reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter D. Preexisting Conditions › Section 1201.153. Coverage for Individuals Age 65 or Older

Sec. 1201.153.  COVERAGE FOR INDIVIDUALS AGE 65 OR OLDER.  (a)  Notwithstanding Section 1201.152 or Clause (b) of the provision required by Section 1201.208(a), an individual accident and health insurance policy delivered or issued for delivery to an individual who is 65 years of age or older may not include a provision that excludes from coverage a loss that occurs from a preexisting condition more than six months after the effective date of coverage under the policy.
(b)  Notwithstanding Subsection (a), the commissioner may authorize a policy provision that excludes coverage for a preexisting condition for a period of not more than one year if the commissioner determines that the provision would serve the public interest.
(c)  This section does not require an insurer to provide coverage for a loss from a preexisting condition specifically excluded from coverage by name or specific description in an exclusion endorsement or rider that is effective on the date of the loss.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter D. Preexisting Conditions › Section 1201.154. Coverage for Certain Previously Covered Persons

Sec. 1201.154.  COVERAGE FOR CERTAIN PREVIOUSLY COVERED PERSONS.  (a)  In this section, "creditable coverage" has the meaning assigned by Section 1205.004(a).
(b)  A preexisting condition provision in an individual accident and health insurance policy may not apply to an individual  who was continuously covered for an aggregate period of 18 months by creditable coverage that was in effect up to a date not more than 63 days before the effective date of the individual coverage, excluding any waiting period.
(c)  In determining whether a preexisting condition provision of an individual accident and health insurance policy applies to an individual, an insurer shall credit the time the individual previously was covered under creditable coverage if the previous coverage was in effect at any time during the 18 months preceding the effective date of the individual coverage.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.024, eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 1070 (H.B. 2548), Sec. 1, eff. June 15, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.201. Policy Provisions Required

Sec. 1201.201.  POLICY PROVISIONS REQUIRED.  (a)  Except as provided by Subsections (b) and (c), an individual accident and health insurance policy must contain the provisions required by this subchapter in the words provided by this subchapter.
(b)  An insurer may substitute for a policy provision required by this subchapter a provision with different wording approved by the commissioner in accordance with reasonable rules adopted by the commissioner.  A substituted provision may not be less favorable to an insured or a beneficiary of the policy than the provision required by this subchapter.
(c)  If a policy provision required by this subchapter is wholly or partly inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the commissioner's approval, shall:
(1)  omit from the policy each inapplicable provision or part of a provision;  and
(2)  modify each inconsistent provision or part of a provision so that the provision as contained in the policy is consistent with the coverage provided by the policy.
(d)  A policy provision required by this subchapter must be preceded by the caption for the provision provided by this subchapter or, at the option of the insurer, by an appropriate individual or group caption or subcaption approved by the commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.202. Order of Required Policy Provisions

Sec. 1201.202.  ORDER OF REQUIRED POLICY PROVISIONS.  (a)  Except as provided by Subsection (b), policy provisions required by this subchapter or corresponding substitute provisions must be printed in the same consecutive order as provided by this subchapter.
(b)  An insurer may print a policy provision required by this subchapter or a corresponding substitute provision as a unit in any part of the policy with other provisions to which the provision is logically related.
(c)  A policy printed under Subsection (b) may not be wholly or partly unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered, or issued.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.203. Other Policy Provisions

Sec. 1201.203.  OTHER POLICY PROVISIONS.  A policy provision that is not otherwise subject to this subchapter may not make an individual accident and health insurance policy or any portion of the policy less favorable in any way to the insured or the beneficiary than the policy provisions that are subject to this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.204. Policy Provisions Required by Other Jurisdiction

Sec. 1201.204.  POLICY PROVISIONS REQUIRED BY OTHER JURISDICTION.  An individual accident and health insurance policy of a foreign or alien insurer may contain any provision that is:
(1)  not less favorable to the insured or the beneficiary than the provisions of this chapter;  and
(2)  prescribed or required by the law of the state under which the insurer is organized.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.205. Policy Provisions for Policy Delivered Outside This State

Sec. 1201.205.  POLICY PROVISIONS FOR POLICY DELIVERED OUTSIDE THIS STATE.  An individual accident and health insurance policy issued by a domestic insurer for delivery in another state or country may contain any provision permitted or required by the laws of that state or country.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.206. Filing Procedure

Sec. 1201.206.  FILING PROCEDURE.  (a)  The commissioner may adopt reasonable rules regarding the procedure for submitting policies subject to this chapter that are necessary, proper, or advisable for the administration of this chapter.
(b)  This section does not limit any authority otherwise granted by law to the commissioner or department.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.207. Policy Provision: Entirety of Contract; Policy Changes

Sec. 1201.207.  POLICY PROVISION:  ENTIRETY OF CONTRACT;  POLICY CHANGES.  An individual accident and health insurance policy must contain the following provision:
"Entire Contract;  Changes:  This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance.  A change in this policy is not valid until the change is approved by an executive officer of the insurer and unless the approval is endorsed on or attached to the policy.  An agent does not have authority to change this policy or to waive any of its provisions."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.208. Policy Provision: Incontestability

Sec. 1201.208.  POLICY PROVISION:  INCONTESTABILITY.  (a)  Except as provided by Subsection (c), an individual accident and health insurance policy must contain the following provision:
"Time Limit on Certain Defenses:  (a) After the second anniversary of the date this policy is issued, a misstatement, other than a fraudulent misstatement, made by the applicant in the application for the policy may not be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) beginning after that anniversary.
"(b) A claim for loss incurred or disability (as defined in the policy) beginning after the second anniversary of the date this policy is issued may not be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss existed before the effective date of coverage of this policy."
(b)  Clause (a) of the provision required by Subsection (a) does not:
(1)  affect any legal requirement for avoidance of a policy or denial of a claim during the initial two-year period;  or
(2)  limit the application of Section 1201.219, 1201.220, or 1201.221 in a case of a misstatement regarding age, occupation, or other insurance.
(c)  For a policy that provides that the insured is entitled to continue the policy in force by the timely payment of premiums until the insured reaches at least 50 years of age or, if the policy was issued after the insured reached 44 years of age, until at least the fifth anniversary of the policy's date of issuance, an insurer may use the following clause instead of Clause (a) of the provision required by Subsection (a):
"After this policy has been in force for a period of two years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become incontestible as to the statements contained in the application."
(d)  The provision provided by Subsection (c) must be under the caption "Incontestable."  An insurer that uses the provision may omit the parenthetical clause.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.209. Policy Provision: Grace Period

Sec. 1201.209.  POLICY PROVISION:  GRACE PERIOD.  (a)  An individual accident and health insurance policy must contain the following provision:
"Grace Period:  A grace period of __________ (insert appropriate number) days will be granted for the payment of each premium due after the first premium.  During the grace period, the policy continues in force."
(b)  The number of days of the grace period may not be less than:
(1)  7 for a weekly premium policy;
(2)  10 for a monthly premium policy;  or
(3)  31 for any other policy.
(c)  A policy that contains a cancellation provision may add, at the end of the provision required by Subsection (a):  "subject to the right of the insurer to cancel the policy in accordance with the policy's cancellation provision."
(d)  A policy in which the insurer reserves the right to refuse any renewal must include the following provision at the beginning of the provision required by Subsection (a):
"Unless, not less than five days before the premium due date, the insurer has delivered to the insured, or has mailed to the insured's last address as shown by the insurer's records, a written notice of the insurer's intention not to renew this policy beyond the period for which the premium has been accepted, ...."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.210. Policy Provision: Reinstatement

Sec. 1201.210.  POLICY PROVISION:  REINSTATEMENT.  (a)  Except as provided by Subsection (b), an individual accident and health insurance policy must contain the following provision:
"Reinstatement:  If a renewal premium is not paid before the expiration of the period granted for the insured to make the payment, a subsequent acceptance of the premium by the insurer or any agent authorized by the insurer to accept the premium, without requiring in connection with the acceptance an application for reinstatement, reinstates the policy.  However, if the insurer or authorized agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated on approval of the application by the insurer or, if the application is not approved, on the 45th day after the date of the conditional receipt unless the insurer before that date has notified the insured in writing of the insurer's disapproval of the application.  The reinstated policy covers only loss resulting from an accidental injury sustained after the date of reinstatement and loss due to sickness that begins more than 10 days after the date of reinstatement.  In all other respects the insured and insurer have the same rights under the reinstated policy as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed in the policy or attached to the policy in connection with the reinstatement.  Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days before the date of reinstatement."
(b)  The insurer may omit the last sentence of the provision required by Subsection (a) in a policy that provides that the insured is entitled to continue the policy in force by the timely payment of premiums until the insured reaches at least 50 years of age or, if the policy was issued after the insured reached 44 years of age, until at least the fifth anniversary of the policy's date of issuance.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.211. Policy Provision: Notice of Claim

Sec. 1201.211.  POLICY PROVISION:  NOTICE OF CLAIM.  (a)  Except as provided by Subsection (b), an individual accident and health insurance policy must contain the following provision:
"Notice of Claim:  A written notice of claim must be given to the insurer before the 21st day after the date of the occurrence or beginning of any loss covered by the policy, or as soon after that date as is reasonably possible.  A notice given by or on behalf of the insured or the beneficiary to the insurer at __________ (insert the location of any office the insurer designates for the purpose), or to any authorized agent of the insurer, with information sufficient to identify the insured, constitutes notice to the insurer."
(b)  In a policy that provides a loss of time benefit that may be payable for at least two years, an insurer may insert, between the first and second sentences of the provision required by Subsection (a), the following provision:
"Subject to the qualifications below, and except in the event of a legal incapacity, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, the insured shall, at least once in every __________ (insert appropriate number) months after having given notice of claim, give to the insurer notice of continuance of the disability.  In applying this provision, the period of __________ (insert appropriate number) months following a filing of proof by the insured or any payment by the insurer on account of the claim or any denial of liability in whole or in part by the insurer shall be excluded.  Delay in giving the notice does not impair the insured's right to any indemnity that would otherwise have accrued during the period of __________ (insert appropriate number) months preceding the date on which the notice is actually given."
(c)  The number of months inserted in the clause permitted by Subsection (b) may not be less than one or greater than six.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.212. Policy Provision: Claim Forms

Sec. 1201.212.  POLICY PROVISION:  CLAIM FORMS.  (a)  Except as provided by Subsection (b), an individual accident and health insurance policy must contain the following provision:
"Claim Forms:  The insurer, on receipt of a notice of claim, will provide to the claimant the forms usually provided by the insurer for filing proof of loss.  If the forms are not provided before the 16th day after the date of the notice, the claimant shall be considered to have complied with the requirements of this policy as to proof of loss on submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character, and the extent of the loss for which the claim is made."
(b)  The provision required by this section is not required to be contained in a policy issued by a corporation operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.213. Policy Provision: Proof of Loss

Sec. 1201.213.  POLICY PROVISION:  PROOF OF LOSS.  An individual accident and health insurance policy must contain the following provision:
"Proof of Loss:  For a claim for loss for which this policy provides any periodic payment contingent on continuing loss, a written proof of loss must be provided to the insurer at the insurer's designated office before the 91st day after the termination of the period for which the insurer is liable.  For a claim for any other loss, a written proof of loss must be provided to the insurer at the insurer's designated office before the 91st day after the date of the loss.  Failure to provide the proof within the required time does not invalidate or reduce any claim if it was not reasonably possible to give proof within the required time.  In that case, the proof must be provided as soon as reasonably possible but not later than one year after the time proof is otherwise required, except in the event of a legal incapacity."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.214. Policy Provision: Time of Payment of Claims

Sec. 1201.214.  POLICY PROVISION:  TIME OF PAYMENT OF CLAIMS.  (a)  Except as provided by Subsection (c), an individual accident and health insurance policy must contain the following provision:
"Time of Payment of Claims:  Indemnities payable under this policy for any loss, other than a loss for which this policy provides any periodic payment, will be paid immediately on receipt of due written proof of the loss.  Subject to due written proof of loss, all accrued indemnities for a loss for which this policy provides periodic payment will be paid __________ (insert period for payment) and any balance remaining unpaid on termination of liability will be paid immediately on receipt of due written proof of loss."
(b)  The period for payment to be inserted in the clause required by Subsection (a) may not be less frequent than monthly.
(c)  The provision required by this section is not required to be contained in a policy issued by a corporation operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.215. Policy Provision: Payment of Claims

Sec. 1201.215.  POLICY PROVISION:  PAYMENT OF CLAIMS.  (a)  Except as provided by Subsection (d), an individual accident and health insurance policy must contain the following provision:
"Payment of Claims:  Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting indemnity payments that may be prescribed in this policy and effective at the time of payment.  If such a designation or provision is not then effective, the indemnity will be payable to the insured's estate.  Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either in accordance with the beneficiary designation or to the insured's estate.  All other indemnities will be payable to the insured."
(b)  An insurer may include with the provision required by Subsection (a) one or both of the following provisions:
"If any indemnity of this policy is payable to the insured's estate, or to an insured or beneficiary who is a minor or is otherwise not competent to give a valid release, the insurer may pay the indemnity, up to an amount not exceeding $__________ (insert amount), to any relative by blood or connection by marriage of the insured or beneficiary who is considered by the insurer to be equitably entitled to the indemnity.  Any payment made by the insurer in good faith in accordance with this provision fully discharges the insurer to the extent of the payment."
"Subject to any written direction of the insured, in the application or otherwise, all or a portion of any indemnity provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proof of the loss, be paid directly to the hospital or person providing the services.  It is not required that the service be provided by a particular hospital or person."
(c)  The amount to be inserted in the clause permitted by Subsection (b) may not exceed $1,000.
(d)  The provision required by Subsection (a) is not required to be contained in a policy issued by a corporation operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.216. Policy Provision: Physical Examinations and Autopsy

Sec. 1201.216.  POLICY PROVISION:  PHYSICAL EXAMINATIONS AND AUTOPSY.  An individual accident and health insurance policy must contain the following provision:
"Physical Examinations and Autopsy:  The insurer at its own expense has the right and opportunity to conduct a physical examination of the insured when and as often as the insurer reasonably requires while a claim under the policy is pending and, in case of death, to require that an autopsy be conducted if not forbidden by law."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.217. Policy Provision: Legal Actions

Sec. 1201.217.  POLICY PROVISION:  LEGAL ACTIONS.  An individual accident and health insurance policy must contain the following provision:
"Legal Actions:  An action at law or in equity may not be brought to recover on this policy before the 61st day after the date written proof of loss has been provided in accordance with the requirements of this policy.  An action at law or in equity may not be brought after the expiration of three years after the time written proof of loss is required to be provided."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.218. Policy Provision: Change of Beneficiary

Sec. 1201.218.  POLICY PROVISION:  CHANGE OF BENEFICIARY.  (a)  Except as provided by Subsection (b), an individual accident and health insurance policy must contain the following provision:
"Change of Beneficiary:  Unless the insured makes an irrevocable designation of beneficiary, the right to change a beneficiary is reserved for the insured, and the consent of the beneficiary or beneficiaries is not required for the surrender or assignment of this policy, for any change of beneficiary or beneficiaries, or for any other changes in this policy."
(b)  An insurer may omit the first clause of the provision required by Subsection (a) relating to an irrevocable designation of beneficiary.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.219. Policy Provision: Change of Occupation

Sec. 1201.219.  POLICY PROVISION:  CHANGE OF OCCUPATION.  An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision:
"Change of Occupation:  If the insured is injured or contracts a sickness after the insured changes the insured's occupation to one classified by the insurer as more hazardous than the occupation stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only the portion of the indemnity provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for the more hazardous occupation.  If the insured changes the insured's occupation to one classified by the insurer as less hazardous than the occupation stated in this policy, the insurer, on receipt of proof of the change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding the receipt of the proof, whichever date is more recent.  In applying this provision, the classification of occupational risk and the premium rates are the classification and rates that, before the occurrence of the loss for which the insurer is liable or before the date of proof of change in occupation, were:
(1)  last filed by the insurer with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued;  or
(2)  if filing was not required, last made effective by the insurer in the state where the insured resided at the time this policy was issued."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.220. Policy Provision: Misstatement of Age

Sec. 1201.220.  POLICY PROVISION:  MISSTATEMENT OF AGE.  An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision:
"Misstatement of Age:  If the age of the insured has been misstated, the amounts payable under this policy are the amounts the premium paid would have purchased at the correct age."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.221. Policy Provision: Excess Insurance

Sec. 1201.221.  POLICY PROVISION:  EXCESS INSURANCE.  An individual accident and health insurance policy must contain one of the following provisions if the policy addresses the subject matter of the provision:
"Other Insurance With This Insurer:  If an accident or health or accident and health policy or policies previously issued by the insurer to the insured is in force concurrently with this policy, making the aggregate indemnity for __________ (insert types of coverages) in excess of $__________ (insert maximum limit of indemnity or indemnities), the excess insurance is void and all premiums paid for the excess shall be returned to the insured or to the insured's estate."
"Other Insurance With This Insurer:  Insurance effective at any one time on the insured under the same type of policy or policies with this insurer is limited to the one policy elected by the insured, the insured's beneficiary, or the insured's estate, as the case may be, and the insurer will return all premiums paid for all other policies of the same type."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.223. Policy Provision: Unpaid Premium

Sec. 1201.223.  POLICY PROVISION:  UNPAID PREMIUM.  An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision:
"Unpaid Premium:  At the time of payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted from the payment."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.224. Policy Provision: Cancellation

Sec. 1201.224.  POLICY PROVISION:  CANCELLATION.  An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision:
"Cancellation:  The insurer may cancel this policy at any time by written notice delivered to the insured, or mailed to the insured's last address as shown by the records of the insurer, stating when the cancellation is effective, which may not be earlier than five days after the date the notice is delivered or mailed.  After this policy has been continued beyond its original term, the insured may cancel the policy at any time by written notice delivered or mailed to the insurer, effective on receipt or on a later date specified in the notice.  In the event of cancellation, the insurer will promptly return the unearned portion of any premium paid.  If the insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued.  If the insurer cancels, the earned premium shall be computed pro rata.  Cancellation is without prejudice to any claim originating before the effective date of cancellation."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.225. Policy Provision: Conformity With State Statutes

Sec. 1201.225.  POLICY PROVISION:  CONFORMITY WITH STATE STATUTES.  An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision:
"Conformity With State Statutes:  Any provision of this policy that, on its effective date, conflicts with the statutes of the state in which the insured resides on the effective date is by this clause effectively amended to conform to the minimum requirements of that state's statutes."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter E. Required Policy Provisions › Section 1201.226. Policy Provision: Illegal Occupation

Sec. 1201.226.  POLICY PROVISION:  ILLEGAL OCCUPATION.  An individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision:
"Illegal Occupation:  The insurer is not liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation."
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter F. Application for Policy › Section 1201.271. Alteration of Policy Application

Sec. 1201.271.  ALTERATION OF POLICY APPLICATION.  (a)  A person may not alter a written application for an individual accident and health insurance policy unless the person has the written consent of the applicant.
(b)  Notwithstanding Subsection (a), an insurer may make an insertion to an application solely for administrative purposes in a manner that indicates clearly that the insertion is not attributed to the applicant.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter F. Application for Policy › Section 1201.272. False Statements

Sec. 1201.272.  FALSE STATEMENTS.  The falsity of a statement in an application for an individual accident and health insurance policy does not bar a right to recovery under the policy unless the statement materially affected the acceptance of the risk or the hazard assumed by the insurer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter F. Application for Policy › Section 1201.273. Binding Statements

Sec. 1201.273.  BINDING STATEMENTS.  An insured may not be bound by a statement made in an application for an individual accident and health insurance policy unless a copy of the application is attached to or endorsed on the policy as a part of the policy when issued.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter F. Application for Policy › Section 1201.274. Insurer's Evidentiary Use of Application for Reinstatement or Renewal

Sec. 1201.274.  INSURER'S EVIDENTIARY USE OF APPLICATION FOR REINSTATEMENT OR RENEWAL.  (a)  If an individual accident and health insurance policy is reinstated or renewed, and the insured or the beneficiary or assignee of the policy makes a written request for a copy of the application for reinstatement or renewal, the insurer shall, not later than the 15th day after the date the insurer receives the request at its home or branch office, deliver or mail a copy of the application to the person who made the request.
(b)  An insurer that fails to comply with this section may not introduce the application for reinstatement or renewal as evidence in any action or proceeding based on or involving the policy or its reinstatement or renewal.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter O. Enforcement › Section 1201.701. Civil Penalty

Sec. 1201.701.  CIVIL PENALTY.  A person, partnership, or corporation that wilfully violates this chapter or an order of the commissioner made under this chapter is liable to the state for a civil penalty in an amount not to exceed $5,000 for each violation.  The penalty may be recovered through a civil action.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1201 - Accident and Health Insurance › Subchapter O. Enforcement › Section 1201.702. Action Against Certificate of Authority or License

Sec. 1201.702.  ACTION AGAINST CERTIFICATE OF AUTHORITY OR LICENSE.  The commissioner may suspend or revoke the certificate of authority or license of an insurer or agent who wilfully violates this chapter or an order of the commissioner made under this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1202 - Cancellation and Continuation of Policies in General › Subchapter A. Continuous Policies › Section 1202.001. Continuous Policies

Sec. 1202.001.  CONTINUOUS POLICIES.  (a)  A guaranteed renewable insurance policy or a noncancellable insurance policy is considered to be a continuous policy, subject only to the policy terms and conditions, including payment of the policy premium.
(b)  A guaranteed renewable insurance policy or a noncancellable insurance policy:
(1)  is continued in effect by the payment of the policy premium in accordance with the policy terms and conditions;  and
(2)  may not be considered or treated as a renewed policy by the payment of the policy premium.
(c)  This section does not apply to a small employer health benefit plan adopted in accordance with Chapter 1501.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1202 - Cancellation and Continuation of Policies in General › Subchapter B. Individual Health Insurance Policies › Section 1202.051. Renewability and Continuation of Individual Health Insurance Policies

Sec. 1202.051.  RENEWABILITY AND CONTINUATION OF INDIVIDUAL HEALTH INSURANCE POLICIES.  (a)  This section applies only to an individual health insurance policy that provides benefits for medical care under a hospital, medical, or surgical policy.
(b)  Except as provided by Subsection (c), an insurer shall renew or continue an individual health insurance policy at the option of the individual.
(c)  An insurer may decline to renew or continue an individual health insurance policy:
(1)  for failure to pay a premium or contribution in accordance with the terms of the policy;
(2)  for fraud or intentional misrepresentation;
(3)  because the insurer is ceasing to offer coverage in the individual market in accordance with rules adopted by the commissioner;
(4)  because an individual no longer resides, lives, or works in an area in which the insurer is authorized to provide coverage, but only if all policies are not renewed or not continued under this subdivision uniformly without regard to any health-status related factor of covered individuals;  or
(5)  in accordance with federal law, including regulations.
(d)  The commissioner shall adopt rules necessary to:
(1)  implement this section;  and
(2)  meet the minimum requirements of federal law, including regulations.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1202 - Cancellation and Continuation of Policies in General › Subchapter B. Individual Health Insurance Policies › Section 1202.052. Cancellation Prohibited for AIDS or HIV

Sec. 1202.052.  CANCELLATION PROHIBITED FOR AIDS OR HIV.  (a)  In this section, "AIDS" and "HIV" have the meanings assigned by Section 81.101, Health and Safety Code.
(b)  Except as provided by Subsection (c), an insurer that delivers or issues for delivery an individual accident and health insurance policy in this state may not cancel that policy during its term because the insured:
(1)  has been diagnosed as having AIDS or HIV;
(2)  has been treated for AIDS or HIV;  or
(3)  is being treated for AIDS or HIV.
(c)  The insurer may cancel the policy for:
(1)  failure to pay a premium when due;  or
(2)  fraud or misrepresentation in obtaining coverage by not disclosing a diagnosis of an AIDS or HIV-related condition.
(d)  The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to this section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter A. Supplemental Insurance Policies › Section 1203.001. Applicability of Subchapter

Sec. 1203.001.  APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to:
(1)  a policy of group accident and health insurance as described by Chapter 1251;
(2)  a policy of blanket accident and health insurance as described by Chapter 1251;
(3)  a policy of individual accident and health insurance as defined by Section 1201.001; or
(4)  an evidence of coverage as defined by Section 843.002.
(b)  This subchapter does not apply to an individual accident and health insurance policy that is designed to fully integrate with other policies through a variable deductible.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 572 (H.B. 3024), Sec. 3, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter A. Supplemental Insurance Policies › Section 1203.002. Certain Coordination of Benefits Provisions Prohibited

Sec. 1203.002.  CERTAIN COORDINATION OF BENEFITS PROVISIONS PROHIBITED.  (a)  An accident and health insurance policy or evidence of coverage may not be delivered, issued for delivery, or renewed in this state if:
(1)  a provision of the policy or evidence of coverage excludes or reduces the payment of benefits to or on behalf of an insured or enrollee;
(2)  the reason for the exclusion or reduction is that benefits are also payable or have been paid to or on behalf of the insured or enrollee under a supplemental policy of accident and health insurance;  and
(3)  the supplemental policy is individually underwritten and individually issued as a plan of coverage for:
(A)  hospital confinement indemnity;
(B)  a specified disease;  or
(C)  a limited benefit.
(b)  Application of Subsection (a) to a provision of an accident and health insurance policy or evidence of coverage is not affected by:
(1)  the mode or channel by which the premium for a supplemental policy of accident and health insurance is paid to the insurer;  or
(2)  a reduction in the premium for a supplemental policy of accident and health insurance because of the insured's membership in an organization or status as an employee.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter A. Supplemental Insurance Policies › Section 1203.003. Certain Coordination of Benefits Provisions Void

Sec. 1203.003.  CERTAIN COORDINATION OF BENEFITS PROVISIONS VOID.  A provision of an accident and health insurance policy or evidence of coverage that violates Section 1203.002 is void.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle A - Health Coverage in General › Chapter 1203 - Coordination of Benefits Provisions › Subchapter B. Dental Insurance › Section 1203.051. Applicability of Subchapter; Exception

Sec. 1203.051.  APPLICABILITY OF SUBCHAPTER; EXCEPTION.  (a)  This subchapter applies only to an insurance policy that provides benefits for dental expenses, including, except as provided by Subsection (b), an individual, group, blanket, or franchise insurance policy or insurance agreement, or a group hospital service contract, that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  a reciprocal exchange operating under Chapter 942; or
(6)  a Lloyd's plan operating under Chapter 941.
(b)  This subchapter does not apply to a separate dental policy that exclusively provides a non-coordinated, fixed indemnity benefit, regardless of expenses incurred paid directly to the policyholder or to the provider under an assignment of benefits provision.
Added by Acts 2015, 84th Leg., R.S., Ch. 572 (H.B. 3024), Sec. 1, eff. September 1, 2015.