JIMMAllOX Attorney Gsnerrl

714Jackwn, SUN.700 DalIa& lx 7520245c4 214l742a244

4624A1b.M Ave..&Jr* 160 ElPMo. lx.702w2722 61YW53464

I1rxrr. SUN.700 Hourton. TX.77002-3111 712l22552Ba

606Broadw8y. Bull. 512 Lubboc~Tx. 72401.2479 m47-5222
4306 N.Tenth. SultrB McAllm,Tx76601~1666 B12MB24B47
260 MaIn Plaza, SLdto 400 BanAnIonlo. TX 722052727 612l2254191 

# TheAttorney General ofTexas

ltr.~Lyndon L. Olron, Jr. Chairman Start Board of Ioeuranct 1110 SanJacinto 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 muchpractitiontr8 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 byadoctwr of rdicint. Nobenefits vi11 bt paid for trtatnnt by adoctor **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 

### inahospital. 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 thtinrurtd 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 aHr. Lyndoo L. Olson. Jr. - Ptrflt2 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

### anout’-patient basis or schtdule vhtn **trtatmtnr** is provi’dtd by 

### a chiroprsctor and are limited to $20ptr wtarmtnt and 20 trtamenta ptr ytar. Thtrs is D,Olimit 

### on btntfits payablt, 

### exceptco-inaurancre and dtductibles, vhtn trtatmtnt is provided byadoctor **of**mtdicint. **T%t**requirement that jnauranct policy **forms** be approvtd by **tht** Statt Board of Insurance a:#well aa tht grounds onwhich the board shall dieapprovt **forms** are !w:rforth 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 orused 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.andonly 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 lawor **to tht**  pu~11.1~ policy **of**this state. (3) **Xc**has anytitlt, htadlng or othtr indication of its provisions which is misleading. -(Emphasis 

### l

ddtd),I Tousptcifically ask:

1. Dote cht :lmsurtd’s article 21.52, fnauranct Code, frttdom 1x1

### atlscta practitioner negate

p. 1360. ‘

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

provisions such **mu** (1) **abovt** which txclude aptcificd pracritianera?
**2.** Arertsrrictiona 

### ofthe type @etout in (2) through (5) 

### l

bovt 

### l

llowablt vhtn’no prwieloo tnumtrattswhich 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

. . . mapstltct a lictnssd doctor of podiatric medkint, a lictnstd dtntist, or a doctor of chiropractic to ptrfort the wdical or surgical 

### strvlceaor procedures echtduled in **tht** policy which fall vithin **tht** scope of the 1ic:enst of that practitioner, a lictnscd doctor 

### elfoptometry to perform the atrvicts or procc!d,urta achedultd in rht policy which fall within the

### tcoptof the license 

### ofthat 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. alictnstd 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 onStnare Bill 

### No. 96, Striate

Economic‘D,evelopment **Ccmnitttt,** 66th Ltg., public htarlng, rtcordtd Jan. 29, 1979. svailablt in Ltgialativt Refertnct Library; Id., llouat Cmittee onHealth Services, rtcorded Ptb. 21. 1979; Tesxony on Roust Bill No. 860. Stnatt CoPaittett 

### on Euman.

Hr. Lyndot L. Olson, Jr. - Pa(Ie4 (Jn-301)

I

Rtsourcts, 66th L.tg.. public hearing, recordtd Apr. 25, 1979, available inLegislative Reference Library. Wt concludt that artic1.e. 21.52 txprtsaly prohibits 

### aninsurer 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 byany of the specified practitioners. anddonot provide **the** same exclusion, restriction or limirsrion onthose services vhtn they are provided byadoeto!, ofmedicint, artunlavful. Webelievt the first an81fifth policy provisions about which you inquire must be disapproved becautt they expressly discriminate against ont 

### ormoreof **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 aperson who elects ro obtain treatment fromalicensed psychologist rather rban a doctor of medicine. In a group insurance policy or group hospital plan, as follove:

Anyperson whola cwtrtd by apolicy

. . . of group insurance or 

### ofagroup hospital plan

. . . and vhoee policy

. . . provides for strvicts or partial or total rleimbursemtnt for services that art within the sc.ampeof 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 apsychologist a,ndthe amount of rtimbursemtnr available for 

### eervictsof 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 apolicy or plan aubjtct to articlt 21.35A. Wtalso concludt that 1:heplain 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 flfth policy 

### prwlsions youquott, 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 prosLsion 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 andart nonenforceablt. Our conclusion is besta ontht plain langusgt 

### of **tht** statute sad ltgislativt intent. Tht plain language of ,rrticlts 21.52 and 21.35A dots noLotlimit the prohibition against discriminarlon to any particular method or means of discrimination. 011tht contrary, 

### l rticlt 21.52, for~txamplt. aprtssly statts rhtr thtrt shall 

### not **bt** (Iany classification, difftrcnciarion. 

### orother dL:6crlmina~iou

. . . in the amount or manner of payment or rtimbursemtnt.
. . .” 

### ToSlot tfftct tolegislativt intent 

### ,astatuLt should be givtn a
“practical and rtaaonablt constrnction rathtr than a literal or thwarting cons)truction.” StaDtnvt~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. 

### Toaccomplish tht object o!!rht legislation , such discrimination must bt prohibittd not only whenit 

### la ght rtsult of txprtssly discriminagory restrictions bug s1a.o **ubtn** is rtsults 

### from discririnatory rtstricCions disguiatd aa n~sn-discriminsgory rtstrictions limitatlona ontht plact or umotr inrgich tht strviet is prwidtd. Ntithtr 

### l

rticlt 21.W~ 

### norl rtielt 21.52 apptars inttndtd to slttr **tht** basic naturt of

### thtbtneflts ptovidtd in aninsurancs 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. 1363nr. Lyndoa I, Olron, Jr, - ?rsr 6 ml-301)

consider 

### fectorrother 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, the 

### Strte Bosrd 

### offneursnce msy 39, consider fsctorr deemed ne:Icrrsry to determine the dlscriminat6+ purpose **or sffect**  of sny glv~kupolicy provision. Touhave slso directed our attention to srtlcle 3.70-2(B) 

### ofthe Insurance Code, vhich provide!,:

Ro pollc9 of clc:cident end sickaert insursnce shell make benefi~:s contingekt upon treatment or l xsmination

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 USCthe 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 bythe 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). 

### Kvenwhen 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 

### statuteswhich, as 

### hers, dssl with **the** same genersl subject. and are therefore conridered tobe .Ln ari msteris. see Texas Stats Board of 

### Pharucyv.Kittman,550S,.Il.26 104, 106 Tex.xv. App. - Tyler 1977. *w no nit); 2AC. 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 

### freedomto choose 

### l mng verious hinds of practitioners. Ye find no iodlcstios DElsgislotive 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. Asport 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 SAIDC8eesion. This second bill added “Doctor 

### ofPsychology ” to 3.70-2(B) **but**

### didnot 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. 137S.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 

### meterlr

l hould be construed together is lreststemsnt **of** the preeumptioo Agaioet the ivplied repel1 of etotutes. SeeFortinberry 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 8gAinSt 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 medicineor l

### uoeother**kind**

### ofhealth coreprsctitiooer. The prohIbition. Applies 

### if the sarvicse obteioed lre within the ecops of esrvicee covered ,

\

p. 1365

### Ur. L9ndoe 1. Olson, Jr.-?rSs6 m-3w I 1 : I !

.

b9 the polic9 endwithin 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 lsms 

### or a elmilar discriminstory purpose or 

### effect.

JIM WATTOX Attorney General ofTexas TotlGKExR First **AesietAnt** Attorney Grnsrsl DAVIDR.RICRARDS Executive **AsSiStAnt** Attorney General RICKCILPIl **Ch~irmao,** Opinion Cmittee Prep&red bylfarienne Wood&Id AseistAnt Attorney General APPRGVED: OPXRIOR

CGM4ITTltX Celia Carl EdoAKemoo Paul Rich

p. 1366