A licensed Texas agent tells a Dallas applicant that the HMO will pay for a treatment the evidence of coverage clearly lists as excluded. The enrollee later claims that treatment. Which statement is correct?
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Under 28 TAC 11.501 and 11.503, the evidence of coverage and any amendment to it must be filed with TDI and approved by the commissioner before they are used, and the approved document governs the HMO's obligations to the enrollee. An agent has no authority to alter a TDI-filed evidence of coverage by oral representation, so an exclusion properly stated in the approved form is enforceable, and an oral statement that contradicts the filed form can be a misrepresentation of the terms of the coverage under TIC 541.052. An enrollee who relied on a contrary oral promise may have a complaint against the agent, but the HMO pays according to the filed document.
Why the other options are wrong
- B) An agent cannot amend a TDI-filed evidence of coverage with an oral statement.
- C) An agent's authority is limited to soliciting and taking the application; it does not extend to rewriting covered benefits.
- D) Exclusions in an approved evidence of coverage are effective without the enrollee's initials.
Memory hook
What is filed beats what was said.