SECTION 21.405. Policy Terms and Conditions

The amount of benefits payable, or any term, condition, or type of coverage may not be restricted, modified, excluded, or reduced on the basis of the sex or marital status of the insured or prospective insured. However, nothing in these sections shall prohibit an insurer from taking marital status into account for the purpose of defining persons eligible for dependents' benefits. Specific practices prohibited by this section shall include, but not be limited to, the following.

(1) No policy may treat complications of pregnancy differently than any other illness or sickness under the policy. For the purpose of this section, complications of pregnancy means:

(A) conditions, requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsis, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and

(B) non-elective cesarean section, termination of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible.

(2) No policy may restrict, reduce, modify, or exclude benefits based solely upon the genital organs of one sex.

(3) No policy may apply arbitrary waiting periods to maternity benefits in such a way as to exclude coverage for premature births when normal maternity benefits are included in the policy. Medical evidence of the prematurity of the baby may reasonably be required.

(4) No disability policy may offer lower maximum monthly benefits to women than to men who are in the same risk classifications.

(5) No disability policy may offer more restrictive basic benefit periods or more restrictive definitions of disability to women than to men. Normal pregnancy is not considered to be a disability.

(6) No policy may establish different conditions by sex as a prerequisite to the exercise of benefit options contained in the policy.

(7) No insurer may limit the scope and/or amount of coverage an insured or prospective insured may purchase based on the insured's or prospective insured's marital status unless such limitation is for the purpose of defining persons eligible for dependents' benefits.

Source Note: The provisions of this §21.405 adopted to be effective January 1, 1978, 2 TexReg 2843.