Texas Work Comp Enforcements for November Include Fines Up to $60K

Final disciplinary actions taken by the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) for November 2010 include fines of up to $60,000.

Final orders for November 2010:

American Zurich Insurance Company of Schaumburg, Ill.
Order Number: DWC-100100
Date of Order: 11/8/2010
Order Final In: November
Action Taken: Fined $32,000
Violation: Failed to timely pay TIBs; Failed to pay for preauthorized treatments/services; Failed to timely process medical bills; Failed to visit the insured within three days of notification and/or knowledge of a fatality

Carrion, George M.D. of San Antonio
Order Number: DWC-100113
Date of Order: 11/16/2010
Order Final In: November
Action Taken: Fined $12,000
Violation: Failed to file DWC Form-69 in a timely manner; Failed to file DWC Form-69 with the carrier via facsimile or electronic submission; Failed to properly assign maximum medical improvement

City of San Antonio of San Antonio
Order Number: DWC-100094
Date of Order: 11/5/2010
Order Final In: November
Action Taken: Fined $48,000; Must undergo TDI-DWC compliance audit in FY2011
Violation: Failed to timely pay TIBs; Failed to submit accurate data to TDI-DWC

City of San Antonio of San Antonio
Order Number: DWC-100096
Date of Order: 11/5/2010
Order Final In: November
Action Taken: Fined $7,000
Violation: Failed to accept a communication in the absence of DWC Form-001 as notice of injury and failed to contact employer within seven days of notification; Failed to timely pay a TDI-DWC or Commissioner Order

Commerce and Industry Insurance Company of New York City, N.Y.
Order Number: DWC-100110
Date of Order: 11/16/2010
Order Final In: November
Action Taken: Fined $60,000
Violation: Failed to timely process medical bills; Failed to sufficiently explain reasons for the reduction or denial of payment for health care services; Failed to timely pay TIBs; Failed to timely comply with a Medical Dispute Resolution order; Failed to timely comply with a Contested Case Hearing order

Dallas Area Rapid Transit of Austin
Order Number: DWC-100104
Date of Order: 11/12/2010
Order Final In: November
Action Taken: Fined $18,000
Violation: Failed to timely pay TIBs; Failed to submit accurate data to TDI-DWC; Failed to timely take final action on a request for reconsideration of a medical bill

Durkop, David Allen D.C. of Houston
Order Number: DWC-100102
Date of Order: 11/12/2010
Order Final In: November
Action Taken: Voluntary withdrawal as treating, consulting and/or referring doctor until March 1, 2014; Allowed to continue to act as Designated Doctor, RME Doctor and/or Peer Review Doctor
Violation: Provided treatment that did not comport with TDI-DWC treatment guidelines and/or principles of evidence-based medicine; Failed to promote a timely, appropriate return to work consistent with evidence-based lost time guideline

Elliston, Bruce M.D. of Addsion
Order Number: DWC100114
Date of Order: 11/18/2010
Order Final In: November
Action Taken: Fined $10,000
Violation: Failed to file DWC Form-69 in a timely manner; Failed to file DWC Form-69 with the carrier via facsimile or electronic submission

Farmers Insurance Exchange of Austin
Order Number: DWC-100105
Date of Order: 11/12/2010
Order Final In: November
Action Taken: Fined $3,500
Violation: Failed to comply with TDI-DWC or Commissioner Order; Failed to pay a TDI-DWC or Commissioner Order

Fidelity & Guaranty Insurance Company of Saint Paul, Minn.
Order Number: DWC-100097
Date of Order: 11/5/2010
Order Final In: November
Action Taken: Fined $50,000
Violation: Failed to timely pay SIBs; Failed to take final action on request for reconsideration of a medical bill; Failed to timely process medical bills; Failed to pay for preauthorized treatments/services

Khan, Rashid M.D. of Houston
Order Number: DWC100112
Date of Order: 11/16/2010
Order Final In: November
Action Taken: Fined $10,000
Violation: Failed to file DWC Form-69 in a timely manner; Failed to file DWC Form-69 with the carrier via facsimile or electronic submission

Kruesel, Roy G., M.D. of Fort Worth
Order Number: DWC-100111
Date of Order: 11/16/2010
Order Final In: November
Action Taken: Fined $15,000
Violation: Failed to file DWC Form-69 in a timely manner; Failed to file DWC Form-69 with the carrier via facsimile or electronic submission

McCall, Norman J., M.D. of Fort Worth
Order Number: DWC-100107
Date of Order: 11/16/2010
Order Final In: November
Action Taken: Fined $6,500
Violation: Failed to file DWC Form-69 in a timely manner; Failed to file DWC Form-69 with the carrier via facsimile or electronic submission

Medical Center Emergency Physicians of Houston
Order Number: DWC-100103
Date of Order: 11/12/2010
Order Final In: November
Action Taken: Fined $7,000
Violation: Improperly billed injured employee for workers’ compensation medical services provided

Pacific Employers Insurance Company of Philadelphia, Pa.
Order Number: DWC-100098
Date of Order: 11/5/2010
Order Final In: November
Action Taken: Fined $15,000
Violation: Failed to comply with TDI-DWC or Commissioner Order

Sentry Insurance, A Mutual Company of Stevens Point, Wis.
Order Number: DWC-100108
Date of Order: 11/16/2010
Order Final In: November
Action Taken: Fined $7,200
Violation: Failed to continue to timely pay benefits; Failed to timely pay SIBs; Failed to take final action on request for reconsideration of a medical bill; Failed to timely send DWC Form-PLN9 to injured employee

Star Insurance Company of Southfield, Mo.
Order Number: DWC-100109
Date of Order: 11/16/2010
Order Final In: November
Action Taken: Fined $10,000
Violation: Failed to timely pay TIBs; Failed to submit accurate data to TDI-DWC; Failed to pay attorney fees as ordered by TDI-DWC

Stuart, John Robert M.D. of Dallas
Order Number: DWC100106
Date of Order: 11/16/2010
Order Final In: November
Action Taken: Fined $5,500
Violation: Failed to file DWC Form-69 in a timely manner; Failed to file DWC Form-69 with the carrier via facsimile or electronic submission

Texas Political Subdivisions Joint Self-Insurance Funds of Dallas
Order Number: DWC-100095
Date of Order: 11/5/2010
Order Final In: November
Action Taken: Fined $20,000
Violation: Failed to timely pay TIBs; Failed to submit accurate data to TDI-DWC; Failed to timely pay or deny a request for reimbursement submitted by injured employee

Westfield Insurance Company of Westfield Center, Ohio
Order Number: DWC-100099
Date of Order: 11/5/2010
Order Final In: November
Action Taken: Fined $5,000
Violation: Failed to timely comply with an Interlocutory Order for payment of accrued and unpaid income benefits

Zurich American Insurance Company of Schaumberg, Ill.
Order Number: DWC-100115
Date of Order: 11/18/2010
Order Final In: November
Action Taken: Fined $45,000
Violation: Failed to timely submit data to TDI-DWC; Failed to timely initiate TIBs; Failed to timely respond to a TDI-DWC request for information; Failed to submit accurate data to TDI-DWC; Failed to comply with TDI-DWC or Commissioner Order; Failed to pay benefits based on opinion of the Designated Doctor while dispute pending; Failed to timely process medical bills; Failed to make payment for health care services in accordance with TDI-DWC’s fee guidelines medical policies; Failed to sufficiently explain reasons for the reduction or denial of payment for health care services

Source: Texas Department of Insurance – Division of Workers’ Compensation