Tex.
Ins. Code Section 843.204
Untrue or Misleading Information
(a)
A health maintenance organization or a representative of a health maintenance organization may not:(1)
use or distribute or knowingly permit the use or distribution of prospective enrollee information that is untrue or misleading; or(2)
use or knowingly permit the use of:(A)
advertising that is untrue or misleading;(B)
solicitation that is untrue or misleading; or(C)
any form of evidence of coverage that is deceptive.(b)
In this chapter, Section 1367.053 (Coverage Required), Subchapter A (Applicability of Certain Definitions), Chapter 1452 (Physician and Provider Credentials), Subchapter B, Chapter 1507 (Consumer Choice of Benefits Plans), Chapters 222 (Life, Health, and Accident Insurance Premium Tax), 251 (General Provisions), and 258 (Health Maintenance Organizations), as applicable to a health maintenance organization, and Chapters 1271 (Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges) and 1272 (Delegation of Certain Functions by Health Maintenance Organization), a statement or item of information is:(1)
considered to be untrue if the statement or item does not conform to fact in any respect that is or may be significant to an enrollee of, or person considering enrollment in, a health care plan; and(2)
considered to be misleading, whether or not the statement or item is literally untrue, if, in the total context in which the statement is made or the item is communicated, the statement or item may be reasonably understood by a reasonable person who does not possess special knowledge regarding health care coverage as indicating:(A)
the inclusion of a benefit or advantage that does not exist and that is of possible significance to an enrollee of, or person considering enrollment in, a health care plan; or(B)
the absence of an exclusion, limitation, or disadvantage that does exist and that is of possible significance to an enrollee of, or person considering enrollment in, a health care plan.(c)
In this chapter, Section 1367.053 (Coverage Required), Subchapter A (Applicability of Certain Definitions), Chapter 1452 (Physician and Provider Credentials), Subchapter B, Chapter 1507 (Consumer Choice of Benefits Plans), Chapters 222 (Life, Health, and Accident Insurance Premium Tax), 251 (General Provisions), and 258 (Health Maintenance Organizations), as applicable to a health maintenance organization, and Chapters 1271 (Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges) and 1272 (Delegation of Certain Functions by Health Maintenance Organization), an evidence of coverage is considered to be deceptive if the evidence of coverage, taken as a whole and with consideration given to typography and format as well as language, would cause a reasonable person who does not possess special knowledge regarding health care plans and evidences of coverage for health care plans to expect charges or benefits, services, or other advantages that the evidence of coverage does not provide or that the health care plan issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage.
Source:
Section 843.204 — Untrue or Misleading Information, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.843.htm#843.204 (accessed Jun. 5, 2024).
