| (a) Purpose and applicability.
(1) The purpose of this section is to provide the means
by which insurers and health maintenance organizations (HMOs) may
comply with the notice requirements of Insurance Code §521.103,
and the means by which insurers may comply with the notice requirements
of Insurance Code §521.005 and §521.056. Compliance with
this section is deemed compliance with these notice requirements.
(2) Except as provided by subsection (b)(3), this section
applies to any new or renewal insurance policy, bond, annuity contract,
subscriber contract, health care plan, certificate, and evidence of
coverage issued for delivery in this state on or after May 1, 1992.
(3) All policies, certificates, or evidences of coverage
that are delivered, issued for delivery, or renewed in the State of
Texas on or after May 1, 1992, by insurers or HMOs must have the notice
included as the first, second, or third page of the policy, certificate,
evidence of coverage, or first written communication indicating renewal
of coverage, under the provisions of subsection (b) of this section.
The notice must appear on a full, separate page with no text other
than that provided in this section. The form of the notice must be
as provided by subsection (b) of this section. The item numbers 1
- 8 in the left-hand column of this form correspond to the respective
paragraphs of subsection (b) of this section, and the item numbers
may be omitted from the notice.
Attached Graphic
(b) Notice requirements. Each respectively numbered
item in the notice provided in subsection (a)(3) of this section must
be set out as provided in this subsection. There must be at least
one blank line between each item, but the text within each item may
be single-spaced. The Spanish portion of each item included in a company's
notice is required only for personal automobile, homeowners, life,
accident, and health policies, certificates, and evidences of coverage.
Text must be in at least 10-point type. The letterhead of the insurer
or HMO and any automated form identification numbers may be included
on the notice.
(1) Item 1 must be included in all notices. "Important
Notice" and "Aviso Importante" must be in all capital letters and
in at least 10-point bold type. There must be at least one blank line
below "Important Notice" and "Aviso Importante."
(2) Item 2 is optional. The title for the English portion
may be either "agent," "third party administrator," "managing general
agent," or "employee benefits coordinator." The title for the Spanish
portion may be either "agente," "administrador tercero," "agente general,"
or "administrador de beneficios para empleados." Instead of a specific
telephone number, the insurer or HMO may refer to the applicable telephone
number and where it can be found.
(3) Item 3 is required unless one of the exemptions
provided in this subsection applies. For purposes of this section
a toll-free telephone number is one that can be used by any covered
person to obtain information or make a complaint without incurring
long-distance calling expenses. The insurer's or HMO's toll-free number
must appear in at least 10-point bold type and must be preceded and
followed by one blank line. Item 3 is not required for an insurer
or HMO:
(A) whose gross initial premium receipts collected
in this state are less than $2 million a year;
(B) with respect to fidelity, surety, or guaranty bonds;
(C) that is a surplus lines insurer; or
(D) with respect to certificates of insurance issued
under a group policy:
(i) if the insurer does not administer the group policy
or determine questions of coverage; or
(ii) if the policyholder to whom the policy is issued
is an employer or a labor union.
(4) Item 4 is optional. If used, the insurer's or HMO's
name and address must be inserted.
(5) Item 5 is required on all notices. The toll-free
number must be in at least 10-point bold type and must be preceded
and followed by one blank line.
(6) Item 6 is required on all notices.
(7) Item 7 is required on all notices except those
notices provided by HMOs with evidences of coverage. "Premium or claim
disputes" and "Disputas sobre primas o reclamos" must be in all capital
letters and 10-point bold type. The insurer may insert either "agent,"
"company," or "agent or company" and may insert either "el agente,"
"la compañía," or "el agente o la compañía."
(8) Item 8 is required on all notices. "Attach this
notice to your policy" and "Adjunte este aviso a su póliza"
must be in all capital letters and 10-point bold type.
(c) Exceptions to notice requirements for insurer's
toll-free number.
(1) Requirements. Any exception claimed under subsection
(b)(3)(A) of this section for a policy, certificate, or evidence of
coverage delivered, issued for delivery, or renewed in a given year
must be based on gross initial premium receipts collected in Texas
during the previous calendar year. Any insurer or HMO claiming an
exception must provide to TDI, at a minimum, the following information:
(A) a statement reciting the statutory basis for the
exception;
(B) a statement detailing the amount of gross initial
premium receipts collected in this state for the calendar year immediately
preceding the calendar year for which an exception is claimed; and
(C) an affirmation by the chief executive officer or
chief financial officer of the insurer or HMO certifying that he or
she has reviewed the information and that the filed information is
true, accurate, and complete, based on that person's best knowledge,
information, and belief.
(2) Procedure. This statement must be filed separately
from all other forms and exception statements filed with respect to
other matters pending before TDI. Claims for exception must be addressed
to the appropriate regulatory division within TDI.
(A) Mail codes for the respective divisions are as
follows:
(i) Rate and Form Review Office (Life, Accident, and
Health, including HMO) 106-1A;
(ii) Property and Casualty (including Workers' Compensation)
104-3B;
(iii) Title 106-2T;
(iv) Risk Retention Groups 305-2C.
(B) Exception statements should be filed with the Texas
Department of Insurance, (Name of Division), (Mail Code #), P.O. Box
149104, Austin, Texas 78714-9104.
(3) Duration of exception. Exceptions remain in effect
for one year. The information required by paragraph (1) of this subsection
must be provided to TDI no later than May 1, 1992, for calendar year
1992, and no later than March 15 of any subsequent year for which
an exception is claimed.
(4) Policy and form filings. When an insurer or HMO
files a policy form or evidence of coverage with TDI for information
or review, any exception to the requirements of this section about
the insurer's toll-free telephone number must be noted in the filing.
If a prior exception has not been granted, the documentation required
by paragraph (1) of this subsection must be filed.
(5) Records maintenance. Except as specifically provided
in subparagraphs (A) and (B) of this paragraph, beginning with calendar
year 1993, any insurer or HMO claiming an exception must maintain
a system by which information about receipt of initial premiums is
tracked on a calendar-year basis. This information must include for
each new policy written during a calendar year the following: the
policy number; the effective date of the policy; and the amount of
initial premium received, including any membership fees, assessments,
dues, and any other considerations for that insurance. This information
and any other data on which the company relied in making the determination
that it was entitled to the exception must be made available to TDI
on request and is subject to examination by TDI. Failure by any insurer
or HMO to maintain the information required in this paragraph or to
provide information to TDI on request constitutes grounds for enforcement
action that may result in the cancellation, revocation, or suspension
of the insurer's or HMO's certificate of authority.
(A) Any insurer or HMO that is authorized to write
business in Texas and that claims an exception to the maintenance
of a toll-free telephone number for a calendar year is not required
to maintain information about initial premium receipts as set out
in this paragraph in order to claim the exception if the exception
is based on the criteria set out in any of clauses (i) - (iv) of this
subparagraph, as follows:
(i) the insurer or HMO claims the exception based on
receipt of gross premiums of less than $2 million for the prior calendar
year for business written in this state, as reported on its annual
statement;
(ii) the insurer or HMO claims the exception based
on receipt of gross first-year premiums of less than $2 million for
the prior calendar year for all business, as reported on its annual
statement;
Cont'd... |
