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Texas Statutes (Last Updated: January 4, 2014) |
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INSURANCE CODE |
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Title 6. ORGANIZATION OF INSURERS AND RELATED ENTITIES |
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Subtitle C. LIFE, HEALTH, AND ACCIDENT INSURERS AND RELATED ENTITIES |
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Chapter 843. HEALTH MAINTENANCE ORGANIZATIONS |
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Subchapter F. RELATIONS WITH ENROLLEES AND GROUP CONTRACT HOLDERS |
Sec. 843.204. UNTRUE OR MISLEADING INFORMATION
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(a) A health maintenance organization or a representative of a health maintenance organization may not:
(1) use or distribute or knowingly permit the use or distribution of prospective enrollee information that is untrue or misleading; or
(2) use or knowingly permit the use of:
(A) advertising that is untrue or misleading;
(B) solicitation that is untrue or misleading; or
(C) any form of evidence of coverage that is deceptive.
(b) In this chapter, Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters 222, 251, and 258, as applicable to a health maintenance organization, and Chapters 1271 and 1272, a statement or item of information is:
(1) considered to be untrue if the statement or item does not conform to fact in any respect that is or may be significant to an enrollee of, or person considering enrollment in, a health care plan; and
(2) considered to be misleading, whether or not the statement or item is literally untrue, if, in the total context in which the statement is made or the item is communicated, the statement or item may be reasonably understood by a reasonable person who does not possess special knowledge regarding health care coverage as indicating:
(A) the inclusion of a benefit or advantage that does not exist and that is of possible significance to an enrollee of, or person considering enrollment in, a health care plan; or
(B) the absence of an exclusion, limitation, or disadvantage that does exist and that is of possible significance to an enrollee of, or person considering enrollment in, a health care plan.
(c) In this chapter, Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters 222, 251, and 258, as applicable to a health maintenance organization, and Chapters 1271 and 1272, an evidence of coverage is considered to be deceptive if the evidence of coverage, taken as a whole and with consideration given to typography and format as well as language, would cause a reasonable person who does not possess special knowledge regarding health care plans and evidences of coverage for health care plans to expect charges or benefits, services, or other advantages that the evidence of coverage does not provide or that the health care plan issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage.