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 1201.222. Policy Provision: Relation of Earnings to Insurance

Sec. 1201.222.  POLICY PROVISION:  RELATION OF EARNINGS TO INSURANCE.  (a)  Subject to Subsection (b), an individual accident and health insurance policy must contain the following provision if the policy addresses the subject matter of the provision:
"Relation of Earnings to Insurance:  If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage on the insured, regardless of whether the benefits are payable on a weekly or monthly basis, exceeds the amount of monthly earnings of the insured at the time the insured's disability began or the insured's average amount of monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever amount is greater, the insurer will be liable only for the proportionate amount of loss of time benefits under this policy as the amount of the insured's monthly earnings or average monthly earnings bears to the total amount of monthly benefits for the same loss under all loss of time coverage on the insured at the time the disability begins and for the return of the part of the premiums paid during the immediately preceding two years that exceeds the pro rata amount of the premiums for the benefits actually paid under this policy.  This provision does not reduce the total monthly amount of benefits payable under all loss of time coverage on the insured to less than $200 or the sum of the monthly benefits specified in the loss of time coverages, whichever amount is less, and does not reduce benefits other than loss of time benefits."
(b)  The provision described by Subsection (a) may be included only in a policy that provides that the insured is entitled to continue the policy in force subject to its terms 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.
(c)  An insurer may include in the provision described by Subsection (a) a definition of "valid loss of time coverage."  The form of the definition must be approved by the commissioner.  The subject matter of the definition must be limited to:
(1)  coverage provided by:
(A)  governmental agencies;  or
(B)  organizations subject to regulation by insurance laws or by insurance authorities of this or any other state or any province of Canada;
(2)  any other coverage the inclusion of which is approved by the commissioner;  or
(3)  any combination of coverages described by Subdivisions (1) and (2).
(d)  In the absence of a definition authorized under Subsection (c), "valid loss of time coverage" does not include:
(1)  coverage provided for the insured under a compulsory benefit statute, including a workers' compensation or employer's liability statute;  or
(2)  benefits provided by:
(A)  a union welfare plan;
(B)  an employer benefit organization;  or
(C)  an employee benefit organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.