Detailed Answer
Under Texas law, an insurance adjuster cannot rely on North Carolina’s Rule 414 to reduce your medical bills. Rule 414 of the North Carolina Rules of Civil Procedure governs how medical expenses are presented at trial in that state. Texas has its own statutes and regulations governing insurance claim handling, medical necessity and billing practices.
In Texas, adjusters must follow the Texas Insurance Code Chapter 541 (prohibiting unfair or deceptive acts) and Chapter 542 (prompt payment of claims). Key points:
- Reasonable and Necessary – Medical bills must be for services that are reasonable, necessary and customary in the locality. An adjuster may question inflated or unrelated charges but cannot unilaterally reduce a valid, covered expense.
- Contractual Discounts – If you received treatment from a provider in the insurer’s network, the insurer will pay the contracted rate. If the provider agrees, bills may be written off above that rate—but only under your provider contract, not under Rule 414.
- Subrogation and Liens – A health insurer may have a lien or subrogation right if it paid your medical bills. But lien rights must comply with Texas Civil Practice & Remedies Code § 38.001 et seq. (health-care provider liens).
- Prompt Payment – Insurers must acknowledge and pay valid claims within specified time frames (15 days for a written response, 45 days maximum for payment) or face penalties under § 542.058–.060.
If your adjuster attempts to reduce bills by citing an out-of-state rule, politely ask them to provide the relevant Texas statute or policy provision. You may also request an itemized explanation of benefits (EOB) showing how each charge was evaluated under Texas law.
Helpful Hints
- Review your insurance policy definition of “reasonable and necessary.”
- Obtain an itemized EOB and provider invoice to verify charges.
- Ask for a written explanation of any reductions citing the Texas Insurance Code.
- Consult the Texas Department of Insurance (TDI) if you suspect unfair practices: tdi.texas.gov.
- Keep all medical records and correspondence with your insurer organized.
Disclaimer: This article is for general education and does not constitute legal advice. Consult a Texas-licensed attorney for advice about your specific situation.