2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle H - Health Benefits and Other Coverages for Governmental Employees › Chapter 1551 - Texas Employees Group Benefits Act › Subchapter H. Sanctions and Adjudication of Claims › Section 1551.351. Administrative Process and Sanctions for Program Violations

Sec. 1551.351.  ADMINISTRATIVE PROCESS AND SANCTIONS FOR PROGRAM VIOLATIONS.  (a)  The Employees Retirement System of Texas may impose one or more sanctions described by this section against any employee, participant, annuitant, or dependent who:
(1)  submits a materially false claim or application for coverage under a group coverage plan offered under the group benefits program;
(2)  defrauds or attempts to defraud a group coverage plan offered under the group benefits program;
(3)  obtains or induces the extension of coverage under any program provided under this chapter by a materially negligent or intentional misrepresentation, a failure to disclose material information, or fraud;  or
(4)  induces the extension of coverage under any program provided under this chapter by supplying false information on an application for coverage or in related documentation or in any communication.
(b)  On receipt of a complaint or on its own motion, if the Employees Retirement System of Texas determines that an employee, participant, annuitant, or dependent has engaged in conduct described by Subsection (a), the retirement system may:
(1)  expel from the program the employee, participant, annuitant, or dependent;
(2)  impose limitations on the person's participation in the program;
(3)  rescind any coverage obtained or extended as a result of the conduct under Subsection (a);
(4)  deny a claim arising from coverage;  or
(5)  require the person to reimburse the employees life, accident, and health insurance and benefits fund for any benefit obtained as a result of the conduct.
(c)  An expulsion under Subsection (b) may be permanent or for a specified period.  A rescission of coverage under Subsection (b) may be from the date of inception of the coverage or from the date of the prohibited conduct.
(d)  A person may appeal a determination made under Subsection (a) or (b) or Section 1551.352 only to the board of trustees.  A proceeding under this subsection is a contested case under Chapter 2001, Government Code.  This subchapter applies to an appeal to the board of trustees under this subsection.  The appellant has the burden of proof on all issues, including issues in the nature of an affirmative defense.  Any sanction imposed is not stayed during an appeal under this subsection.   An appeal of a decision of the board of trustees under this subsection is under the substantial evidence rule.
(e)  An employee, participant, annuitant, or dependent expelled from the group benefits program may not participate in a coverage plan offered by the program for the period determined by the Employees Retirement System of Texas.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 3, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1111, Sec. 36, eff. Sept. 1, 2003;  Acts 2003, 78th Leg., ch. 1276, Sec. 10A.409(b), eff. Sept. 1, 2003.
Amended by:
Acts 2005, 79th Leg., Ch. 347 (S.B. 1176), Sec. 30, eff. September 1, 2005.