JIM MAllOX 

Attorney Gsnerrl 

714 Jackwn, SUN. 700 

DalIa& lx 7520245c4 

214l742a244 

4624 A1b.M Ave.. &Jr* 160 

El PMo. lx. 702w2722 

61YW53464 

I 1rxrr. SUN. 700 

Hourton. TX. 77002-3111 

712l22552Ba 

606 Broadw8y. Bull. 512 

Lubboc~Tx. 72401.2479 

m47-5222 

4306 N. Tenth. Sultr B 

McAllm,Tx 76601~1666 

B12MB24B47 

260 MaIn Plaza, SLdto 400 

Ban AnIonlo. TX 722052727 

612l2254191 

The Attorney General of Texas 

ltr.~ Lyndon L. Olron, Jr. 

Chairman 

Start Board of Ioeuranct 

1110 San Jacinto Boulevard 

Austin, Ttxat 70786 

opillion lo. m-301 

Re: Ubtthtr tht Ttxao Insurmct 

Ctdt prohibit8 health insuranct 

policy proviaionr that dircriminatt with regard to payment for 

trtatrant by certain typtr of 

health care practitlontro bastd 

on (1) an txprtsr txclusion of 

much practitiontr8 or (2) “place 

and manntr” rtstrictlonr that 

indirtctly txclude such practitiontra 

Dear Mr. Olson: 

Tou havt asked our opinion regarding vhtther tht Statt Board of 

fnsuranct ehould ap:)rove the folloving types of eickneso and accident 

iosuranct policy prtnrlsionr: 

1. Pa:nntnt of btnefitr . . . i8 sptcifically 

limited to inatancco where trtatmtn.t is provided 

by a doctwr of rdicint. No benefits vi11 bt paid 

for trtatnnt by a doctor of dentistry, doctor of 

chiropractk, doctor of optometry, doctor of 

podiatry, doctor in psychology, l udlologlat. or 

rpttch-lrquapt pathologitt. 

2. Btmfita art payable for manipulation of 

tht l pine:. Eovtvtr, benefit. will bt paid only 

vhen ouch treatnent is providtd in a hospital. 

3. Benefits art payiblt for unipulation of 

tht rpim, vhtn trtatmtnt ir providtd whllt the 

inturtd’lt undtr stntral l ntttbttla. 

4. Bcntfitt art oayablt for trtatmtnt of 

mtntal illntsr or prychologiul impairment. txctpt 

that btmfitr payablt whtn tht inrurtd ir an outpatitnt wd trtatmtnt is providtd by a prycboloslot are limirtd to $20 ptr trtatlcnt and 25 

trtatmtntr per ytar. Thtrt it no limit on 

benefitr payablt whtn treatment ir providtd by a 
Hr. Lyndoo L. Olson. Jr. - Ptrflt 2 ml-301) 

. 

psychiscrisr 0Oar than co-insurance and 

dtductiblts. 

5. Btntfirt sre paysbls for wtatment of 

chiropractic atrv:kes, txctpt rhat btnefits art 

payablt on an out’-patient basis or schtdule vhtn 

trtatmtnr is provi’dtd by a chiroprsctor and are 

limited to $20 ptr wtarmtnt and 20 trtamenta ptr 

ytar. Thtrs is D,O limit on btntfits payablt, 

except co-inaurancre and dtductibles, vhtn trtatmtnt is provided by a doctor of mtdicint. 

T%t requirement that jnauranct policy forms be approvtd by tht 

Statt Board of Insurance a:# well aa tht grounds on which the board 

shall dieapprovt forms are !w:r forth in articlt 3.42 of tht Ineuranet 

Code. Article 3.42(a) provMea: 

No policy, cortract or certiflcatt of lift. 

ttrm or tndowmtnl: ineuranct, group lift or term 

insuranct, indust~r:Lsl life insurance, accident or 

health insurance, group accident or health 

Insurance, hospitalization insuranct, group 

hospitalization :Lnaurance. medical or surgical 

insuranct, [or] group medical or surgical 

insursnct . . . 1Aal1 bt dtlivtrtd. issued or used 

In this statt . . . unless tht form of said 

Policy 8 contract or cerrificact has betn filed 

vith rht Statt Beard of Insurance and approvtd by 

said Board. . . . 

Articlt 3.42(s) provides: 

Tht Start Board of Insurance shall forthwith 

disapprovt any , . . form, or vithdrav sny 

prtvious approval thertro if. and only if, 

(1) It la in any rtaptct in violation of or 

dots not comply esth this Code. 

(2) IL contt,fns provisions which tncourage 

misrtprtstntatior~ or art unjust, unfair, intquitable. mialtading. dtctprivt or contrary to 

law or to tht pu~11.1~ policy of this state. 

(3) Xc has any titlt, htadlng or othtr indication of its provisions which is misleading. 

-(Emphasis l ddtd) ,I 

Tou sptcifically ask: 

1. Dote cht :lmsurtd’s article 21.52, fnauranct 

Code, frttdom 1x1 atlsct a practitioner negate 

p. 1360 
. ‘_ 

Hr. Lyndon 1. Olsom, Jr. - Psp~ 3 (JM-301) 

provisions such mu (1) abovt which txclude 

aptcificd pracritianera? 

2. Are rtsrrictiona of the type @et out in (2) 

through (5) l bovt l llowablt vhtn’no prwieloo 

tnumtratts which p~rtrc~itiontrs vi11 bt rtcognized 

and vhich ~111 not be? In othtr words, vhtn not 

txcluded by refemnct, can a pracritiontr bt 

txcludtd by rtsrricrions on tht plsct and msnntr 

in which trtatmtnt bt administtrtd? 

Tht provision of rht tneurance Code about vhich you inquire, 

art.iclt 21.52. section 3, atckl:ta: 

Any person vhl, la issutd . . . any htalth 

insuranct policy . . , by any insuranct company, 

asaociafion. or organiaation . . . map stltct a 

lictnssd doctor of podiatric medkint, a lictnstd 

dtntist, or a doctor of chiropractic to ptrfort 

the wdical or surgical strvlcea or procedures 

echtduled in tht policy which fall vithin tht 

scope of the 1ic:enst of that practitioner, a 

lictnscd doctor elf optometry to perform the 

atrvicts or procc!d,urta achedultd in rht policy 

which fall within the tcopt of the license of that 

doctor of opto~~rp. an audiologist to measurt 

hearing . . . or 4~ speech-language pathologlsc to 

evaluate speech and languagt . . . if thoat 

etwicts or procedures art schtduled in tht 

policy. Tht payrrent or reimburstment by the 

Insurance cmpan:r . . . shall not bt denied 

btcause the same were ptrformtd by a lictnstd 

doctor of podiatric: medicine. a lictnstd doctor of 

opt--Y. a liwnsed doctor of chiropractic, a 

lictnaed dtntisr. an audiologist. or a aptechlanguagt patholog,ist. Thtrt shall not bt any 

clasaificatlon, difftrentstion. or other discrimination in the :?ayment schedule or the paymtnt 

provisions . . . nor in rht amount. . . . 

The prtstnr list of practi,:lloners in arricle 21.52 is the result of 

stvtrsl amendmtnra to the original article enacted in 1977. In 

ltgislativs etamitttt htsrirlSs , tht bills which tddtd praccieioners co 

l rticlt 21.52 vert frtqutntly rtftrrtd to as “fretdom of choice” 

bills. Th+ purport vat tc permit rhe insurtd. not tht insurtr, to 

stltct tht kind of practiriwer rhat would perform tht strvicte 

covtred in tht insuranct pc~ficp. Stt, t.g.. Ttatimony on Stnare Bill 

No. 96, Striate Economic ‘D,evelopment Ccmnitttt, 66th Ltg., public 

htarlng, rtcordtd Jan. 29, 1979. svailablt in Ltgialativt Refertnct 

Library; Id., llouat Cmittee on Health Services, rtcorded Ptb. 21. 

1979; Tesxony on Roust Bill No. 860. Stnatt CoPaittett on Euman 
. 

Hr. Lyndot L. Olson, Jr. - Pa(Ie 4 (Jn-301) 

I 

Rtsourcts, 66th L.tg.. public hearing, recordtd Apr. 25, 1979, 

available in Legislative Reference Library. 

Wt concludt that artic1.e. 21.52 txprtsaly prohibits an insurer 

from ~acriminating sgainst an inaurtd, vith rtgard to paywnt or 

rtimburatmant, based on tht L’ppt of pracritiontr rht insurtd aeltcta 

to provide mtdieal cars. Iht prohibition againer discrimination 

txtenda to the em-vices of six kinds of health cart practi~ionera: 

podiatrlstsr dtntiats, chiropractors, optomtrriats. sudlologiate and 

speech-languegt parhologista. Tht prohibition against discrimination 

applies vlrh resptcr ro tho:;e eervicta (1) covtrtd by rht reltvannt 

insurance policy and (2) within the acopt of rho affecttd practltiontr’s license or certlfica~ion. Policy provisions which exclude, 

restricr or limit payment or reimbursement for such strvices vhtn they 

are provided by any of the specified practitioners. and do not provide 

the same exclusion, restriction or limirsrion on those services vhtn 

they are provided by a doeto!, of medicint, art unlavful. 

We believt the first an81 fifth policy provisions about which you 

inquire must be disapproved becautt they expressly discriminate 

against ont or more of tht preictitiontra identified in articlt 21.52. 

Article 21.35A of rhe Te:Kaa Insurance Code is similar to article 

21.52 and relevant to the fourth policy provision about which you 

inquire. Article 21.35A prohibits discrimination against a person who 

elects ro obtain treatment from a licensed psychologist rather rban a 

doctor of medicine. In a group insurance policy or group hospital 

plan, as follove: 

Any person who la cwtrtd by a policy . . . of 

group insurance or of a group hospital plan . . . 

and vhoee policy . . . provides for strvicts or 

partial or total rleimbursemtnt for services that 

art within the sc.ampe of pracrict of a lictnetd 

psychologist. is mtitltd to obtain thtae strvicea 

or rtceive rtiml~nraamant for these services 

regardless of whtdrtr the services are performed 

by a lictnstd doc:t.or of mtdicint or a lictnaed 

psychologist. 

The fourth policy proMsion about vhich you inquire expressly 

differentiates bttveen the amount of rtimburatmtnt availablt for 

scrvicts of a psychologist a,nd the amount of rtimbursemtnr available 

for eervicts of a pcrychlotriar. Sptcial limirations apply to 

reimbursement for psychologl:sts that do not apply to psychistrlste. 

Thus. ve btlitvt the fourth policy prwision you identifp.muat also bt 

disapproved whtn it appears in a policy or plan aubjtct to articlt 

21.35A. 

Wt also concludt that 1:he plain language of articles 21.52 and 

21.35A prohibits nor only rhost fores which expressly statt thst the 

amount or txistence of rtinl~uraamtnt shall vary according to the type 

p. 1362 
Mr. Lyndon L. Oleoe, Jr. - ?sp 9 (JM-301) 

of prtctitiontr providing the atrvict, as in tht first. fourth and 

f lfth policy prwlsions you quott, but also those forma vhkh havt tht 

same or similar discriminatory tfftct , such as tht stcond and third 

policyprovisions quottd. 

To dtrtrmint titthtr c.ht policy diseriminatta against ctrtain 

typts of pracritiontra, the “place or manntr” restric.tions about which 

you inquirt must bt svaluatc!d in light of tht naturt of rhe btneflta 

co which thty apply. Tht ,xtcond and third prwision@ atstt that 

btntfits art payable for sanipulation of tht apint. Bovevtr , tht 

stcond provision limita tht btnefits to msnipulation performed in a 

hospital and tht third pros Lsion limits tht bentflts to msnipulation 

ptrfomtd vhilt tht insurtd is undtr gentral antscheaia. 

l4snipulation of tht splat la a etrvict cctmonly provided by 

chiropractors and la virhin tht scope of rhtir llctnats. Chiropractors’ lictnsts do not. however , ptrmit thtm to administer general 

anesthesia or admit ps~itnrs to hospitals. Thus, the tffect of the 

quottd rtstrictions ia a crkgorical txclusion of tbt only type of 

practitiontr comonly associa~ttd with tht trtatmtnt purporttdly within 

tht scopt of the insuranct polic7 cwtragt. Since chiropractors art 

aaong tht prsctiriontrs idantifitd in l rriclt 21.52, such prwiaions 

subvert the statute and art nonenforceablt. 

Our conclusion is besta on tht plain langusgt of tht statute sad 

ltgislativt intent. 

Tht plain language of ,rrticlts 21.52 and 21.35A dots noLot limit 

the prohibition against discriminarlon to any particular method or 

means of discrimination. 011 tht contrary, l rticlt 21.52, for~txamplt. 

aprtssly statts rhtr thtrt shall not bt (Iany classification, 

difftrcnciarion. or other dL:6crlmina~iou . . . in the amount or manner 

of payment or rtimbursemtnt. . . .” 

To Slot tfftct to legislativt intent , a statuLt should be givtn a 

“practical and rtaaonablt constrnction rathtr than a literal or 

thwarting cons)truction.” Sta Dtnvt~r-Albuqutrqut Motor Transport, Inc. 

v. SraLt. 586 S.Y.Zd 73g;‘%O (Ttx. Civ. App, - Amarillo 1979, no 

‘vrit)d casts cittd rhtr~rlo. Articlts 21.52 and 21.3SA prohibit 

discrimination or dlffaren~~iation bastd upon tht typt of practitiontr 

prwiding tht ttrvict if !:ht practiriontr is among thost sptcifLtd. 

To accomplish tht object o!! rht legislation , such discrimination must 

bt prohibittd not only when it la ght rtsult of txprtssly discriminagory restrictions bug s1a.o ubtn is rtsults from discririnatory 

rtstricCions disguiatd aa n~sn-discriminsgory rtstrictions limitatlona 

on tht plact or umotr in rgich tht strviet is prwidtd. 

Ntithtr l rticlt 21.W~ nor l rtielt 21.52 apptars inttndtd to 

slttr tht basic naturt of tht btneflts ptovidtd in an insurancs policy 

txctpt to tht txttnt ntcc:rstry to prohibit discrimination baatd on 

categorical distinctions b’cltvten ctrtain typts of practitiontrs. The 

Ttxas Suprtme Court has btld that tht Qtatt Board of Insurance msy 

p. 1363 
nr. Lyndoa I, Olron, Jr, - ?rsr 6 ml-301) 

consider fectorr other thr!l those which spperr vithin the “four 

corners of the POLICY” in dwiding vhcthcr to approve a policy form. 

Key Western LIti Ins~rence Co.. v. State Board of ‘kurance, 3SdS.U.Zd 

ykefororc, 39, the Strte Bosrd of fneursnce msy 

consider fsctorr deemed ne:Icrrsry to determine the dlscriminat6+ 

purpose or sffect of sny glv~ku policy provision. 

Tou have slso directed our attention to srtlcle 3.70-2(B) of the 

Insurance Code, vhich provide!,: 

Ro pollc9 of clc:cident end sickaert insursnce 

shell make benefi~:s contingekt upon treatment or 

l xsmina tio n by a ,particular practitioner or by 

particular practitioners of the healing arts 

hereinafter designated unless such policy contains 

A provision desigrmting the practitioner or 

practitioners vhcl will be recognized by the 

insurer and thors vho vi11 not be recognized by 

the Insurer. . . . In designating the practltioners vho vi11 md will not be recognized, such 

provision shall USC the following tams: Doctor 

of Medicine, Doctor of Osteopathy, Doctor of 

Dentistry, Docto:r of Chiropractic, Doctor of 

Optometry, Doctor of Podiatry. Audiologist, and 

Speech-language Pathologist . 

Another vereion of thil, amended article passed by the legislature 

in s separate bill at the 13ame session as the sbove-quoted version 

includes psychologists end excludes sudiologists and speech-language 

psthologists from the list of prsctitloners. 

, 

klthsr version of srticls 3.70-2(B) should be rud to conflict 

with article 21.52. Art1c:l.e 3.70-2(B) nsithsr l uthorizes nor prohibits sny discrimination b8etveen practitioners. Artlcls 3.70-2(B) 

merely prescribes the fonut for sxcluding practitionera when such 

sxclusious are not prohibitc,d elsewhere in the Insurance Code. 

Zveo if l rticle 3.704(B) end srticle 21.52 were ambiguous or 

potentially contradictory, hovever, vsrious rules of ststutoty 

COMtNCtiOU support the fcregoins interpretetlon. Statutes should be 

conrtrued in harmony vlth other ststutes unless A cootrary intention 

ir clearly manifest. Tree18 v. Walker, 26 S.Y.Zd 627, 630 (Tex. 

1930). Kven when the ll.il language of one ensctment conflicts vith 

th8t of 8nother. they &NJld be read together and hormmised, if 

reasonably posribls. Dsl:las Rallvay b Tsrrlnsl Co. v. Strickland 

transportetion Co., 225%.2d 901. 905 (Tax. Cir. App. - Amarillo 

1949. no vrit). This proqositlon is especially true vlth respect to 

statutes which, as hers, dssl with the same genersl subject. and are 

therefore conridered to be .Ln ari msteris. see Texas Stats Board of 

Pharucy v. Kittman, 550 S,.Il.26 *w 104, 106 Tex.xv. App. - Tyler 1977. 

no nit); 2A C. Sanda, Sutherlsad Statutory Construction, 651.02, et 

453-55 (rev. 4th ad. 1986’ 
: . Hr. IFdon L. Olroa, Jr. - ?a&@ 7 (JM-301) 

. . 

. 

Our construction of l rt!Lcls 3.70-2(B) is sleo mpported by the 

Nle that, by reoson of the disparity lo b&rgsinlng poritions betveen 

ineuronce covponiss l od purcl~mere of insurance, St&Cute8 regullting 

the re~t1onohips of lneurers cud insuredr ore interpreted strictly 

against the insurance covpouies end liberally in favor of insured 

pereone. 2A C. Sands, su rs, 15S.04, et 716; 3 id.. 

-F 

170.05. At 308 

(4th l d. 1974). This N a fwors upholding the polic9 smbodlsd lo 

article 21.52 of giving the insured freedom to choose l mng verious 

hinds of practitioners. 

Ye find no iodlcstios DE lsgislotive intent vhich justifies e 

Coutrory ioterpretatiov. k’th article 21.52 And article 3.70-2(B) 

vers emended in 1983. Artim:le 21.52.. section 3 VAS amended to odd 

audiologists And rpeech-lsn~;uoge pathologists (vithout the express 

“acope of license” requirement included for the other specified 

practitioners). Acts 1983, ‘58th Leg., ch. 380, at 2065. As port of 

the SAM bill, orticls 3.70-2(B) vas also mended to odd “mdiologists” md “speech longuoge pathologiets.” A second bill, vhlch also 

emended l rticle 3.70-2(B), ws passed later during the SAIDC 8eesion. 

This second bill added “Doctor of Psychology” to 3.70-2(B) but did not 

Include “eudiologieta” or “qmech lmguegs pothologimte.” Senate Bill 

Ro. 255, 68th Leg., ch. b92, At 2887. Both blllr vsrs signsd by the 

governor. 

The omeodmeot of botb article 21.52. eection 3 And srtlcle 

3.70-2(B) in the some session reinforcer the reoeons for cooetNing 

the statutes to give vemlug and effect to both. See ?Jere v. 

Crenshov. 137 S.W.2d 7, 13 (‘iex. 1940) (two statute. relxng to saxe 

eubject and mended ot some sersioo should be reed together); 2A C. 

Bonds, n, 151.03, At &Iii’. The principle that St8tUtCA i0 pAti 

meter l lhould r be construed together is l reststemsnt of the preeumptioo Agaioet the ivplied repel1 of etotutes. See Fortinberry v. Store 

iti+-zs. 

283 S.U. 146, 149 (Ten. 1926);2A C. Sender e, 

The l dditkmr to the list of prsctltlonere mede in 

both articles during the sme lsgislstive l seelon plain19 indicates 

that the legislrturs did avc contemplate eo9 conflict or intend on 

implied repeal of either Article. 

SUWtlART 

Article 21.52, eectiou 3. of the Texse 

Insurance Code lwohibitr discriviustios by an 

insurer 8g AinSt l II iaeured vith rsssrd to pepeot 

of beoefite bsea# on the lneursd’e electlon to 

ebtsin the l ervicee of l podlotriet. dsotiet. 

chiropractor, optmetrist, sudiologlst or epcechlaoguoge pathologist rrther than a’ doctor of 

medic ine or l uoe o ther kind of health core prsctitiooer. The prohIbition. Applies if the sarvicse 

obteioed l re within the ecops of esrvicee covered 

, 

\ 

p. 1365 
Ur. L9ndoe 1. Olson, Jr. - ?rSs 6 m-3w I 1 

: I 

! . 

b9 the polic9 end within the scope of the prsctitioner’e liceoee or certificstion. The prohlbitfou extends to those ineuronce polic9 provisions 

vhich sxpreeel9 discrinlnetc sgoinet oue or more 

of tbo spsclfied types of prscgitionsre, eo us11 

as to those provirkme. including piece sod unnsr 

reetrictions, vhitib hsvs the l sms or a elmilar 

discriminstory purpose or effect. 

JIM WATTOX 

Attorney General of Texas 

TotlGKExR 

First AesietAnt Attorney Grnsrsl 

DAVID R. RICRARDS 

Executive AsSiStAnt Attorney General 

RICK CILPIl 

Ch~irmao, Opinion Cmittee 

Prep&red by lfarienne Wood&Id 

AseistAnt Attorney General 

APPRGVED: 

OPXRIOR CGM4ITTltX 

Celia Carl 

EdoAKemoo 

Paul Rich 

p. 1366