By: Sibley S.B. No. 1884
A BILL TO BE ENTITLED
AN ACT
1-1 relating to independent review of certain health insurance claims.
1-2 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-3 SECTION 1. Section 88.003, Civil Practice and Remedies Code,
1-4 as added by Chapter 163, Acts of the 75th Legislature, Regular
1-5 Session, 1997, is amended to read as follows:
1-6 Sec. 88.003. Limitations on Cause of Action. (a) A person
1-7 may not maintain a cause of action under this chapter against a
1-8 health insurance carrier, health maintenance organization, or other
1-9 managed care entity that is required to comply with or otherwise
1-10 complies with the utilization review requirements of Article
1-11 21.58A, Insurance Code, or the Texas Health Maintenance
1-12 Organization Act (Chapter 20A, Vernon's Texas Insurance Code),
1-13 unless the affected insured or enrollee or the insured's or
1-14 enrollee's representative:
1-15 (1) has exhausted the appeals and review applicable
1-16 under the utilization review requirements; or
1-17 (2) before instituting the action:
1-18 (A) gives written notice of the claim as
1-19 provided by Subsection (b); and
1-20 (B) agrees to submit the claim to a review by an
1-21 independent review organization under Article 21.58A, Insurance
1-22 Code, as required by Subsections [Subsection] (c) and (d).
1-23 (b) The notice required by Subsection (a)(2)(A) must be
1-24 delivered or mailed to the health insurance carrier, health
2-1 maintenance organization, or managed care entity against whom the
2-2 action is made not later than the 30th day before the date the
2-3 claim is filed.
2-4 (c) The insured or enrollee or the insured's or enrollee's
2-5 representative must submit the claim to a review by an independent
2-6 review organization if the health insurance carrier, health
2-7 maintenance organization, or managed care entity against whom the
2-8 claim is made requests the review not later than the 14th day after
2-9 the date notice under Subsection (a)(2)(A) is received by the
2-10 health insurance carrier, health maintenance organization, or
2-11 managed care entity. If the health insurance carrier, health
2-12 maintenance organization, or managed care entity does not request
2-13 the review within the period specified by this subsection, the
2-14 insured or enrollee or the insured's or enrollee's representative
2-15 is not required to submit the claim to independent review before
2-16 maintaining the action.
2-17 (d) A review conducted under Subsection (c) as requested by
2-18 a health insurance carrier, health maintenance organization, or
2-19 managed care entity must be performed in accordance with Article
2-20 21.58C, Insurance Code. The health insurance carrier, health
2-21 maintenance organization, or managed care entity requesting the
2-22 review must agree to comply with Subdivisions (2), (3), and (4),
2-23 Section 6A, Article 21.58A, Insurance Code.
2-24 (e) Subject to Subsection (f) [(e)], if the enrollee has not
2-25 complied with Subsection (a), an action under this section shall
2-26 not be dismissed by the court, but the court may, in its
3-1 discretion, order the parties to submit to an independent review or
3-2 mediation or other nonbinding alternative dispute resolution and
3-3 may abate the action for a period of not to exceed 30 days for such
3-4 purposes. Such orders of the court shall be the sole remedy
3-5 available to a party complaining of an enrollee's failure to comply
3-6 with Subsection (a).
3-7 (f) [(e)] The enrollee is not required to comply with
3-8 Subsection (c) and no abatement or other order pursuant to
3-9 Subsection (e) [(d)] for failure to comply shall be imposed if the
3-10 enrollee has filed a pleading alleging in substance that:
3-11 (1) harm to the enrollee has already occurred because
3-12 of the conduct of the health insurance carrier, health maintenance
3-13 organization, or managed care entity or because of an act or
3-14 omission of an employee, agent, ostensible agent, or representative
3-15 of such carrier, organization, or entity for whose conduct it is
3-16 liable under Section 88.002(b); and
3-17 (2) the review would not be beneficial to the
3-18 enrollee, unless the court, upon motion by a defendant carrier,
3-19 organization, or entity finds after hearing that such pleading was
3-20 not made in good faith, in which case the court may enter an order
3-21 pursuant to Subsection (e) [(d)].
3-22 (g) [(f)] If the insured or enrollee or the insured's or
3-23 enrollee's representative seeks to exhaust the appeals and review
3-24 or provides notice, as required by Subsection (a), before the
3-25 statute of limitations applicable to a claim against a managed care
3-26 entity has expired, the limitations period is tolled until the
4-1 later of:
4-2 (1) the 30th day after the date the insured or
4-3 enrollee or the insured's or enrollee's representative has
4-4 exhausted the process for appeals and review applicable under the
4-5 utilization review requirements; or
4-6 (2) the 40th day after the date the insured or
4-7 enrollee or the insured's or enrollee's representative gives notice
4-8 under Subsection (a)(2)(A).
4-9 (h) [(g)] This section does not prohibit an insured or
4-10 enrollee from pursuing other appropriate remedies, including
4-11 injunctive relief, a declaratory judgment, or relief available
4-12 under law, if the requirement of exhausting the process for appeal
4-13 and review places the insured's or enrollee's health in serious
4-14 jeopardy.
4-15 SECTION 2. This Act takes effect September 1, 1999.
4-16 SECTION 3. This Act applies only to a cause of action that
4-17 accrues on or after the effective date of this Act. A cause of
4-18 action that accrues before the effective date of this Act is
4-19 governed by the law as it existed immediately before the effective
4-20 date of this Act and that law is continued in effect for this
4-21 purpose.
4-22 SECTION 4. The importance of this legislation and the
4-23 crowded condition of the calendars in both houses create an
4-24 emergency and an imperative public necessity that the
4-25 constitutional rule requiring bills to be read on three several
4-26 days in each house be suspended, and this rule is hereby suspended.