Untitled Texas Attorney General Opinion ( 1985 )

The Attorney General of Texas
JIM MAllOX
Attorney Gsnerrl
ltr.~ Lyndon L. Olron, Jr. opillion lo. m-301
Chairman
Start Board of Ioeuranct Re: Ubtthtr tht Ttxao Insurmct
1110 San Jacinto Boulevard Ctdt prohibit8 health insuranct
Austin, Ttxat 70786 policy proviaionr that dircrimi-
natt with regard to payment for
trtatrant by certain typtr of
714 Jackwn, SUN. 700 health care practitlontro bastd
DalIa& lx 7520245c4
214l742a244
on (1) an txprtsr txclusion of
much practitiontr8 or (2) “place
and manntr” rtstrictlonr that
4624 A1b.M Ave.. &Jr* 160 indirtctly txclude such practi-
El PMo.lx. 702w2722 tiontra
61YW53464
Dear Mr. Olson:
I 1rxrr. SUN. 700
Hourton. TX. 77002-3111 Tou havt asked our opinion regarding vhtther tht Statt Board of
712l22552Ba fnsuranct ehould ap:)rove the folloving types of eickneso and accident
iosuranct policy prtnrlsionr:
606 Broadw8y. Bull. 512
Lubboc~Tx. 72401.2479 1. Pa:nntnt of btnefitr . . . i8 sptcifically
m47-5222 limited to inatancco where trtatmtn.t is provided
by a doctwr of rdicint. No benefits vi11 bt paid
for trtatnnt by a doctor of dentistry, doctor of
4306N.Tenth.Sultr B doctor of optometry, doctor of
McAllm,Tx 76601~1666 chiropractk,
B12MB24B47 podiatry, doctor in psychology, ludlologlat. or
rpttch-lrquapt pathologitt.
260 MaInPlaza,SLdto400 2. Btmfita art payable for manipulation of
tht l
Ban AnIonlo. TX 722052727
612l2254191
pine:. Eovtvtr, benefit. will bt paid only
vhen ouch treatnent is providtd in a hospital.
3. Benefits art payiblt for unipulation of
tht rpim, vhtn trtatmtnt ir providtd whllt the
inturtd’lt undtr stntral lntttbttla.
4. Bcntfitt art oayablt for trtatmtnt of
mtntal illntsr or prychologiul impairment. txctpt
that btmfitr payablt whtn tht inrurtd ir an out-
patitnt wd trtatmtnt is providtd by a prycbo-
loslot are limirtd to $20 ptr trtatlcnt and 25
trtatmtntr per ytar. Thtrt it no limit on
benefitr payablt whtn treatment ir providtd by a
Hr. Lyndoo L. Olson. Jr. - Ptrflt 2 ml-301)
.
psychiscrisr 0Oar than co-insurance and
dtductiblts.
5. Btntfirt sre paysbls for wtatment of
chiropractic atrv:kes, txctpt rhat btnefits art
payablt on an out’-patient basis or schtdule vhtn
trtatmtnr is provi’dtd by a chiroprsctor and are
limited to $20 ptr wtarmtnt and 20 trtamenta ptr
ytar. Thtrs is D,O limit on btntfits payablt,
except co-inaurancre and dtductibles, vhtn trtat-
mtnt is provided by a doctor of mtdicint.
T%t requirement that jnauranct policy forms be approvtd by tht
Statt Board of Insurance a:# well aa tht grounds on which the board
shall dieapprovt forms are !w:r forth in articlt 3.42 of tht Ineuranet
Code. Article 3.42(a) provMea:
No policy, cortract or certiflcatt of lift.
ttrm or tndowmtnl: ineuranct, group lift or term
insuranct, indust~r:Lsl life insurance, accident or
health insurance, group accident or health
Insurance, hospitalization insuranct, group
hospitalization :Lnaurance. medical or surgical
insuranct, [or] group medical or surgical
insursnct . . . 1Aal1 bt dtlivtrtd. issued or used
In this statt . . . unless tht form of said
Policy 8 contract or cerrificact has betn filed
vith rht Statt Beard of Insurance and approvtd by
said Board. . . .
Articlt 3.42(s) provides:
Tht Start Board of Insurance shall forthwith
disapprovt any , . . form, or vithdrav sny
prtvious approval thertro if. and only if,
(1) It la in any rtaptct in violation of or
dots not comply esth this Code.
(2) IL contt,fns provisions which tncourage
misrtprtstntatior~ or art unjust, unfair, in-
tquitable. mialtading. dtctprivt or contrary to
law or to tht pu~11.1~policy of this state.
(3) Xc has any titlt, htadlng or othtr indica-
tion of its provisions which is misleading.
-(Emphasis l ddtd) ,I
Tou sptcifically ask:
1. Dote cht :lmsurtd’s article 21.52, fnauranct
Code, frttdom 1x1 atlsct a practitioner negate
p. 1360
. ‘_
Hr. Lyndon 1. Olsom, Jr. - Psp~ 3 (JM-301)
provisions such mu (1) abovt which txclude
aptcificd pracritianera?
2. Are rtsrrictiona of the type @et out in (2)
through (5) lbovt lllowablt vhtn’no prwieloo
tnumtratts which p~rtrc~itiontrs vi11 bt rtcognized
and vhich ~111 not be? In othtr words, vhtn not
txcluded by refemnct, can a pracritiontr bt
txcludtd by rtsrricrions on tht plsct and msnntr
in which trtatmtnt bt administtrtd?
Tht provision of rht tneurance Code about vhich you inquire,
art.iclt 21.52. section 3, atckl:ta:
Any person vhl, la issutd . . . any htalth
insuranct policy . . , by any insuranct company,
asaociafion. or organiaation . . . map stltct a
lictnssd doctor of podiatric medkint, a lictnstd
dtntist, or a doctor of chiropractic to ptrfort
the wdical or surgical strvlcea or procedures
echtduled in tht policy which fall vithin tht
scope of the 1ic:enst of that practitioner, a
lictnscd doctor elf optometry to perform the
atrvicts or procc!d,urta achedultd in rht policy
which fall within the tcopt of the license of that
doctor of opto~~rp. an audiologist to measurt
hearing . . . or 4~ speech-language pathologlsc to
evaluate speech and languagt . . . if thoat
etwicts or procedures art schtduled in tht
policy. Tht payrrent or reimburstment by the
Insurance cmpan:r . . . shall not bt denied
btcause the same were ptrformtd by a lictnstd
doctor of podiatric: medicine. a lictnstd doctor of
opt--Y. a liwnsed doctor of chiropractic, a
lictnaed dtntisr. an audiologist. or a aptech-
languagt patholog,ist. Thtrt shall not bt any
clasaificatlon, difftrentstion. or other discri-
mination in the :?ayment schedule or the paymtnt
provisions . . . nor in rht amount. . . .
The prtstnr list of practi,:lloners in arricle 21.52 is the result of
stvtrsl amendmtnra to the original article enacted in 1977. In
ltgislativs etamitttt htsrirlSs , tht bills which tddtd praccieioners co
lrticlt 21.52 vert frtqutntly rtftrrtd to as “fretdom of choice”
bills. Th+ purport vat tc permit rhe insurtd. not tht insurtr, to
stltct tht kind of practiriwer rhat would perform tht strvicte
covtred in tht insuranct pc~ficp. Stt, t.g.. Ttatimony on Stnare Bill
No. 96, StriateEconomic ‘D,evelopment Ccmnitttt, 66th Ltg., public
htarlng, rtcordtd Jan. 29, 1979. svailablt in Ltgialativt Refertnct
Library; Id., llouat Cmittee on Health Services, rtcorded Ptb. 21.
1979; Tesxony on Roust Bill No. 860. Stnatt CoPaittett on Euman
.
Hr. Lyndot L. Olson, Jr. - Pa(Ie 4 (Jn-301)
I
Rtsourcts, 66th L.tg.. public hearing, recordtd Apr. 25, 1979,
available in Legislative Reference Library.
Wt concludt that artic1.e. 21.52 txprtsaly prohibits an insurer
from ~acriminating sgainst an inaurtd, vith rtgard to paywnt or
rtimburatmant, based on tht L’ppt of pracritiontr rht insurtd aeltcta
to provide mtdieal cars. Iht prohibition againer discrimination
txtenda to the em-vices of six kinds of health cart practi~ionera:
podiatrlstsr dtntiats, chiropractors, optomtrriats. sudlologiate and
speech-languegt parhologista. Tht prohibition against discrimination
applies vlrh resptcr ro tho:;e eervicta (1) covtrtd by rht reltvannt
insurance policy and (2) within the acopt of rho affecttd practl-
tiontr’s license or certlfica~ion. Policy provisions which exclude,
restricr or limit payment or reimbursement for such strvices vhtn they
are provided by any of the specified practitioners. and do not provide
the same exclusion, restriction or limirsrion on those services vhtn
they are provided by a doeto!, of medicint, art unlavful.
We believt the first an81 fifth policy provisions about which you
inquire must be disapproved becautt they expressly discriminate
against ont or more of tht preictitiontra identified in articlt 21.52.
Article 21.35A of rhe Te:Kaa Insurance Code is similar to article
21.52 and relevant to the fourth policy provision about which you
inquire. Article 21.35A prohibits discrimination against a person who
elects ro obtain treatment from a licensed psychologist rather rban a
doctor of medicine. In a group insurance policy or group hospital
plan, as follove:
Any person who la cwtrtd by a policy . . . of
group insurance or of a group hospital plan . . .
and vhoee policy . . . provides for strvicts or
partial or total rleimbursemtnt for services that
art within the sc.ampe of pracrict of a lictnetd
psychologist. is mtitltd to obtain thtae strvicea
or rtceive rtiml~nraamant for these services
regardless of whtdrtr the services are performed
by a lictnstd doc:t.or of mtdicint or a lictnaed
psychologist.
The fourth policy proMsion about vhich you inquire expressly
differentiates bttveen the amount of rtimburatmtnt availablt for
scrvicts of a psychologist a,nd the amount of rtimbursemtnr available
for eervicts of a pcrychlotriar. Sptcial limirations apply to
reimbursement for psychologl:sts that do not apply to psychistrlste.
Thus. ve btlitvt the fourth policy prwision you identifp.muat also bt
disapproved whtn it appears in a policy or plan aubjtct to articlt
21.35A.
Wt also concludt that 1:he plain language of articles 21.52 and
21.35A prohibits nor only rhost fores which expressly statt thst the
amount or txistence of rtinl~uraamtnt shall vary according to the type
p. 1362
Mr. Lyndon L. Oleoe, Jr. - ?sp 9 (JM-301)
of prtctitiontr providing the atrvict, as in tht first. fourth and
f lfth policy prwlsions you quott, but also those forma vhkh havt tht
same or similar discriminatory tfftct , such as tht stcond and third
policyprovisions quottd.
To dtrtrmint titthtr c.ht policy diseriminatta against ctrtain
typts of pracritiontra, the “place or manntr” restric.tions about which
you inquirt must bt svaluatc!d in light of tht naturt of rhe btneflta
co which thty apply. Tht ,xtcond and third prwision@ atstt that
btntfits art payable for sanipulation of tht apint. Bovevtr , tht
stcond provision limita tht btnefits to msnipulation performed in a
hospital and tht third pros Lsion limits tht bentflts to msnipulation
ptrfomtd vhilt tht insurtd is undtr gentral antscheaia.
l4snipulation of tht splat la a etrvict cctmonly provided by
chiropractors and la virhin tht scope of rhtir llctnats. Chiro-
practors’ lictnsts do not. however , ptrmit thtm to administer general
anesthesia or admit ps~itnrs to hospitals. Thus, the tffect of the
quottd rtstrictions ia a crkgorical txclusion of tbt only type of
practitiontr comonly associa~ttd with tht trtatmtnt purporttdly within
tht scopt of the insuranct polic7 cwtragt. Since chiropractors art
aaong tht prsctiriontrs idantifitd in lrriclt 21.52, such prwiaions
subvert the statute and art nonenforceablt.
Our conclusion is besta on tht plain langusgt of tht statute sad
ltgislativt intent.
Tht plain language of ,rrticlts 21.52 and 21.35A dots noLot limit
the prohibition against discriminarlon to any particular method or
means of discrimination. 011 tht contrary, lrticlt 21.52, for~txamplt.
aprtssly statts rhtr thtrt shall not bt (Iany classification,
difftrcnciarion. or other dL:6crlmina~iou . . . in the amount or manner
of payment or rtimbursemtnt. . . .”
To Slot tfftct to legislativt intent , a statuLt should be givtn a
“practical and rtaaonablt constrnction rathtr than a literal or
thwarting cons)truction.” Sta Dtnvt~r-Albuqutrqut Motor Transport, Inc.
v. SraLt. 586 S.Y.Zd 73g;‘%O (Ttx. Civ. App, - Amarillo 1979, no
‘vrit)d casts cittd rhtr~rlo. Articlts 21.52 and 21.3SA prohibit
discrimination or dlffaren~~iation bastd upon tht typt of practitiontr
prwiding tht ttrvict if !:ht practiriontr is among thost sptcifLtd.
To accomplish tht object o!! rht legislation , such discrimination must
bt prohibittd not only when it la ght rtsult of txprtssly discrimina-
gory restrictions bug s1a.o ubtn is rtsults from discririnatory
rtstricCions disguiatd aa n~sn-discriminsgory rtstrictions limitatlona
on tht plact or umotr in rgich tht strviet is prwidtd.
Ntithtr lrticlt 21.W~ no r lrtielt 21.52 apptars inttndtd to
slttr tht basic naturt of tht btneflts ptovidtd in an insurancs policy
txctpt to tht txttnt ntcc:rstry to prohibit discrimination baatd on
categorical distinctions b’cltvten ctrtain typts of practitiontrs. The
Ttxas Suprtme Court has btld that tht Qtatt Board of Insurance msy
p. 1363
nr. Lyndoa I, Olron, Jr, - ?rsr 6 ml-301)
consider fectorr other thr!l those which spperr vithin the “four
corners of the POLICY” in dwiding vhcthcr to approve a policy form.
Key Western LIti Ins~rence Co.. v. State Board of ‘kurance, 3SdS.U.Zd
ykefororc,
39, the Strte Bosrd of fneursnce msy
consider fsctorr deemed ne:Icrrsry to determine the dlscriminat6+
purpose or sffect of sny glv~ku policy provision.
Tou have slso directed our attention to srtlcle 3.70-2(B) of the
Insurance Code, vhich provide!,:
Ro pollc9 of clc:cident end sickaert insursnce
shell make benefi~:s contingekt upon treatment or
lx smina tio n by a ,particular practitioner or by
particular practitioners of the healing arts
hereinafter designated unless such policy contains
A provision desigrmting the practitioner or
practitioners vhcl will be recognized by the
insurer and thors vho vi11 not be recognized by
the Insurer. . . . In designating the practl-
tioners vho vi11 md will not be recognized, such
provision shall USC the following tams: Doctor
of Medicine, Doctor of Osteopathy, Doctor of
Dentistry, Docto:r of Chiropractic, Doctor of
Optometry, Doctor of Podiatry. Audiologist, and
Speech-language Pathologist .
Another vereion of thil, amended article passed by the legislature
in s separate bill at the 13ame session as the sbove-quoted version ,
includes psychologists end excludes sudiologists and speech-language
psthologists from the list of prsctitloners.
klthsr version of srticls 3.70-2(B) should be rud to conflict
with article 21.52. Art1c:l.e 3.70-2(B) nsithsr luthorizes nor pro-
hibits sny discrimination b8etveen practitioners. Artlcls 3.70-2(B)
merely prescribes the fonut for sxcluding practitionera when such
sxclusious are not prohibitc,d elsewhere in the Insurance Code.
Zveo if lrticle 3.704(B) end srticle 21.52 were ambiguous or
potentially contradictory, hovever, vsrious rules of ststutoty
COMtNCtiOU support the fcregoins interpretetlon. Statutes should be
conrtrued in harmony vlth other ststutes unless A cootrary intention
ir clearly manifest. Tree18 v. Walker, 26 S.Y.Zd 627, 630 (Tex.
1930). Kven when the ll.il language of one ensctment conflicts vith
th8t of 8nother. they &NJld be read together and hormmised, if
reasonably posribls. Dsl:las Rallvay b Tsrrlnsl Co. v. Strickland
transportetion Co., 225%.2d 901. 905 (Tax. Cir. App. - Amarillo
1949. no vrit). This proqositlon is especially true vlth respect to
statuteswhich, as hers, dssl with the same genersl subject. and are
therefore conridered to be .Ln ari msteris. see Texas Stats Board of
Pharucy v. Kittman, 550 S,.Il.26 *w 104, 106 Tex.xv. App. - Tyler 1977.
no nit); 2A C. Sanda, Sutherlsad Statutory Construction, 651.02, et
453-55 (rev. 4th ad. 1986’
: . Hr. IFdon L. Olroa, Jr. - ?a&@7 (JM-301)
. . ,
.
Our construction of lrt!Lcls 3.70-2(B) is sleo mpported by the
Nle that, by reoson of the disparity lo b&rgsinlng poritions betveen
ineuronce covponiss lod purcl~mere of insurance, St&Cute8 regullting
the re~t1onohips of lneurers cud insuredr ore interpreted strictly
against the insurance covpouies end liberally in favor of insured
pereone. 2A C. Sands, su rs, 15S.04, et 716; 3 id.. 170.05. At 308
(4th ld. 1974). This N-F a fwors upholding the polic9 smbodlsd lo
article 21.52 of giving the insured freedom to choose lmng verious
hinds of practitioners.
Ye find no iodlcstios DE lsgislotive intent vhich justifies e
Coutrory ioterpretatiov. k’th article 21.52 And article 3.70-2(B)
vers emended in 1983. Artim:le 21.52.. section 3 VAS amended to odd
audiologists And rpeech-lsn~;uoge pathologists (vithout the express
“acope of license” requirement included for the other specified
practitioners). Acts 1983, ‘58th Leg., ch. 380, at 2065. As port of
the SAM bill, orticls 3.70-2(B) vas also mended to odd “mdiolo-
gists” md “speech longuoge pathologiets.” A second bill, vhlch also
emended lrticle 3.70-2(B), ws passed later during the SAIDC 8eesion.
This second bill added “Doctor of Psychology” to 3.70-2(B) but did not
Include “eudiologieta” or “qmech lmguegs pothologimte.” Senate Bill
Ro. 255, 68th Leg., ch. b92, At 2887. Both blllr vsrs signsd by the
governor.
The omeodmeot of botb article 21.52. eection 3 And srtlcle \
3.70-2(B) in the some session reinforcer the reoeons for cooetNing
the statutes to give vemlug and effect to both. See ?Jere v.
Crenshov. 137 S.W.2d 7, 13 (‘iex. 1940) (two statute. relxng to saxe
eubject and mended ot some sersioo should be reed together); 2A C.
Bonds, n, 151.03, At &Iii’. The principle that St8tUtCA i0 pAti
meter l lr
hould be construed together is l reststemsnt of the preeump-
tioo Agaioet the ivplied repel1 of etotutes. See Fortinberry v. Store
283 S.U. 146, 149 (Ten. 1926);2A C. Sender e,
iti+-zs. The ldditkmr to the list of prsctltlonere mede in
both articles during the sme lsgislstive lseelon plain19 indicates
that the legislrturs did avc contemplate eo9 conflict or intend on
implied repeal of either Article.
SUWtlART
Article 21.52, eectiou 3. of the Texse
Insurance Code lwohibitr discriviustios by an
insurer 8g AinSt lII iaeured vith rsssrd to pepeot
of beoefite bsea# on the lneursd’e electlon to
ebtsin the lervicee of l podlotriet. dsotiet.
chiropractor, optmetrist, sudiologlst or epcech-
laoguoge pathologist rrther than a’ doctor of
medic ine o r luoe o th e r kind of health core prscti-
tiooer. The prohIbition. Applies if the sarvicse
obteioed lre within the ecops of esrvicee covered
p. 1365
Ur. L9ndoe 1. Olson, Jr. - ?rSs 6 m-3w I 1
: I
! .
b9 the polic9 end within the scope of the prscti-
tioner’e liceoee or certificstion. The prohlbi-
tfou extends to those ineuronce polic9 provisions
vhich sxpreeel9 discrinlnetc sgoinet oue or more
of tbo spsclfied types of prscgitionsre, eo us11
as to those provirkme. including piece sod unnsr
reetrictions, vhitib hsvs the lsms or a elmilar
discriminstory purpose or effect.
JIM WATTOX
Attorney General of Texas
TotlGKExR
First AesietAnt Attorney Grnsrsl
DAVID R. RICRARDS
Executive AsSiStAnt Attorney General
RICK CILPIl
Ch~irmao, Opinion Cmittee
Prep&red by lfarienne Wood&Id
AseistAnt Attorney General
APPRGVED:
OPXRIORCGM4ITTltX
Celia Carl
EdoAKemoo
Paul Rich
p. 1366