| (a) If the department disapproves any portion of an
evidence of coverage, the department will specify the reason for the
disapproval. The department may disapprove any form or withdraw any
previous approval if a form:
(1) fails to meet the requirements of Insurance Code
Chapter 1271 (concerning Benefits Provided by Health Maintenance Evidence
of Coverage; Charges), this chapter, or other applicable statutes
and regulations;
(2) does not properly describe the services and benefits;
(3) contains any statements that are unclear, untrue,
unjust, unfair, inequitable, misleading, or deceptive or that violate
Insurance Code Chapters 541 (concerning Unfair Methods of Competition
and Unfair or Deceptive Acts or Practices), 542 (concerning Processing
and Settlement of Claims), 543 (concerning Prohibited Practices Related
to Policy or Certificate of Membership), 544 (concerning Prohibited
Discrimination), or 547 (concerning False Advertising by Unauthorized
Insurers), or any other applicable law or regulations;
(4) provides services or benefits that are too restrictive
to achieve the purpose for which the form was designed;
(5) fails to attain a reasonable degree of readability,
simplicity, and conciseness;
(6) provides services or benefits or contains other
provisions that would endanger the solvency of the issuing HMO; or
(7) is contrary to the law or policy of this state.
(b) If the department disapproves a form, the HMO may
file a written request for a hearing on the matter under Insurance
Code §1271.102 (concerning Procedures for Approval of Form of
Evidence of Coverage or Group Contract; Withdrawal of Approval).
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