28 Tex. Admin. Code § 11.504 - Disapproval of an Evidence of Coverage
(a) If the
department disapproves any portion of an evidence of coverage, the department
will specify the reason for the disapproval. The department may disapprove any
form or withdraw any previous approval if a form:
(1) fails to meet the requirements of
Insurance Code Chapter 1271 (concerning Benefits Provided by Health Maintenance
Evidence of Coverage; Charges), this chapter, or other applicable statutes and
regulations;
(2) does not properly
describe the services and benefits;
(3) contains any statements that are unclear,
untrue, unjust, unfair, inequitable, misleading, or deceptive or that violate
Insurance Code Chapters 541 (concerning Unfair Methods of Competition and
Unfair or Deceptive Acts or Practices), 542 (concerning Processing and
Settlement of Claims), 543 (concerning Prohibited Practices Related to Policy
or Certificate of Membership), 544 (concerning Prohibited Discrimination), or
547 (concerning False Advertising by Unauthorized Insurers), or any other
applicable law or regulations;
(4)
provides services or benefits that are too restrictive to achieve the purpose
for which the form was designed;
(5) fails to attain a reasonable degree of
readability, simplicity, and conciseness;
(6) provides services or benefits or contains
other provisions that would endanger the solvency of the issuing HMO;
or
(7) is contrary to the law or
policy of this state.
(b) If the department disapproves a form, the
HMO may file a written request for a hearing on the matter under Insurance Code
§
1271.102 (concerning
Procedures for Approval of Form of Evidence of Coverage or Group Contract;
Withdrawal of Approval).
Notes
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