Texas Insurance Code 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.
Terms Used In Texas Insurance Code 1271.057
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Common law: The legal system that originated in England and is now in use in the United States. It is based on judicial decisions rather than legislative action.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.