Section 11.504 - Disapproval of an Evidence of Coverage(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).28 Tex. Admin. Code § 11.504
The provisions of this §11.504 adopted to be effective January 1, 1980, 4 TexReg 4622; amended to be effective December 6, 1984, 9 TexReg 6011; amended to be effective December 4, 1987, 12 TexReg 4363; amended to be effective August 17, 1992, 17 TexReg 5356; amended to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854; amended to be effective November 15, 2006, 31 TexReg 9298; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2232, eff. 8/1/2017