KP-0250

Summary

A court would likely conclude that the deadline provisions of sections 843.338 and 1301.103 of the Insurance Code relate to prompt payment and, therefore, apply to claims filed by out-ofnetwork emergency care providers pursuant to section 843.351 or 1301.069 of that Code. However, a court would likely conclude that the penalty provisions in sections 843.342 and 1301.137 do not apply to claims filed by out-of-network emergency care providers pursuant to sections 843.351 or 1301.069.

The Legislature provided a penalty regime through sections 843.342 and 1301.137 of the Code for insurers who do not make timely payments on eligible clean claims submitted to them. Thus, the Department cannot impose an additional penalty. But depending on the circumstances, a court could conclude that a particular enforcement action to compel the claim payment required by statute to a non-network emergency care provider is not in the nature of a penalty and is within the Department's authority to implement.