(a) No HMO or representative of the HMO may cause or knowingly permit the use of advertising that is untrue or misleading, solicitation that is untrue or misleading, or any form of evidence of coverage that is deceptive. For the purpose of this chapter:
Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
Evidence of coverage: means any certificate, agreement or contract issued to an enrollee setting out the coverage to which the enrollee is entitled. See Tennessee Code 56-32-102
person: includes an individual, insurer, company, association, organization, Lloyds, society, reciprocal insurer or interinsurance exchange, partnership, syndicate, business trust, corporation, agent, general agent, broker, solicitor, service representative, adjuster, and every legal entity. See Tennessee Code 56-32-102
Representative: when applied to those who represent a decedent, includes executors and administrators, unless the context implies heirs and distributees. See Tennessee Code 1-3-105
State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
(1) A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect that is or may be significant to an enrollee of, or person considering enrollment with, an HMO;(2) A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information may be reasonably understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation or disadvantage or possible significance to an enrollee of, or person considering enrollment in, an HMO, if the benefit or advantage or absence or limitation, exclusion or disadvantage does not in fact exist; and(3) An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, is such as to cause a reasonable person, not possessing special knowledge regarding HMOs and evidences of coverage for HMOs, to expect benefits, services, charges or other advantages that the evidence of coverage does not provide or that the HMO issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage.(b) Chapter 8, part 1 of this title shall be construed to apply to HMOs and evidences of coverage, except to the extent that the commissioner determines the nature of HMOs and evidences of coverage render chapter 8, part 1 of this title inappropriate.(c) An HMO may not cancel or refuse to renew an enrollee, except for reasons stated in the organization’s rules applicable to all enrollees, or for the failure to pay the charge for coverage, or for other reasons promulgated by the commissioner.(d) No HMO, unless licensed as an insurer, may refer to itself as an insurer or use a name deceptively similar to the name or description of any insurance or surety corporation doing business in this state.(e) Any person not in possession of a valid certificate of authority issued pursuant to this chapter may not use the phrase “health maintenance organization” or “HMO” in the course of operation.
