Tex. Ins. Code Section 1271.057
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.

Source: Section 1271.057 — Discretionary Clauses Prohibited, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1271.­htm#1271.­057 (accessed May 18, 2024).

1271.001
Applicability of Definitions 1271.002
Right to Evidence of Coverage 1271.003
Evidence of Coverage Not Health Insurance Policy 1271.004
Individual Health Care Plan 1271.005
Applicability of Other Law 1271.006
Benefits to Dependent Child and Grandchild 1271.007
Religious Convictions 1271.008
Balance Billing Prohibition Notice 1271.051
Evidence of Coverage: Contract and Certificate Requirements 1271.052
Information About Benefits and Limitations 1271.053
Information About Obtaining Services 1271.054
Information About Complaints and Appeals 1271.055
Out-of-network Services 1271.056
Unfair or Deceptive Provisions and Statements Prohibited 1271.057
Discretionary Clauses Prohibited 1271.101
Approval of Form of Evidence of Coverage or Group Contract 1271.102
Procedures for Approval of Form of Evidence of Coverage or Group Contract 1271.103
Withdrawal of Approval of Form 1271.104
Information Required by Commissioner 1271.151
Provision of Basic Health Care Services 1271.152
Standards for Basic Health Care Services 1271.153
Periodic Health Evaluations 1271.154
Well-child Care from Birth 1271.155
Emergency Care 1271.156
Benefits for Rehabilitation Services and Therapies 1271.157
Non-network Facility-based Providers 1271.158
Non-network Diagnostic Imaging Provider or Laboratory Service Provider 1271.159
Non-network Emergency Medical Services Provider 1271.201
Designation of Specialist as Primary Care Physician 1271.202
Appeal 1271.203
Effective Date of Designation 1271.251
Approval of Formula or Method for Computing Schedule of Charges 1271.252
Consideration of Individual Health Status Prohibited 1271.253
Information Required by Commissioner 1271.301
Entitlement to Continuation of Group Coverage 1271.302
Request for Continued Coverage 1271.303
Payment for Continued Coverage 1271.304
Termination of Continued Coverage 1271.306
Conversion Contracts 1271.307
Renewability of Coverage: Individual Health Care Plans and Conversion Contracts
Green check means up to date. Up to date

Accessed:
May 18, 2024

§ 1271.057’s source at texas​.gov