SECTION 354.1153. Subrogation

(a) The health insuring agent will be subrogated to any individual's right of recovery against third parties for personal injury or to any other right to payment under any insurance coverage to the extent of the allowable claims paid under this chapter for services caused by illness or injury.

(b) The health insuring agent and the department, through mutual agreement, establish procedures, controls, and guidelines so as to ensure that all such appropriate cases are discovered, that necessary action is taken, and that all facts necessary are acquired and evaluated to determine if any right of recovery exists.

(c) The health insuring agent and the department mutually agree on guidelines for action to be taken on subrogation claims by the health insuring agent to effectuate recovery of amounts paid under the health insuring contract for services caused by illness or injury. The health insuring agent has authority to commence legal action, compromise, and settle such claims in accordance with the procedures and guidelines so established, and to execute appropriate releases.

(d) The health insuring agent exerts all reasonable efforts to acquire and evaluate all appropriate facts to determine if subrogation rights exist. When a case is reviewed by the health insuring agent, if it appears the facts are such that there are valid rights of recovery, the case is reported by the health insuring agent to the department in accordance with procedures as mutually agreed.

(e) Any sums recovered under subrogation by the health insuring agent, less court costs, attorney's fees, and other costs of litigation, if any, are applied back against the claims involved in accordance with procedures and documentation as approved by the department. Any sums recovered by the department on subrogation claims which the health insuring agent notifies the department of its election not to pursue are retained by the department.

Source Note: The provisions of this §354.1153 adopted to be effective May 30, 1977, 2 TexReg 1929; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561