                                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




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