By: Sibley S.B. No. 1884
Line and page numbers may not match official copy.
Bill not drafted by TLC or Senate E&E.
A BILL TO BE ENTITLED
AN ACT
1-1 relating to an independent review conducted under Chapter 88, Civil
1-2 Practice and Remedies Code.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Section 88.003, Chapter 88, Civil Practice and
1-5 Remedies Code, as added by Chapter 163, Acts of the 75th
1-6 Legislature, Regular Session, 1997, is amended to read as follows:
1-7 Sec. 88.003. Limitations on Cause of Action. (a) A person
1-8 may not maintain a cause of action under this chapter against a
1-9 health insurance carrier, health maintenance organization, or other
1-10 managed care entity that is required to comply with or otherwise
1-11 complies with the utilization review requirements of Article
1-12 21.58A, Insurance Code, or the Texas Health Maintenance
1-13 Organization Act (Chapter 20A, Vernon's Texas Insurance Code),
1-14 unless the affected insured or enrollee or the insured's or
1-15 enrollee's representative:
1-16 (1) has exhausted the appeals and review applicable
1-17 under the utilization review requirements; or
1-18 (2) before instituting the action:
1-19 (A) gives written notice of the claim as
1-20 provided by Subsection (b); and
1-21 (B) agrees to submit the claim to a review by an
1-22 independent review organization under Article 21.58A, Insurance
2-1 Code, as required by Subsections [Subsection] (c) and (d).
2-2 (b) The notice required by Subsection (a)(2)(A) must be
2-3 delivered or mailed to the health insurance carrier, health
2-4 maintenance organization, or managed care entity against whom the
2-5 action is made not later than the 30th day before the date the
2-6 claim is filed.
2-7 (c) The insured or enrollee or the insured's or enrollee's
2-8 representative must submit the claim to a review by an independent
2-9 review organization if the health insurance carrier, health
2-10 maintenance organization, or managed care entity against whom the
2-11 claim is made requests the review not later than the 14th day after
2-12 the date notice under Subsection (a)(2)(A) is received by the
2-13 health insurance carrier, health maintenance organization, or
2-14 managed care entity. If the health insurance carrier, health
2-15 maintenance organization, or managed care entity does not request
2-16 the review within the period specified by this subsection, the
2-17 insured or enrollee or the insured's or enrollee's representative
2-18 is not required to submit the claim to independent review before
2-19 maintaining the action.
2-20 (d) A review conducted under Subsection (c) as requested by
2-21 a health insurance carrier, health maintenance organization, or
2-22 managed care entity must be performed in accordance with Article
2-23 21.58C, Insurance Code. The health insurance carrier, health
2-24 maintenance organization, or managed care entity requesting the
2-25 review must agree to comply with Subdivisions (2), (3), and (4) of
2-26 Section 6A, Article 21.58A, Insurance Code.
3-1 (e) [(d)] Subject to Subsection (f) [(e)], if the enrollee
3-2 has not complied with Subsection (a), an action under this section
3-3 shall not be dismissed by the court, but the court may, in its
3-4 discretion, order the parties to submit to an independent review or
3-5 mediation or other nonbinding alternative dispute resolution and
3-6 may abate the action for a period of not to exceed 30 days for such
3-7 purposes. Such orders of the court shall be the sole remedy
3-8 available to a party complaining of an enrollee's failure to comply
3-9 with Subsection (a).
3-10 (f) [(e)] The enrollee is not required to comply with
3-11 Subsection (c) and no abatement or other order pursuant to
3-12 Subsection (d) for failure to comply shall be imposed if the
3-13 enrollee has filed a pleading alleging in substance that:
3-14 (1) harm to the enrollee has already occurred because
3-15 of the conduct of the health insurance carrier, health maintenance
3-16 organization, or managed care entity or because of an act or
3-17 omission of an employee, agent, ostensible agent, or representative
3-18 of such carrier, organization, or entity for whose conduct it is
3-19 liable under Section 88.002(b); and
3-20 (2) the review would not be beneficial to the
3-21 enrollee, unless the court, upon motion by a defendant carrier,
3-22 organization, or entity finds after hearing that such pleading was
3-23 not made in good faith, in which case the court may enter an order
3-24 pursuant to Subsection (e) [(d)].
3-25 (g) [(f)] If the insured or enrollee or the insured's or
3-26 enrollee's representative seeks to exhaust the appeals and review
4-1 or provides notice, as required by Subsection (a), before the
4-2 statute of limitations applicable to a claim against a managed care
4-3 entity has expired, the limitations period is tolled until the
4-4 later of:
4-5 (1) the 30th day after the date the insured or
4-6 enrollee or the insured's or enrollee's representative has
4-7 exhausted the process for appeals and review applicable under the
4-8 utilization review requirements; or
4-9 (2) the 40th day after the date the insured or
4-10 enrollee or the insured's or enrollee's representative gives notice
4-11 under Subsection (a)(2)(A).
4-12 (h) [(g)] This section does not prohibit an insured or
4-13 enrollee from pursuing other appropriate remedies, including
4-14 injunctive relief, a declaratory judgment, or relief available
4-15 under law, if the requirement of exhausting the process for appeal
4-16 and review places the insured's or enrollee's health in serious
4-17 jeopardy.
4-18 SECTION 2. This Act takes effect September 1, 1999.
4-19 SECTION 3. This Act applies only to a cause of action
4-20 accrues on or after the effective date of this Act. A cause of
4-21 action that accrues before the effective date of this Act is
4-22 governed by the law as it existed immediately before the effective
4-23 date of this Act and that law is continued in effect for this
4-24 purpose.
4-25 SECTION 4. The importance of this legislation and the
4-26 crowded condition of the calendars in both houses create an
5-1 emergency and an imperative public necessity that the
5-2 constitutional rule requiring bills to be read on three several
5-3 days in each house be suspended, and this rule is hereby suspended.