Case Information
*1 The Attorney General of Texas
JIM MAllOX
Attorney Gsnerrl
ltr.~ Lyndon L. Olron, Jr. opillion lo. m-301 Chairman Re: Ubtthtr tht Ttxao Insurmct
Start Board of Ioeuranct 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 on (1) an txprtsr txclusion of 214l742a244 much practitiontr8 or (2) “place
and manntr” rtstrictlonr 4624 A1b.M Ave.. &Jr* 160 indirtctly txclude such practi- El PMo. lx. 702w2722 tiontra 61YW53464
Dear Mr. Olson: I 1rxrr. SUN. 700 Tou havt asked our opinion regarding vhtther tht Statt Board of Hourton. TX. 77002-3111 fnsuranct ehould ap:)rove the folloving types of eickneso and accident 712l22552Ba
iosuranct policy prtnrlsionr: 606 Broadw8y. Bull. 512 1. Pa:nntnt of btnefitr i8 sptcifically Lubboc~Tx. 72401.2479 limited inatancco where trtatmtn.t is provided m47-5222 by a doctwr of rdicint. No benefits vi11 bt paid for trtatnnt by a doctor of dentistry, doctor of 4306 N. Tenth. Sultr B optometry, doctor chiropractk, doctor of McAllm,Tx 76601~1666 in psychology, udlologlat. podiatry, doctor B12MB24B47 rpttch-lrquapt pathologitt.
260 MaIn Plaza, SLdto 400 2. Btmfita art payable for manipulation Ban AnIonlo. TX 722052727 tht pine:. Eovtvtr, benefit. will bt paid only 612l2254191 a hospital. vhen ouch treatnent is providtd
3. Benefits art payiblt for unipulation rpim, vhtn trtatmtnt ir providtd whllt inturtd’lt undtr stntral ntttbttla.
4. Bcntfitt art oayablt trtatmtnt mtntal illntsr or prychologiul impairment. txctpt that btmfitr payablt whtn 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 ir providtd by a treatment *2 ml-301) Hr. Lyndoo L. Olson. Jr. - Ptrflt 2 0Oar than co-insurance
psychiscrisr
dtductiblts. for wtatment sre paysbls of 5. Btntfirt art rhat btnefits
chiropractic atrv:kes, txctpt on an out’-patient payablt basis or schtdule vhtn is provi’dtd by a chiroprsctor and are trtatmtnr limited to $20 ptr wtarmtnt and 20 trtamenta ptr on btntfits Thtrs is D,O limit payablt, ytar. except co-inaurancre and dtductibles, trtat- vhtn mtnt is provided by a doctor mtdicint.
T%t requirement jnauranct forms be approvtd by tht Statt Board of Insurance a:# well aa grounds on which 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 lift. or tndowmtnl: ineuranct, group lift or term ttrm insuranct, indust~r:Lsl life insurance, accident or health insurance, accident or health group Insurance, hospitalization insuranct, group hospitalization :Lnaurance. medical surgical or insuranct, [or] group medical or surgical insursnct . . . 1Aal1 bt dtlivtrtd. issued or used In this statt . . . unless form said Policy 8 contract or cerrificact has betn filed rht Statt Beard Insurance and approvtd by said Board.
Articlt 3.42(s) provides:
Tht Start Board of Insurance forthwith or vithdrav sny disapprovt form, any , . . thertro if. and only prtvious approval if, (1) It la any rtaptct in violation dots not comply esth this Code.
(2) IL contt,fns provisions which tncourage misrtprtstntatior~ or art unjust, unfair, in- tquitable. mialtading. dtctprivt or contrary
law or to tht pu~11.1~ policy this state.
(3) Xc has any titlt, htadlng or othtr indica- tion its provisions which is misleading. -(Emphasis ddtd) ,I
Tou sptcifically ask:
1. Dote cht :lmsurtd’s article fnauranct 1x1 atlsct a practitioner Code, frttdom negate *3 ‘_ Hr. Lyndon 1. Olsom, Jr. - Psp~ 3 (JM-301)
provisions mu (1) abovt which txclude aptcificd pracritianera? of the type @et out in (2) 2. Are rtsrrictiona (5) bovt llowablt
through vhtn’no prwieloo tnumtratts which p~rtrc~itiontrs vi11 bt rtcognized and vhich ~111 not be? In othtr words, vhtn not can a pracritiontr bt txcluded by refemnct, txcludtd by rtsrricrions on tht plsct and msnntr in which trtatmtnt bt administtrtd? of rht tneurance Code about vhich you inquire, Tht 3, atckl:ta:
art.iclt section
Any person vhl, la issutd . . . any htalth insuranct . . , 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 strvlcea or procedures wdical surgical echtduled in tht policy which fall vithin tht scope of the 1ic:enst that practitioner, a elf optometry lictnscd doctor to perform the atrvicts or procc!d,urta achedultd in rht policy which fall within the tcopt the license doctor of opto~~rp. an audiologist to measurt hearing . . . or 4~ speech-language pathologlsc to evaluate speech languagt . . . thoat procedures etwicts art schtduled in tht policy. payrrent or reimburstment by Tht
Insurance cmpan:r . . . shall not bt denied btcause same were ptrformtd a lictnstd doctor doctor of podiatric: medicine. a lictnstd doctor chiropractic, a liwnsed a opt--Y. a aptech- lictnaed dtntisr. an audiologist.
languagt patholog,ist. Thtrt not bt any clasaificatlon, difftrentstion. or other discri- mination in :?ayment schedule or the paymtnt provisions . . . nor in rht amount. list practi,:lloners
The prtstnr in arricle 21.52 is result enacted in 1977. stvtrsl amendmtnra to the original article In ltgislativs htsrirlSs etamitttt , tht bills which tddtd praccieioners co rticlt 21.52 vert frtqutntly rtftrrtd to as “fretdom of choice” Th+ purport vat tc permit bills. rhe insurtd. not insurtr, tht kind practiriwer stltct rhat would perform tht strvicte covtred in insuranct pc~ficp. Stt, t.g.. Ttatimony on Stnare Bill No. 96, Striate Economic ‘D,evelopment Ccmnitttt, 66th Ltg., public htarlng, rtcordtd Jan. 29, 1979. svailablt Ltgialativt Refertnct Library; Id., on Health Services, llouat Cmittee rtcorded Ptb. 21. on Roust Bill No. 860. Stnatt CoPaittett on Euman 1979; Tesxony *4 (Jn-301)
Hr. Lyndot L. Olson, Jr. - Pa(Ie 4
I Rtsourcts, 66th L.tg.. public hearing, recordtd Apr. 25, 1979, available in Legislative Reference Library. an insurer
Wt concludt that artic1.e. 21.52 txprtsaly prohibits from ~acriminating sgainst an inaurtd, rtgard to paywnt or based on tht L’ppt of pracritiontr rtimburatmant, rht insurtd aeltcta to provide mtdieal cars. prohibition againer discrimination Iht txtenda to the em-vices of six kinds of health cart practi~ionera: podiatrlstsr dtntiats, chiropractors, optomtrriats. sudlologiate speech-languegt parhologista. Tht prohibition against discrimination applies vlrh resptcr ro tho:;e eervicta (1) covtrtd 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 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 first an81 fifth policy provisions about which you inquire must be disapproved becautt they expressly discriminate ont or more preictitiontra against identified in articlt
Article 21.35A of rhe Te:Kaa Insurance Code is similar to article 21.52 and relevant fourth policy 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 a group hospital
group insurance plan and vhoee policy . . . provides for strvicts or partial or total rleimbursemtnt for services
art within sc.ampe of pracrict a lictnetd
psychologist. is mtitltd to obtain thtae strvicea rtceive rtiml~nraamant for these services regardless 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 amount rtimburatmtnt availablt scrvicts of a psychologist a,nd the amount of rtimbursemtnr available for eervicts of a pcrychlotriar. Sptcial limirations apply 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 a 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 amount txistence rtinl~uraamtnt vary according to the type *5 Mr. Lyndon L. Oleoe, Jr. - ?sp 9 (JM-301) the atrvict, as in tht first.
of prtctitiontr providing fourth and you quott, but also f lfth policy prwlsions those forma vhkh havt tht tfftct , such as tht stcond and third same or similar discriminatory policyprovisions quottd.
To dtrtrmint titthtr c.ht policy diseriminatta against ctrtain typts of pracritiontra, the “place or manntr” restric.tions about which of rhe btneflta you inquirt must bt svaluatc!d in light of tht naturt that co which thty apply. ,xtcond and third prwision@ atstt Tht art payable Bovevtr btntfits sanipulation of tht apint. , tht stcond 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. la a etrvict l4snipulation splat cctmonly provided by of tht chiropractors la virhin scope of rhtir llctnats. Chiro- tht do not. however , ptrmit
practors’ lictnsts thtm to administer general tffect of anesthesia or admit ps~itnrs to hospitals. Thus, of tbt quottd rtstrictions ia a crkgorical txclusion only type of practitiontr comonly associa~ttd with tht trtatmtnt purporttdly within tht scopt of insuranct polic7 cwtragt. Since chiropractors art rriclt aaong tht prsctiriontrs idantifitd 21.52, such prwiaions subvert the statute and art nonenforceablt. langusgt of tht statute
Our conclusion is besta on tht plain sad ltgislativt intent.
Tht plain language of ,rrticlts 21.52 and 21.35A dots noLot limit prohibition against discriminarlon to any particular method or 011 tht contrary, rticlt means of discrimination. for~txamplt. not bt
aprtssly statts rhtr thtrt (Iany classification, other dL:6crlmina~iou difftrcnciarion. . . . in amount or manner payment or rtimbursemtnt. . .” To Slot tfftct to legislativt , a statuLt should be givtn a intent “practical and rtaaonablt constrnction rathtr than a literal Sta Dtnvt~r-Albuqutrqut Motor Transport, thwarting cons)truction.” 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 practitiontr discrimination or dlffaren~~iation bastd upon tht typt prwiding !:ht practiriontr is among thost sptcifLtd. ttrvict To accomplish tht object o!! rht legislation , discrimination must bt prohibittd la ght rtsult of txprtssly discrimina- not only when it from discririnatory gory restrictions bug s1a.o ubtn is rtsults rtstricCions disguiatd aa n~sn-discriminsgory rtstrictions limitatlona on tht plact or umotr in rgich tht strviet is prwidtd. Ntithtr rticlt 21.W~ no r l rtielt 21.52 apptars inttndtd tht basic naturt of tht btneflts
slttr ptovidtd in an insurancs txctpt to tht txttnt ntcc:rstry to prohibit discrimination baatd on typts practitiontrs. categorical distinctions b’cltvten ctrtain The Qtatt Board Insurance msy Ttxas Suprtme Court has btld *6 nr. Lyndoa I, Olron, Jr, - ?rsr 6 ml-301) fectorr other the “four
consider thr!l those which spperr vithin corners of the POLICY” in dwiding to approve a policy form. vhcthcr Key Western LIti Ins~rence Co.. v. State Board of ‘kurance, 3SdS.U.Zd the Strte Bosrd of fneursnce msy ykefororc, 39, consider fsctorr deemed ne:Icrrsry to determine the dlscriminat6+ purpose or sffect of sny glv~ku policy provision. 3.70-2(B) the
Tou have slso directed our attention to srtlcle Insurance Code, vhich provide!,:
Ro pollc9 of clc:cident end sickaert insursnce shell make benefi~:s contingekt upon treatment or l xsmination a ,particular practitioner or by particular practitioners the healing arts hereinafter designated unless contains A provision desigrmting the practitioner or practitioners vhcl will be recognized the by insurer and thors vho vi11 not be recognized by the Insurer. In designating the practl- vho vi11 md will not be recognized, tioners such shall USC the following tams: Doctor of Medicine, Doctor of Osteopathy, Doctor Docto:r of Chiropractic,
Dentistry, Doctor Doctor Podiatry. Audiologist,
Optometry,
Speech-language Pathologist Another vereion of thil, amended article passed by the legislature in s separate bill at the 13ame session as sbove-quoted version , includes psychologists end excludes sudiologists and speech-language psthologists from list of prsctitloners. srticls
klthsr version 3.70-2(B) should be rud to conflict with article Art1c:l.e 3.70-2(B) nsithsr uthorizes nor pro- hibits sny discrimination b8etveen practitioners. Artlcls 3.70-2(B) merely prescribes the fonut sxcluding practitionera when such sxclusious are not prohibitc,d elsewhere in the Insurance Code.
Zveo if rticle 3.704(B) end srticle 21.52 were ambiguous ststutoty potentially contradictory, hovever, vsrious rules support fcregoins interpretetlon. Statutes should be COMtNCtiOU conrtrued harmony vlth other ststutes unless A cootrary intention ir clearly manifest. Tree18 v. Walker, 26 S.Y.Zd 627, 630 (Tex.
1930). Kven when ll.il language one ensctment conflicts th8t of 8nother. they &NJld be read together and hormmised, posribls. reasonably 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 statutes which, as hers, dssl with same genersl subject. and are therefore conridered be .Ln ari msteris. see Texas Stats Board of Pharucy v. Kittman, 550 S,.Il.26 104, 106 Tex.xv. App. - Tyler 1977. *w 2A C. Sanda, Sutherlsad Statutory Construction, et no nit); 453-55 (rev. 4th ad. 1986’ *7 Hr. IFdon L. Olroa, Jr. - ?a&@ 7 (JM-301)
: . . . ,
Our construction of l rt!Lcls 3.70-2(B) is sleo mpported by the Nle that, by reoson of the disparity lo b&rgsinlng poritions betveen covponiss l od purcl~mere ineuronce of insurance, St&Cute8 regullting the re~t1onohips lneurers cud insuredr ore interpreted strictly of against insurance the covpouies end liberally in favor insured pereone. 170.05. At 308 2A C. Sands, su rs, 15S.04, et 716; 3 id..
(4th l d. 1974). This N a fwors upholding -F the polic9 smbodlsd lo freedom to choose l mng verious article 21.52 of giving the insured hinds of practitioners.
Ye find no iodlcstios DE lsgislotive intent vhich justifies e k’th article 21.52 And article 3.70-2(B) Coutrory ioterpretatiov.
vers emended in 1983. Artim:le 21.52.. section 3 VAS amended to odd audiologists And rpeech-lsn~;uoge pathologists (vithout the express “acope license” requirement included 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 l rticle 3.70-2(B), ws passed later during the SAIDC 8eesion. added “Doctor of Psychology” to 3.70-2(B) but did not
This second bill 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 3 And srtlcle eection 3.70-2(B) in the some session reinforcer the reoeons for cooetNing 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, i0 pAti 151.03, At &Iii’. The principle that St8tUtCA meterlr l hould be construed together is l reststemsnt of the preeump- tioo Agaioet ivplied repel1 of etotutes. See Fortinberry v. Store
283 S.U. 146, 149 (Ten. 1926);2A C. Sender e, iti+-zs. The l dditkmr prsctltlonere the list mede in both articles during the sme seelon plain19 lsgislstive indicates did avc contemplate eo9 conflict intend on legislrturs implied repeal either Article.
SUWtlART Article eectiou 3. Texse an Insurance Code lwohibitr discriviustios insurer 8gAinSt l II iaeured rsssrd to pepeot beoefite bsea# on the lneursd’e electlon ervicee l podlotriet. dsotiet. ebtsin epcech- chiropractor, optmetrist, sudiologlst laoguoge pathologist rrther than a’ doctor of medicine o r l uoe oth er kind of health core prscti- tiooer. the sarvicse The prohIbition. Applies obteioed re within the ecops of esrvicee covered *8 I 1 Ur. L9ndoe 1. Olson, Jr. - ?rSs 6 m-3w : I
! . the scope of the prscti- b9 the polic9 end within tioner’e The prohlbi- liceoee or certificstion.
tfou extends to those ineuronce polic9 provisions oue more vhich sxpreeel9 discrinlnetc sgoinet tbo spsclfied types of prscgitionsre, eo us11 as those provirkme. including piece sod unnsr sms a elmilar reetrictions, vhitib hsvs purpose or effect. discriminstory
JIM WATTOX Attorney General Texas TotlGKExR
First AesietAnt Attorney Grnsrsl
DAVID R. RICRARDS
Executive Attorney General AsSiStAnt
RICK CILPIl
Ch~irmao, Opinion Cmittee
Prep&red by lfarienne Wood&Id
AseistAnt Attorney General
APPRGVED:
OPXRIOR CGM4ITTltX
Celia Carl
EdoAKemoo
Paul Rich