Untitled Texas Attorney General Opinion

QBfficeof tfy 18ttotnep Qaeneral
dbtatt of lkxae
DAN MORALES
ATTORSEY
GESERAL April 13.1593

Honor&k 0. H. “Ike”Hartis OpinionNo. DM-215
ch8irmM
JurirprudalwCommitta Ike Interpret8tion of article 2 I .24-l. section 4(c)
Texas State hue of ti. Itmmnce code relating to ass@nent of
P.O. Box 12068,Ofke 128-C health itlsumw b8neflts 8nd w8iver of
Austin, Texas 78711 deductibles or wp8yments (q-353)

Dear SalNor Hmis:

Section 4, subsection (c) of atticlc 21.24-l of the Insumce Code provides:
The payment of bendits under an assignment does not relieve
thecoveredpersonofmycomnctualrrsponsiiforthepeyment
of deductiiks cod copqments. A phJMcfun or other health core
provi&r mqv not waiw cqqwnts ar &&tibles by acqmnce of
m asignme~. bhasis rddcd.]
You8skwhethertheeffkctofthesecond mtence of section 4(c) is to prohibit a
physician’s or other health care provideh waiving a copaymeitt or deductible in any
htanceinwhichthereisanass@nentofknehu. WeconciudeUutthel8ngwgein
questiongenuauyoper8tesonlytoslarifythet8wepuwe ofmusi~entdoesnot
rrlieverbcahhcanprovidcrofmyobliBationsiacumbadon,)rimtobillforortoU#lr
c~p8yment or d8ductible8mount.

We mive 8t this construction of the section 4(c) prohibition mg8rding 8 health
cue provider’sw8ivcr of 8 copayment or deductible on the buir of its context. butancc
Code article 21.24-l. added in 1991, cont8ins Kvenl provisions th8t clrrily the leg8i
ri~~urdobligatioar~unangtbcnriourputitsg#tedbyururi~~0f
bendlts &om m insured to 8 baltb exe provider. For rumple, 8ection 3(8) &r&s the
tight of 8n insured to 8sSigninswnccbeneGtsto8h&hareprovider: Itprovidesthrtr
bulthinruMapoUcyrrmywtconuinluy(urgethrtwould~~or~athe
written 8ssim of bendits by 8 “Kwcred person”-Lc.. 111insured-to 8 he&h cue
provider who fiunishes he&h cue services covered by the policy. Acts 1991.72d Leg..
c& 242, Q 11.87(a). Another provision of 8tticle 21.24-l. 8ection 4(r) defines how
ptymentofproceedsistobemuleoncermitta~~~irmrdeby8covcrrdpason
and detivcrcd to or obGned by the insurer. It provides th8t “the bat&t p8pent sh8ll be
mrde directly to the physickn or other health we provider.” Ins. Code 8rt. 21.24-l.
5 4(a); see also 5s I (definitions of, inter dia. “covered person,” “health c8re provider,”

p. 1135
Honomble 0. H. “Be’ H8rris - Pllge 2 (DM-215)

“health care service,”“health iaumnce POW*”8nd “ihwa”), 2 (8pptiution of 8rticle to
mpbya bet&t pbms, 8nd to Taclu Employees Uniform Group Insumnce Benefits Act
8nd the Tacos St8te College 8nd Univashy Employees Unifotm Laumnce Ber&s Act).

gection 3(b) provides th8t the 8ttide does not crate bet&s not 8v8h8bieunder 8
p8rticul8rhe8lthinsurMw policy,~hddasaot~owtheusigMKntofbencfitsto
recipiwtS or providers of 8ervica not covered by 8 policy or not kg8gy entitkd to receive
rmchdina~;~thrtitdoesWtprohibitmihsurrr’r~~t&savias
wereprovided. SctiW4(b)providesth8twherethehtsurerp8ysthepmviderdhectly
undamusigmncnt,theihwaisrelievedoftheobli~ontoprythebarcfiuinquestion
to the covered person.

All of the previously disarssed provisions save to detke the rights ud oblig8tions
of the v8rious p8rtia 8fRcted by the 8ssigtmtentof be-&its. We reed the second sentence
ofsection4(c)8sh8ving8simil8rpuQo8e. Just8stheSrst saltewe of 8ection 4(c)
drrifiatheobtigatiw,ofrcomedpasononccheorthemrkerWusig~~mtof
benditq the second sentence of th8t section m8ka 8 simil8rprovisk with respect to the
he&h are provider, i.e., th8t W 8s&nment of bat&s by m insured doa not relieve the
physickn or he8hh are provider who receives the benefits from 8ny Wnttxtu8l
rCSpIsibiity reg8rding big or wkcting cop8yments or deductiia. such 8 reading of
the second sentence of section 4(c) comports with the &titicetory tenor of the other
provisions of section 4 8nd of section 3(b) of 8rticle 21.24-l.

We therefore conclude that the second sentence of section 4(c) is httendW to
ck@th#the acqunce of uI 8s&mnan ofben&s does not relieve the provider of my
Ob&ItiOttSmg8rdhg bii for or Wkcting 8 Wp8yment or deduct&k. whrrt 8 health
are provider mu8t do to s8ti8@my wntmctu8l obligations in this regard is not addressed
by section 4 md is beyond the scope of this opinion. Such obliSationsmay be created by
the insumnce policy 8ssignd or perhaps by other applicable lew. We do caution,
howmr.~8healthurrprovidawouldbeill~sedtorrprrsenttorclicntor
prospective client th8t 8 deductiile or wp8yment will be w8ived i8 ordm to htduce th8t
individd to use the health M ptwidefs at-vices. See ge~mlly Kennel v.
Cannecticut Gen. UfeIm.Co., 924 F.2d 698,702 (7th Cu. 1991) (im order to receive
paymentsupda- pl8n in que8tio~ which required wp8ymem8 provider must
collect wpsiyments “or 8t last leave the patient leg8lly responsii for than”); Attorney
Gener8l opinion IM-1154 (1990) (w8iver of insmanw deductible uoder section 27.02 of
the Business md Commerce Code); 49 AL.R 4th 1219 et seq..8nd wtborhia cited there
(he&h provide&r8greanent 8s to p8tient’sWp8yment liability 8fkr 8w8rd by profesJiott8)
8uviw insurer uunfair tmde pmctice).

p. 1136
Honorable 0. H. “Ike”Harris - Page 3 (DM-215)

SUMMARY
Section 4(c) of article 21.24-l of the Insurance Code
ckritks that 8 he&h care provider who accepts an assignment of
benefits is not relieved of any obligations regarding big for or
wllecting 8 copayment or deductible. What 8 health care provider
must do to satisfy any wntrwtual obligations in this regard is not
8ddressed by section 4 8nd is beyond the scope of this opinion. We
caution, however, that I health care provider would be ill advised to
mpreswt to 8 client or prospective client that 8 deductible or
Wp8)‘lWtlt will be waived in order to induce that individual to use
the health care providds services.

DAN MORALES
Attorney General of Texas

WILL PRYOR
Fii AsshUnt Attorney General

MARYKELLER
Deputy Attorney General for Litigation

RENEAHICKS
St8te Solicitor

MADELEINE B. JOHNSON
Chisir.Opiion Committw

Prepared by Wh M. walker
As8ist8ntAttorney oener8l

p. 1137