Officials consider limiting insurers' ability to set coverage

Here's a development that should make Texas health plans--and perhaps the entire industry--more than a bit concerned. The Texas state insurance consumer advocate is attempting to eliminate the ability of health and disability insurers to decide what their policies cover, joining many states that have already enacted such rules.

Right now, many of Texas' health plans have "discretionary" clauses in their policies that give them the right to interpret what policy language means and decide what they must pay. Twenty-two states have already banned the use of such clauses, and the National Association of Insurance Commissioners wants to see the practice ended entirely.

According to Public Insurance Counsel Deeia Beck, fights over such clauses typically pop up over cancer drugs, mental illness coverage and home-based diabetes treatment. To evaluate such claims, insurers hire their own in-house doctors, or contract with doctors to evaluate the medical records. "It is an inherently unfair process," Beck says.

The state's health insurance industry is fighting hard to shoot down this proposal, which they say will raise insurance costs and lead to more litigation.

Find out more about this dispute:
- read this Dallas News piece

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