Texas § IN.1271.057 - DISCRETIONARY CLAUSES PROHIBITED

§ IN.1271.057. DISCRETIONARY CLAUSES PROHIBITED

DISCRETIONARY CLAUSES PROHIBITED. (a) An evidence of coverage may not contain a discretionary clause provision. (b) A discretionary clause provision includes a provision that: (1) purports or acts to bind the enrollee to, or grant deference in subsequent proceedings to, adverse eligibility or benefit decisions or interpretations of the evidence of coverage by the health maintenance organization; or (2) specifies: (A) that an enrollee or other claimant may not contest or appeal a denial of a benefit; (B) that the health maintenance organization's interpretation of the terms of an evidence of coverage or other form or its decision to deny coverage or the amount of benefits is binding on an enrollee or other claimant; (C) that in an appeal, the health maintenance organization's decision-making power as to the interpretation of the terms of an evidence of coverage or other form, or as to coverage, is binding; or (D) a standard of review in any appeal process that gives deference to the original benefit decision or provides standards of interpretation or review that are inconsistent with the laws of this state, including the common law. Added by Acts 2011, 82nd Leg., R.S., Ch. 560 (H.B. 3017 ), Sec. 1, eff. June 17, 2011. SUBCHAPTER C. COMMISSIONER APPROVAL