1-1 By: Sibley S.B. No. 1884
1-2 (In the Senate - Filed April 23, 1999; April 23, 1999, read
1-3 first time and referred to Committee on Economic Development;
1-4 April 27, 1999, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 4, Nays 0; April 27, 1999,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 1884 By: Sibley
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to independent review of certain health insurance claims.
1-11 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-12 SECTION 1. Section 88.003, Civil Practice and Remedies Code,
1-13 as added by Chapter 163, Acts of the 75th Legislature, Regular
1-14 Session, 1997, is amended to read as follows:
1-15 Sec. 88.003. Limitations on Cause of Action. (a) A person
1-16 may not maintain a cause of action under this chapter against a
1-17 health insurance carrier, health maintenance organization, or other
1-18 managed care entity that is required to comply with or otherwise
1-19 complies with the utilization review requirements of Article
1-20 21.58A, Insurance Code, or the Texas Health Maintenance
1-21 Organization Act (Chapter 20A, Vernon's Texas Insurance Code),
1-22 unless the affected insured or enrollee or the insured's or
1-23 enrollee's representative:
1-24 (1) has exhausted the appeals and review applicable
1-25 under the utilization review requirements; or
1-26 (2) before instituting the action:
1-27 (A) gives written notice of the claim as
1-28 provided by Subsection (b); and
1-29 (B) agrees to submit the claim to a review by an
1-30 independent review organization under Article 21.58A, Insurance
1-31 Code, as required by Subsections [Subsection] (c) and (d).
1-32 (b) The notice required by Subsection (a)(2)(A) must be
1-33 delivered or mailed to the health insurance carrier, health
1-34 maintenance organization, or managed care entity against whom the
1-35 action is made not later than the 30th day before the date the
1-36 claim is filed.
1-37 (c) The insured or enrollee or the insured's or enrollee's
1-38 representative must submit the claim to a review by an independent
1-39 review organization if the health insurance carrier, health
1-40 maintenance organization, or managed care entity against whom the
1-41 claim is made requests the review not later than the 14th day after
1-42 the date notice under Subsection (a)(2)(A) is received by the
1-43 health insurance carrier, health maintenance organization, or
1-44 managed care entity. If the health insurance carrier, health
1-45 maintenance organization, or managed care entity does not request
1-46 the review within the period specified by this subsection, the
1-47 insured or enrollee or the insured's or enrollee's representative
1-48 is not required to submit the claim to independent review before
1-49 maintaining the action.
1-50 (d) A review conducted under Subsection (c) as requested by
1-51 a health insurance carrier, health maintenance organization, or
1-52 managed care entity must be performed in accordance with Article
1-53 21.58C, Insurance Code. The health insurance carrier, health
1-54 maintenance organization, or managed care entity requesting the
1-55 review must agree to comply with Subdivisions (2), (3), and (4),
1-56 Section 6A, Article 21.58A, Insurance Code.
1-57 (e) Subject to Subsection (f) [(e)], if the enrollee has not
1-58 complied with Subsection (a), an action under this section shall
1-59 not be dismissed by the court, but the court may, in its
1-60 discretion, order the parties to submit to an independent review or
1-61 mediation or other nonbinding alternative dispute resolution and
1-62 may abate the action for a period of not to exceed 30 days for such
1-63 purposes. Such orders of the court shall be the sole remedy
1-64 available to a party complaining of an enrollee's failure to comply
2-1 with Subsection (a).
2-2 (f) [(e)] The enrollee is not required to comply with
2-3 Subsection (c) and no abatement or other order pursuant to
2-4 Subsection (e) [(d)] for failure to comply shall be imposed if the
2-5 enrollee has filed a pleading alleging in substance that:
2-6 (1) harm to the enrollee has already occurred because
2-7 of the conduct of the health insurance carrier, health maintenance
2-8 organization, or managed care entity or because of an act or
2-9 omission of an employee, agent, ostensible agent, or representative
2-10 of such carrier, organization, or entity for whose conduct it is
2-11 liable under Section 88.002(b); and
2-12 (2) the review would not be beneficial to the
2-13 enrollee, unless the court, upon motion by a defendant carrier,
2-14 organization, or entity finds after hearing that such pleading was
2-15 not made in good faith, in which case the court may enter an order
2-16 pursuant to Subsection (e) [(d)].
2-17 (g) [(f)] If the insured or enrollee or the insured's or
2-18 enrollee's representative seeks to exhaust the appeals and review
2-19 or provides notice, as required by Subsection (a), before the
2-20 statute of limitations applicable to a claim against a managed care
2-21 entity has expired, the limitations period is tolled until the
2-22 later of:
2-23 (1) the 30th day after the date the insured or
2-24 enrollee or the insured's or enrollee's representative has
2-25 exhausted the process for appeals and review applicable under the
2-26 utilization review requirements; or
2-27 (2) the 40th day after the date the insured or
2-28 enrollee or the insured's or enrollee's representative gives notice
2-29 under Subsection (a)(2)(A).
2-30 (h) [(g)] This section does not prohibit an insured or
2-31 enrollee from pursuing other appropriate remedies, including
2-32 injunctive relief, a declaratory judgment, or relief available
2-33 under law, if the requirement of exhausting the process for appeal
2-34 and review places the insured's or enrollee's health in serious
2-35 jeopardy.
2-36 SECTION 2. This Act takes effect September 1, 1999.
2-37 SECTION 3. This Act applies only to a cause of action that
2-38 accrues on or after the effective date of this Act. A cause of
2-39 action that accrues before the effective date of this Act is
2-40 governed by the law as it existed immediately before the effective
2-41 date of this Act and that law is continued in effect for this
2-42 purpose.
2-43 SECTION 4. The importance of this legislation and the
2-44 crowded condition of the calendars in both houses create an
2-45 emergency and an imperative public necessity that the
2-46 constitutional rule requiring bills to be read on three several
2-47 days in each house be suspended, and this rule is hereby suspended.
2-48 * * * * *