an order or decision of thecommissioner.

Failure to Comply with a MDRO14. 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. AceAmerican was ordered to reimburse the health care provider (HCP) $732.20, plusinterest 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 fifthday after the date on which the insurance carrier receives the doctor's report certifyingmaximum medical improvement. IIBs shall be paid for a period based on the impairment

rating, unless that rating is disputed.16. TEX. LAB. CODE ANN 408.1225(c) and 408.125(c) states the report of the designateddoctor has presumptive weight, and the division shall base its determination of whetherthe employee has reached maximum medical improvement (MMI) on the report unless thepreponderance of the other medical evidence it to the contrary.


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COMMISSIONER'S ORDER DWr. 1 0 0 0 8 0Ace American Insurance Company . '.j - -CTS# 54941, 55675, 56349, 56732, 57105, 57135, 57618, 57106 .Page 5 of 1617. TEX. LAB. CODE ANN 408.0041 () states unless otherwise ordered by thecommissioner, the carrier shall pay benefits based on the opinion of the designated doctorduring the pendency of any dispute.18. TEX. LAB. CODE ANN. 408.081 requires a carrier to pay benefits weekly, as and whenthe benefits accrue without order from the commissioner. Weekly benefits are to be paidseven days after the first day of a pay period and monthly benefits are to be paid sevendays after the end of the pay period.

Failure to Timely Pay IIBs19. Ace American failed to timely pay nBs within five days after receipt of the MMI reportfor 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 ratingof 15%.

b. On February 27, 2009, Ace American received a DWC Form-69 from the injuredemployee's certifying doctor. The carrier was required to issue nBs for twelve weekswithin 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 dayslate.

20. Ace American failed to timely pay nBs within five days after receipt of the MMI reportfor injured employee: A.C., Carrier No.YLLC60069, Division Claim No. XXXX7521,CIS No.867671, and CTS No.56732a. The injured employee reached MMI on December 22, 2008 with an impairmentrating of 7%.b. On March 6, 2009, Ace American received a DWC Form-69 from the injuredemployee'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 reportfor 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 of10%.


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COMMISSIONER'S ORDER l ) W r - l 0 - o o ~ O Ace American Insurance CompanyCTS# 54941,55675, 56349, 56732,57105, 57135, 57618, 57106Page 6 of 16b. Ace American received a DWC Form-69 from the injured employee's certifyingdoctor on April 16, 2009. Ace American was required to issue IIBs benefits for 30weeks 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 whenthe benefits accrue without order from the commissioner. Weekly benefits are to be paidseven days after the first day of a period and monthly benefits are to be paid seven daysafter the end of the pay period.23. TEX. LAB. CODE ANN 408.1225(c) and 408.125(c) states the report of thedesignated doctor has presumptive weight, and the division shall base its determination ofwhether the employee has reached maximum medical improvement on the report unlessthe preponderance of the other medical evidence it to the contrary.24. TEX. LAB. CODE ANN 409.021(a-e) states an insurance carrier shall initiatecompensation under this subtitle promptly, not later than the 15 th day after the date onwhich 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 andthe employee in writing of it refusal to pay and advise the employee of (a) the right torequest a benefit review conference; and (b) the means to obtain additional informationfrom the division.

25. TEX. LAB. CODE ANN 409.023(a) states an insurance carrier shall continue to paybenefits promptly as and when the benefits accrue without a final decision, order, or otheraction of the commissioner.26. TEX. LAB. CODE ANN. 409.023(d) states an insurance carrier that commits multipleviolations of this section commits an additional administrative violation.

Failure to Timely Pay Tills27. Ace American failed to timely pay Tills within seven days after the first day of a payperiod 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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COMMISSIONER'S ORDER DWC-IO-0080Ace American Insurance CompanyCTS#54941,55675,56349,56732,57105,57135,57618,57106Page 7 of 16

b. On April 24, 2009, the injured employee reported to TDI-DWC that he had notreceived a TIBs payment in two weeks. The TDI-DWC contacted the insurancecarrier and the adjuster stated, "That somehow the injured employee was not in thesystem and that the payment would be issued and second day delivered". AceAmerican was required to continue to pay TIBs benefits weekly as and when thebenefits accrue.c. Ace American issued a payment in the amount of $1,146.10 on April 24, 2009, 9 dayslate for benefit week of April 5, 2009 through April 14, 2009 and 2 days late forbenefit 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 payperiod 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 firstday of TIBs eligibility was on April 23, 2007 and the due date to initiate TIBs was nolater than May 8, 2007. Ace American was required to initiate compensationpromptly, not later than the 15 th day after the date on which an insurance carrierreceives written notice of an injury. Ace American was required to use wageinformation provided by the employee until the necessary information is provided bythe 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 andsubsequent 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 payperiod or within seven days of a pay period ending for injured employee: K.S., CarrierNo.C494C0223443, Division Claim No. XXXX9364, CIS No.851827, and CTSNo.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 forweeks September 26, 2008 through December 18, 2008. Ace American was requiredto 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 dayslate.


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COMMISSIONER'S ORDER Dwe 1 0 0 0 8 0Ace American Insurance Company - -CTS#54941, 55675,56349, 56732, 57105, 57135, 57618, 57106Page 8 of 1630. Ace American failed to timely pay TIBs within seven days after the first day of a payperiod 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 June15,2009 and subsequent week June 19,2009 through June 22, 2009. The carrier wasrequired 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 theweeks 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 payperiod or within seven days of a pay period ending for injured employee: D.M., CarrierNo. 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 wasrequired 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 Manner32. TEX. LAB. CODE ANN. 408.027(b) states the insurance carrier must pay, reduce, ordetermine 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.33. In accordance with 28 TEX. ADMIN.CODE 133.240(e), an insurance carrier shall takefinal action after conducting bill review on a complete medical bill, or determine to auditthe medical bill not later than the 45 th day after the date the insurance carrier received acomplete medical bill.

Failure to Take Timely Final Action on a Medical Bill34. 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 aproperly completed medical bill from the HCP on September 8, 2008 in the amount

of $847.25.


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COMMISSIONER'S ORDER DWC-IO-0080Ace American Insurance CompanyCTS#54941, 55675, 56349,56732, 57105, 57135, 57618, 57106Page 9 of 16b. Ace American was required to take final action on the medical bill within 45 days ofreceipt 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 forReduction or Denial of a Payment for Medical Services35. TEX. LAB. CODE ANN. 408.027(e) states if an insurance carrier disputes the amount ofpayment or the health care provider's entitlement to payment, the insurance carrier shallsend to the division, the health care provider, and the injured employee a report thatsufficiently explains the reasons for the reduction or denial of payment for health careservices provided to the employee.36. In accordance with 28 TEX. ADMIN. CODE 133.3(a), any communication between thehealth care provider and the insurance carrier related to medical bill processing shall besufficient, specific detail to allow the responder to easily identify the information requiredto resolve the issue or question related to the medical bill.

Failure to Provide Sufficient Reason for Reduction or Denial to Pay for Medical Services37. Ace American failure to provide sufficient reason for reduction or denial to pay formedical services for injured employee: K.L., Carrier No.C135C7166698, and DivisionClaim 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 decisionand order issued on March 27, 2009 determined that the injured employee sustained acompensable injury.

38. Ace American failed to provide sufficient reason for reduction or denial to pay for medicalservices 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. Thecarrier received the medical bill on June 26, 2009.b. In response, on September 4, 2009 Ace American denied stating "29-The time limitfor filing has expired".


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COMMISSIONER'S ORDER DWC-IO-0080Ace American Insurance CompanyCTS#54941, 55675,56349, 56732, 57105, 57135, 57618, 57106Page 10 of 16c. This was an insufficient reason for the denial because the HCP provided a faxconfirmation 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 medicalservices for injured employee: R.S., Carrier No.027940000040760001, Division ClaimNo. 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 inthe 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 toaccurately review this charge (X368 ANSI - 16)".c. This was an insufficient reason for the denial because the services rendered do notrequire documentation.

Responsibility to Pay Medical Bills in Accordance with Medical Fee Guidelines40. TEX. LAB. CODE ANN. 413.011(a-d) states the commissioner shall adopt health carereimbursement policies and guidelines that reflect the standardized reimbursementstructures found in other health care delivery systems with minimal modifications to thosereimbursement methodologies as necessary to meet occupational injury requirements. Toachieve standardization, the commissioner shall adopt the most current reimbursement

methodologies, models, and values or weights used by the Federal Centers for Medicareand Medicaid Services, including applicable payment policies relating to coding, billing,and reporting, and may modify documentation requirements as necessary to meet therequirements of Section 413.053.41. 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 feeschedule 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, themaximum 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 byapplication of the formula to calculate the MAR as outlined in subsection (f) of thissection, reimbursement shall be determined in accordance with 134.1 of this title(relating to Medical Reimbursement). The reimbursement calculation used forestablishing the MAR shall be the Medicare ASC reimbursement amount determined byapplying the most recently adopted and effective Medicare Payment System Policies forServices Furnished in Ambulatory Surgical Centers and Outpatient Prospective PaymentSystem reimbursement formula and factors as published annually in the Federal Register.


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COMMISSIONER'S ORDER DWC-lO-0080Ace American Insurance CompanyCTS#54941, 55675, 56349, 56732, 57105, 57135,57618, 57106Page II of 16Reimbursement shall be based on the fully implemented payment amount as inADDENDUM 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 Guidelines42. 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, andCPT 99456-W7 on September 22, 2008 in the amount of $1,525.00. In response tothe medical bill the Ace American paid a reduced amount of $350.00, stating code"WI Workers Compensation State Fee schedule Adjustment" and "Providercontracted/negotiated rate expired or not on file".

b. The HCP submitted a request for reconsideration for the remaining balance of $1,175on September 1, 2009, on the same day a complaint was filed with the Division. Thecarrier 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 timelyinitiation and continuation of indemnity benefit payments within 60 days of the date ofthe signing of this Order.

CONCLUSIONS OF LAWBased upon the foregoing findings of fact, the Commissioner of Workers' Compensation makesthe following conclusions of law:1. The Commissioner of Workers' Compensation has jurisdiction over this matter pursuantto 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. 2001.051-2001.178.2. The Commissioner of Workers' Compensation has authority to informally dispose of thismatter 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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COMMISSIONER'S ORDER DWC-IO-0080Ace American Insurance CompanyCTS#54941, 55675,56349, 56732, 57105, 57135, 57618, 57106Page 12 of 163. Ace American has knowingly and voluntarily waived all procedural rights to which theymay 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.4. In accordance with TEX. LAB. CODE ANN. 415.021, the Commissioner of Workers'Compensation may assess an administrative penalty against a person who commits anadministrative violation.5. In accordance with TEX. LAB. CODE ANN. 415.021, in addition to any otherprovisions in this subtitle relating to violations, a person commits an administrativeviolation if the person violates, fails to comply with, or refuses to comply with thissubtitle or a rule, order, or decision of the commissioner.6. Ace American violated TEX. LAB. CODE ANN 410.169 by its failure to comply with adecision or order of the commission.7. Ace American violated TEX. LAB. CODE ANN 41O.20S(e) by its failure or refusal tocomply with an interlocutory order, final order, or decision of the commissioner withintwenty days after the date of the order or decision.S. Ace American violated TEX. LAB. CODE ANN 415.002(a)(17) when it failed to payan order awarding benefits.9. Ace American violated TEX. LAB. CODE ANN 415.002(a)(20) when it did not complywith a commissioner rule.10. Ace American violated TEX. LAB. CODE ANN 142.16(f) by its failure or refusal tocomply with a final decision within twenty days.11. Ace American violated TEX. LAB. CODE ANN 142.16(g) by its failure or refusal tocomply with an appealed decision that is binding on appeal.12. Ace American violated TEX. LAB. CODE ANN 142.16(h) by its failure or refusal tocomply with a binding decision regarding benefits pending appeal within five days afterthe date of the appealed decision.13. Ace American violated TEX. LAB. CODE ANN 40S.121 when it failed to pay benefitswithin five days after receipt of the MMI.14. Ace American violated TEX. LAB. CODE ANN 40S.1225(c) and 40S.125(c) byfailing to give the report of the designated doctor presumptive weight of whether theemployee has reached MMI on the report.


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COMMISSIONER'S ORDER DWC-IO-0080Ace American Insurance CompanyCTS#54941, 55675,56349, 56732, 57105, 57135, 57618,57106Page 13 of 1615. Ace American violated TEX. LAB. CODE ANN 408.0041(f) when it failed to paybenefits based on the opinion of the designated doctor during the pendency of any

dispute.16. Ace American violated TEX. LAB. CODE ANN 409.021 (a-e) when it failed to initiatecompensation benefits within fifteen days after it received written notice of anemployee's injury.17. Ace American violated TEX. LAB. CODE ANN 409.023(a) when it failed to paybenefits promptly when the benefits accrued.18. 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 receiptby the carrier of the provider's claim.19. Ace American violated 28 TEX. ADMIN. CODE 133.240(e) by failing to take finalaction after conducting bill review on a complete medical bill, or determine to audit themedical bill not later than the 45 th day after the date the insurance carrier received acomplete medical bill.20. Ace American violated TEX. LAB. CODE ANN. 408.027(e) by failing to send to thedivision, the HCP, and the injured employee a report that sufficiently explains the reasonsfor the reduction or denial of payment for health care services provided to the employee.21. Ace American violated 28 TEX. ADMIN. CODE 133.3(a) by failing to communicatewith the health care provider in a manner that was sufficient and with specific detail toallow the responder to easily identify the information required to resolve the issue orquestion related to the medical bill.22. Ace American violated TEX. LAB. CODE ANN. 413.011 by failing to pay medicalbills according to the Division Medical Fee Guidelines.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 anadministrative penalty and full compliance with the terms of this Order.IT IS THEREFORE ORDERED that Ace American Insurance Company shall pay, and ishereby directed to pay, on or before thirty (30) days from the date of this Order, anadministrative penalty in the amount of ONE HUNDRED FORTY SEVEN THOUSANDDOLLARS 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 theTexas Department of Insurance, Enforcement Division-DWC, Division 3721, MC-9999, P.O.Box 149104, Austin, Texas 78714-9104.


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COMMISSIONER'S ORDER DWC- 1 0 -0080Ace American Insurance CompanyCTS#54941,55675, 56349, 56732, 57105,57135, 57618,57106Page 14 of 16IT IS FURTHER ORDERED that Ace American shall submit to the Division, within 60 daysof the date of the signing of this Order, a compliance plan to ensure timely initiation andcontinuation of indemnity benefit payments.IT IS ALSO ORDERED by the Commissioner of Workers' Compensation that if AceAmerican Insurance Company fails to comply with the terms of this Order that Ace AmericanInsurance Company will have committed an additional administrative violation and it's failure tocomply with the terms of this Order may subject Ace American Insurance Company to furtherpenalties 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 peroccurrence.

, COMPENSATION


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COMMISSIONER'S ORDER DWC- 10-0080Ace American Insurance Company


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COMMISSIONER'SORDER DWC-IO-0080Ace American Insurance CompanyCTS#54941,55675,56349,56732,57105,57135,57618,57106Page 16 of 16S T A T E O F ~ ~

COUNTYOF ' ~ ~

BEFORE ME, cl1 ( ? ~ a notary public in and for the State o f ~ ~ n this day pxrsonally appeared 9- o.&1t.. L V ~ , known to me or proven to methrough /fCe ?j511 lh....wj{" . 0..- to be the person whose name is subscribed to theforegoing instrument, and acknowledged to me that (he/she) executed the same for the purposesand consideration therein expressed, who being by me duly sworn, deposed as follows:1. "My name is :rAc.t. L1J. 20WA,J . I am of sound mind, capable of making this

statement, and personally acquainted with the facts herein stated.2. I hold the office of Vi ct... PrOs ,ItA.! r . I am an authorized representative of AceAmerican Insurance Company, which holds a Certificate of Authority to transact the business ofinsurance in the State of Texas, and I am duly authorized by said company to execute thisstatement.3. Ace American Insurance Company has knowingly and voluntarily entered into this ConsentOrder and agrees with and consents to the issuance and service of the foregoing Consent Orderby the Commissioner of Workers' Compensation in the State of Texas,"

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ACE American Insurance Company Disciplinary Action 091610 Part II

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