28 Tex. Admin. Code § 3.1202 - Discretionary Clauses Defined

For the purpose of this subchapter, a discretionary clause is a provision that:

(1) purports or acts to bind the claimant to, or grant deference in subsequent proceedings to, adverse claim decisions or policy interpretations by the insurer or health maintenance organization;

(2) specifies that a policyholder or other claimant may not contest or appeal a denial of a claim;

(3) specifies that the insurer's or health maintenance organization's interpretation of the terms of a form or its decision to deny coverage or the amount of benefits is binding upon a policyholder or other claimant;

(4) specifies that in any appeal the insurer's or health maintenance organization's decision-making power as to the interpretation of the terms of a form or as to coverage is binding; or

(5) specifies or gives rise to a standard of review in any appeal process that gives deference to the original claim decision or provides standards of interpretation or review that are inconsistent with the laws of this state.

Notes

28 Tex. Admin. Code § 3.1202

The provisions of this §3.1202 adopted to be effective December 23, 2010, 35 TexReg 11259