Title IN, Insurance Code

Sec. 1201.223. POLICY PROVISION: UNPAID PREMIUM. An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision: "Unpaid Premium: At the time of payment of a claim under this policy, any premium …

Sec. 1201.224. POLICY PROVISION: CANCELLATION. An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision: "Cancellation: The insurer may cancel this policy at any time by written notice deli…

Sec. 1201.225. POLICY PROVISION: CONFORMITY WITH STATE STATUTES. An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision: "Conformity With State Statutes: Any provision of this policy that…

Sec. 1201.226. POLICY PROVISION: ILLEGAL OCCUPATION. An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision: "Illegal Occupation: The insurer is not liable for any loss to which a contrib…

Sec. 1201.271. ALTERATION OF POLICY APPLICATION. (a) A person may not alter a written application for an individual accident and health insurance policy unless the person has the written consent of the applicant. (b) Notwithstanding Subsection (a), an insurer may make an insertio…

Sec. 1201.272. FALSE STATEMENTS. The falsity of a statement in an application for an individual accident and health insurance policy does not bar a right to recovery under the policy unless the statement materially affected the acceptance of the risk or the hazard assumed by the …

Sec. 1201.273. BINDING STATEMENTS. An insured may not be bound by a statement made in an application for an individual accident and health insurance policy unless a copy of the application is attached to or endorsed on the policy as a part of the policy when issued. Added by Acts…

Sec. 1201.274. INSURER'S EVIDENTIARY USE OF APPLICATION FOR REINSTATEMENT OR RENEWAL. (a) If an individual accident and health insurance policy is reinstated or renewed, and the insured or the beneficiary or assignee of the policy makes a written request for a copy of the applica…

Sec. 1201.701. CIVIL PENALTY. A person, partnership, or corporation that wilfully violates this chapter or an order of the commissioner made under this chapter is liable to the state for a civil penalty in an amount not to exceed $5,000 for each violation. The penalty may be reco…

Sec. 1201.702. ACTION AGAINST CERTIFICATE OF AUTHORITY OR LICENSE. The commissioner may suspend or revoke the certificate of authority or license of an insurer or agent who wilfully violates this chapter or an order of the commissioner made under this chapter. Added by Acts 2003,…

Sec. 1202.001. CONTINUOUS POLICIES. (a) A guaranteed renewable insurance policy or a noncancellable insurance policy is considered to be a continuous policy, subject only to the policy terms and conditions, including payment of the policy premium. (b) A guaranteed renewable insur…

Sec. 1202.051. RENEWABILITY AND CONTINUATION OF INDIVIDUAL HEALTH INSURANCE POLICIES. (a) This section applies only to an individual health insurance policy that provides benefits for medical care under a hospital, medical, or surgical policy. (b) Except as provided by Subsection…

Sec. 1202.052. CANCELLATION PROHIBITED FOR AIDS OR HIV. (a) In this section, "AIDS" and "HIV" have the meanings assigned by Section 81.101, Health and Safety Code. (b) Except as provided by Subsection (c), an insurer that delivers or issues for delivery an individual accident and…

Sec. 1203.001. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to: (1) a policy of group accident and health insurance as described by Chapter 1251; (2) a policy of blanket accident and health insurance as described by Chapter 1251; (3) a policy of individual accide…

Sec. 1203.002. CERTAIN COORDINATION OF BENEFITS PROVISIONS PROHIBITED. (a) An accident and health insurance policy or evidence of coverage may not be delivered, issued for delivery, or renewed in this state if: (1) a provision of the policy or evidence of coverage excludes or red…

Sec. 1203.003. CERTAIN COORDINATION OF BENEFITS PROVISIONS VOID. A provision of an accident and health insurance policy or evidence of coverage that violates Section 1203.002 is void. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. SUBCHAPTER B. DENTAL INSURA…

Sec. 1203.051. APPLICABILITY OF SUBCHAPTER; EXCEPTION. (a) This subchapter applies only to an insurance policy that provides benefits for dental expenses, including, except as provided by Subsection (b), an individual, group, blanket, or franchise insurance policy or insurance ag…

Sec. 1203.052. COORDINATION OF BENEFITS BETWEEN PRIMARY AND SECONDARY INSURERS. (a) This section applies if: (1) an insured is covered by at least two different insurance policies; and (2) each policy provides the insured dental benefits. (b) The primary insurer, as determined un…

Sec. 1203.053. CERTAIN COORDINATION OF BENEFITS PROVISIONS PROHIBITED. An insurance policy subject to this subchapter may not be delivered, issued for delivery, or renewed in this state if: (1) a provision of the policy excludes or reduces the payment of benefits for dental expen…

Sec. 1203.054. CERTAIN COORDINATION OF BENEFITS PROVISIONS VOID. A provision of an insurance policy that violates Section 1203.053 is void. Added by Acts 2015, 84th Leg., R.S., Ch. 572 (H.B. 3024), Sec. 1, eff. September 1, 2015. SUBCHAPTER C. VISION AND EYE CARE BENEFITS

Sec. 1203.101. DEFINITIONS. In this subchapter: (1) "Eye care expenses" means expenses related to vision or medical eye care services, procedures, or products. (2) "Health benefit plan" means a policy, agreement, contract, or evidence of coverage that provides comprehensive medic…

Sec. 1203.102. APPLICABILITY OF SUBCHAPTER. This subchapter applies only to a health benefit plan or vision benefit plan that provides or arranges for benefits for vision or medical eye care services, procedures, or products, including an individual, group, blanket, or franchise …

Sec. 1203.103. EXCEPTION. This subchapter does not apply to a supplemental insurance policy that only pays benefits directly to the policyholder. Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023.

Sec. 1203.104. COORDINATION OF BENEFITS BETWEEN PRIMARY AND SECONDARY PLAN ISSUERS. (a) This section applies if: (1) an enrollee is covered by at least two different health benefit plans or vision benefit plans; and (2) each plan provides the enrollee coverage for the same vision…

Sec. 1203.105. CERTAIN COORDINATION OF BENEFITS PROVISIONS PROHIBITED. (a) A health benefit plan or vision benefit plan subject to this subchapter may not be delivered, issued for delivery, or renewed in this state if: (1) a provision of the plan excludes or reduces the payment o…

Sec. 1203.106. CERTAIN COORDINATION OF BENEFITS PROVISIONS VOID. A provision of a health benefit plan or vision benefit plan that violates this subchapter is void. Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023.

Sec. 1203.107. RULES. The commissioner may adopt rules necessary to implement this subchapter. Added by Acts 2023, 88th Leg., R.S., Ch. 15 (S.B. 861), Sec. 1, eff. September 1, 2023. SUBCHAPTER D. COORDINATION OF BENEFITS QUESTIONNAIRE

Sec. 1203.151. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise i…

Sec. 1203.152. CREATION OF UNIFORM COORDINATION OF BENEFITS QUESTIONNAIRE. In collaboration with appropriate stakeholders, the commissioner shall adopt rules establishing a uniform coordination of benefits questionnaire to be used by all health benefit plan issuers in this state.…

Sec. 1203.153. UNIFORM COORDINATION OF BENEFITS QUESTIONNAIRE REQUIRED. Each health benefit plan issuer that issues a health benefit plan that includes a coordination of benefits provision shall use the uniform coordination of benefits questionnaire established under Section 1203…

Sec. 1204.001. NONAPPLICABILITY TO CERTAIN FACILITIES. This subchapter does not apply to indigent care or chronic disease care provided in or by an eleemosynary institution, sanitarium, sanitorium, mental health treatment facility, tuberculosis treatment facility, or cancer treat…

Sec. 1204.002. BENEFITS PAYABLE FOR TREATMENT PROVIDED BY HOSPITAL OWNED BY STATE OR UNIT OF LOCAL GOVERNMENT. An insurance policy providing hospital, nursing, medical, or surgical coverage that is issued or delivered in this state after August 27, 1973, may not include a provisi…

Sec. 1204.051. DEFINITIONS. In this subchapter: (1) "Covered person" means a person who is insured or covered by a health insurance policy or is a participant in an employee benefit plan. The term includes: (A) a person covered by a health insurance policy because the person is a…

Sec. 1204.052. APPLICABILITY TO CERTAIN PLANS OR PROGRAMS. This subchapter applies to: (1) an employee benefit plan, to the extent not preempted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.); (2) benefit programs under Chapters 1551 and 1…

Sec. 1204.053. ASSIGNMENT OF BENEFITS. (a) An insurer may not deliver, renew, or issue for delivery in this state a health insurance policy that prohibits or restricts a covered person from making a written assignment of benefits to a physician or other health care provider who p…

Sec. 1204.054. PAYMENT OF BENEFITS ACCORDING TO ASSIGNMENT. An insurer shall pay benefits directly to a physician or other health care provider, and the insurer is relieved of the obligation to pay, and of any liability for paying, those benefits to the covered person if: (1) the…

Sec. 1204.055. CONTRACTUAL RESPONSIBILITY FOR DEDUCTIBLES AND COPAYMENTS. (a) The payment of benefits under an assignment does not relieve a covered person of a contractual obligation to pay a deductible or copayment. (b) A physician or other health care provider may not waive a …

Sec. 1204.101. DEFINITIONS. In this subchapter: (1) "Health benefit plan" means a group, blanket, or franchise insurance policy, a group hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization, that provides be…

Sec. 1204.102. REQUIRED CLAIM BILLING FORMS. A provider who seeks payment or reimbursement under a health benefit plan and the health benefit plan issuer that issued the plan shall use uniform claim billing form UB-82/HCFA or HCFA 1500, or a successor to one of those forms, as de…

Sec. 1204.151. DEFINITION. In this subchapter, "policy" means an individual or group policy of accident and health insurance, including a policy issued by a group hospital service corporation operating under Chapter 842. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April…

Sec. 1204.152. PAYMENT FOR CERTAIN EXPENSES INCURRED BY TEXAS DEPARTMENT OF HUMAN SERVICES. Each policy delivered or issued for delivery in this state must provide for the repayment of the actual costs of medical expenses the Texas Department of Human Services pays through medica…

Sec. 1204.153. PAYMENTS TO TEXAS DEPARTMENT OF HUMAN SERVICES FOR CERTAIN CHILDREN. (a) This section applies only to a policy that is delivered, issued for delivery, or renewed in this state and that provides coverage for a child whose parent: (1) purchased the policy; or (2) is …

Sec. 1204.154. UNIFORM PROVISIONS. (a) The commissioner shall adopt uniform policy provisions, riders, and endorsements for the policy requirement of Section 1204.153. (b) Before the commissioner adopts or makes a change to a provision, rider, or endorsement under Subsection (a),…

Sec. 1204.201. PROHIBITION OF EXCLUSION OF CERTAIN MEDICAL ASSISTANCE BENEFITS. An individual or group accident and health insurance policy delivered or issued for delivery in this state, including a policy issued by a group hospital service corporation operating under Chapter 84…

Sec. 1204.251. PAYMENT TO CONSERVATOR OTHER THAN GROUP MEMBER. (a) An insurer or group hospital service corporation operating under Chapter 842 that delivers, issues for delivery, or renews in this state a group accident and health insurance policy that provides coverage for a mi…

Sec. 1204.252. PRECONDITIONS FOR PAYMENT; EXCEPTIONS. (a) In accordance with the terms of the policy and this subchapter, an insurer or group hospital service corporation may be required to pay benefits under a group accident and health insurance policy to a person who is not a g…