Texas Administrative Code

Supplemental coverage is a policy of accident and sickness insurance which may be issued only to supplement in-force policies of individual and group accident and sickness insurance, employee benefit plans, hospital, medical, and dental service organization subscriber contracts, …

The minimum basis for cash values is stated in Insurance Code Chapter 1105, wherein the adjusted premiums are required to be computed as a "uniform percentage of the respective premiums specified by the policy." Maximum guaranteed premiums in the policy are specified premiums as …

(a) Limited benefit coverage is a policy of accident and sickness insurance providing the types of coverage set forth in § 3.3071 of this title (relating to Minimum Standards for Basic Hospital Expense Coverage), § 3.3072 of this title (relating to Minimum Standards for Basic Med…

(a) "Specified disease coverage" is a policy written on a guaranteed renewable basis as prescribed in § 3.3050 (b) of this title (relating to Standards for Renewability Provisions) which meets one of the following definitions. (1) A policy which provides coverages for each person…

"Accident only coverage" is a policy of accident insurance which provides coverage, singularly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident. Such coverage provided shall meet the following criteria. (1) Accidental death …

"Disability income protection coverage" is a policy which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or accident or a combination thereof, which: (1) provides for periodic payments …

(a) "Major Medical Expense Coverage" is an accident and sickness insurance policy which provides hospital, medical, and surgical expense coverage as follows: (1) an aggregate maximum of not less than $10,000; (2) a co-payment by the covered person, shall not exceed 20% of covered…

(a) "Hospital Confinement Indemnity Coverage" is a policy of accident and sickness insurance which provides daily benefits for hospital confinement on an indemnity basis in an amount not less than $15 per day or $100 per week and not less than 31 days during any "one period of co…

(a) "Basic medical-surgical expense coverage" is a policy of accident and sickness insurance which provides coverage for each person insured under the policy for the expenses incurred for the necessary services rendered by a physician for treatment of an injury or sickness for at…

(a) "Basic hospital expense insurance" is a policy of accident and health insurance which provides coverage for a period of not less than 31 days during any one period of confinement for each person insured under the policy for the expense incurred for necessary treatment and ser…

The following minimum standards for benefits are prescribed for the categories noted in §§ 3.3071 - 3.3077 and § 3.3079 of this title (relating to Minimum Standards and Benefits and Readability for Accident and Health Insurance Policies). No individual policy of accident and sick…

No insurer may, for premium redetermination purposes, reclassify into subclasses or new classes the original class established for an indeterminate premium reduction policy at date of issue. Notes 28 Tex. Admin. Code § 3.307 The provisions of this §3.307 adopted to be effective M…

The following provisions shall apply to conditional receipts. (1) A conditional receipt which requires a determination of insurability as a condition precedent to coverage shall include an agreement to provide: (A) coverage subject to any limit regarding the amount of insurance s…

(a) Application forms shall include a question relating to replacement designed to elicit information as to whether the insurance to be issued is intended to replace any other accident and sickness insurance presently in force. A supplementary application or other form to be sign…

(a) If a policy contains a conversion privilege, the caption shall be "Conversion Privilege," or words of similar import. The provision shall indicate the persons eligible for conversion. The circumstances applicable to the conversion privilege, including any limitations on the c…

A policy may contain provisions relating to recurrent disability; provided, however, a recurrent disability provision may not specify that such disabilities be separated by a period greater than six months. Notes 28 Tex. Admin. Code § 3.3059 The provisions of this §3.3059 adopted…

Elimination period shall relate to the initial period of time, during the continuance of a condition insured against, for which such benefit will not be paid. Such periods must be clearly expressed in the policy schedule of benefits page and clearly expressed or referenced in the…

(a) An exception or exclusion is any provision in a policy whereby coverage for a specified hazard in entirely eliminated. It is a statement of a risk not assumed under the terms and provisions of the contract. Extensive listing of diseases to be excluded will not be acceptable u…

The limitations on the risk undertaken, whether applicable to amounts, durations of benefits (age, or other matters) must be specified with clarity and certainty in the appropriate provision of the contract. Notes 28 Tex. Admin. Code § 3.3056 The provisions of this §3.3056 adopte…

A probationary or waiting period, if one is specified in the policy, is that period of time commencing with the date a person is initially insured under the policy to the date the coverage or coverages of the policy shall become effective as to such person. (1) A probationary or …

(a) The policy must clearly disclose the intent of the insurer as to the applicability or nonapplicability of coverage to preexisting conditions. In accordance with § 3.3018 of this title (relating to Policy Definition of Preexisting Condition), a policy offering individual hospi…

A family policy providing hospital, surgical, medical expense, hospital confinement indemnity, or accident only insurance shall include provisions which specify the indemnity and qualifications applicable to those family members who may become insured under the policy initially o…

(a) Each policy subject to this subchapter: (1) Shall include a renewal, continuation, or nonrenewal provision, consistent with the requirements of this subchapter. The language or specifications of such provision must be consistent with the type of contract to be issued (e.g., g…

If the policy offers an initial premium which is different from the maximum guaranteed premium specified in the policy for later policy years, no solicitation or advertisement may display or state the smaller premium in such a fashion that the larger premium charge is rendered ob…

(a) No policies or riders for additional coverage may be issued as a dividend unless an equivalent cash payment is offered to the policyholder as an alternative to such a dividend policy or rider. (b) All riders or endorsements added after date of issue, except those by which the…

(a) Upon application for an indeterminate premium reduction policy or group certificate, a separate form containing a summary which adequately describes the contractual premium provisions must be signed by the applicant and submitted to the insurer in conjunction with the applica…

(a) Each individual policy of accident and sickness insurance, including a policy issued by a company subject to Insurance Code Chapter 842, that is delivered, issued for delivery, or renewed in Texas on or after January 1, 1988, must contain a benefit provision which states, "Al…

(a) Except as provided by this section, all individual hospital, medical, or surgical coverage (as defined in § 3.3002 (b)(12) of this title (relating to Definitions)) must be renewed or continued in force at the option of the insured. (b) Medicare eligibility or entitlement is n…

(a) The initial premium charge and its period of guarantee, the maximum premium charge, the fact that the maximum premium charge might be charged, and the frequency of premium redetermination dates must be set forth prominently in: (1) any advertising containing an application or…

Complications of pregnancy shall be treated, in all cases, as any other sickness. Complications of pregnancy mean: (1) conditions, requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by preg…

(a) In regards to individual hospital, medical or surgical coverage, the term "guaranteed renewable" shall not be defined more restrictively than set forth in § 3.3038 of this title (relating to Mandatory Guaranteed Renewability Provisions for Individual Hospital, Medical or Surg…

(a) No indeterminate premium reduction policy may be approved for use in Texas unless the insurer files with the Texas Department of Insurance in conjunction with such indeterminate premium reduction policy a statement: (1) that, to the best of its knowledge and belief, the polic…

(a) The term "noncancellable" may be used only in a policy which the insured has the right to continue by the timely payment of premiums set forth in the policy until at least age 50, or in the case of a policy issued after age 44, for at least five years. The insurer may not uni…

(a) Subject to the conditions set forth in subsection (b) of this section, a policy subject to this subchapter may contain provisions limiting or denying coverage based on the existence of a preexisting condition or conditions. "Preexisting condition" may not be defined to be mor…

One period of confinement-continuous hospital confinement means consecutive days of in-hospital service received as an inpatient, or successive confinements when discharge from and readmission to the hospital occurs within a period of time not more than 90 days or three times the…

A definition of "mental or nervous disorder" as used in a policy may not be more restrictive than a neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind. Notes 28 Tex. Admin. Code § 3.3016 The provisions of this §3.3016 adopted …

A definition of "Medicare" shall be included in any hospital, surgical, or medical expense policy which relates its coverage to eligibility for Medicare or Medicare benefits. The term Medicare may not be defined as more restrictive than: (1) "the Health Insurance for the Aged Act…

Residual disability shall be defined in relation to the insured's reduction in earnings and may be related either to the inability to perform one or more, but not all, of the "major," "important," or "essential" duties of employment or occupation, or to the inability to perform a…

This term shall be defined in relation to the insured's inability to perform one or more, but not all, of the "major," "important," or "essential" duties of employment or occupation or may be related to a "percentage" of time worked or to a "specified number of hours" or to "comp…

(a) A general definition of "total disability" may not be more restrictive than one requiring the individual to be totally disabled from engaging in any employment or occupation for which he or she is or becomes qualified by reason of education, training, or experience, and such …

The definition or description of "nurse" may be restricted to a type of nurse, such as registered graduate professional nurse (RN), or a licensed vocational nurse (LVN), or its equivalent under other state laws. If the words "nurse," "trained nurse," or similar terms are used wit…

This term may be defined by including words such as "duly qualified physician" or "duly licensed physician." The use of such terms requires an insurer to recognize and to accept to the extent of its obligation under the contract all providers of medical care and treatment when su…

(a) This subchapter is promulgated to regulate life insurance policies which have the following characteristics: (1) the premium for the policy is guaranteed for an initial period of time but subsequent to such initial period, a maximum premium charge is specified in the policy; …

Except as provided in this subchapter, the definition of "sickness" may not be more restrictive than the following: Sickness means illness or disease of an insured person which first manifested itself after the effective date of insurance and while the insurance is in force. A de…

(a) These terms shall be defined to employ "result" language and may not include words which establish an accidental means test. Except for accidental death or dismemberment, said definitions may not include words such as "external, violent, visible wounds" or similar words of de…

The term "convalescent nursing home" or "extended care facility" shall be defined in relation to its status, facilities, and available services. (1) Except as provided in these sections, a definition of such home or facility may not be more restrictive than one requiring that it:…

The term "hospital" may be defined in relation to its status, facilities, and available services. The definition may not stipulate as a condition that a hospital be incorporated or that it be recognized by any accrediting organizations. (1) Except as provided in these sections, t…