Citations Affected:
IC 27-8-5-2.5
;
IC 27-8-5-19
.
Synopsis: Health insurance waivers. Provides that an individual policy
of accident and sickness insurance or a group policy of accident and
sickness insurance under which a certificate of coverage is issued to an
individual member of an association or a discretionary group may
contain a multiple year waiver of coverage that does not exceed ten
years for a specified condition, if the insurer meets certain
requirements. Specifies that an offer of coverage under a policy that
includes a waiver does not preclude eligibility for an Indiana
comprehensive health insurance association policy for an individual
who is otherwise eligible.
Effective: Upon passage.
January 11, 2000, read first time and referred to Committee on Insurance, Corporations and
Small Business.
A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
individual has not received or had recommended to the
individual medical advice, diagnosis, care, or treatment
related to the waived condition for at least two (2) years; and
(6) the insurer discloses to the applicant that the applicant
may decline the offer of coverage and apply for coverage
under an Indiana comprehensive health insurance association
policy under
IC 27-8-10.
The insurer shall require an applicant to initial the notice under
subdivision (1) and the waiver under subdivision (2) to
acknowledge acceptance of the waiver of coverage. An offer of
coverage under a policy that includes a waiver does not preclude
eligibility for coverage under an Indiana comprehensive health
insurance association policy if the applicant meets all other criteria
under
IC 27-8-10.
contested, except for nonpayment of premiums, after the policy
has been in force for two (2) years after its date of issue, and that
no statement made by a person covered under the policy relating
to the person's insurability may be used in contesting the validity
of the insurance with respect to which the statement was made,
unless:
(A) the insurance has not been in force for a period of two (2)
years or longer during the person's lifetime; or
(B) the statement is contained in a written instrument signed
by the insured person.
However, a provision under this subdivision may not preclude the
assertion at any time of defenses based upon a person's
ineligibility for coverage under the policy or based upon other
provisions in the policy.
(3) A provision that a copy of the application, if there is one, of
the policyholder must be attached to the policy when issued, that
all statements made by the policyholder or by the persons insured
are to be deemed representations and not warranties, and that no
statement made by any person insured may be used in any contest
unless a copy of the instrument containing the statement is or has
been furnished to the insured person or, in the event of death or
incapacity of the insured person, to the insured person's
beneficiary or personal representative.
(4) A provision setting forth the conditions, if any, under which
the insurer reserves the right to require a person eligible for
insurance to furnish evidence of individual insurability
satisfactory to the insurer as a condition to part or all of the
person's coverage.
(5) A provision specifying any additional exclusions or limitations
applicable under the policy with respect to a disease or physical
condition of a person that existed before the effective date of the
person's coverage under the policy and that is not otherwise
excluded from the person's coverage by name or specific
description effective on the date of the person's loss. An exclusion
or limitation that must be specified in a provision under this
subdivision:
(A) may apply only to a disease or physical condition for
which medical advice, diagnosis, care, or treatment was
received by the person or recommended to the person during
the six (6) months before the enrollment date of the person's
coverage; and
(B) may not apply to a loss incurred or disability beginning
after the earlier of:
(i) the end of a continuous period of twelve (12) months
beginning on or after the enrollment date of the person's
coverage; or
(ii) the end of a continuous period of eighteen (18) months
beginning on the enrollment date of the person's coverage if
the person is a late enrollee.
This subdivision applies only to group policies of accident and
sickness insurance other than those described in section 2.5(a)(1)
through 2.5(a)(8) of this chapter.
(6) A provision specifying any additional exclusions or
limitations applicable under the policy with respect to a disease
or physical condition of a person that existed before the effective
date of the person's coverage under the policy. An exclusion or
limitation that must be specified in a provision under this
subdivision:
(A) may apply only to a disease or physical condition for
which medical advice or treatment was received by the person
during a period of three hundred sixty-five (365) days before
the effective date of the person's coverage; and
(B) may not apply to a loss incurred or disability beginning
after the earlier of the following:
(i) The end of a continuous period of three hundred
sixty-five (365) days, beginning on or after the effective date
of the person's coverage, during which the person did not
receive medical advice or treatment in connection with the
disease or physical condition.
(ii) The end of the two (2) year period beginning on the
effective date of the person's coverage.
This subdivision applies only to group policies of accident and
sickness insurance described in section 2.5(a)(1) through
2.5(a)(8) of this chapter.
(6) (7) If premiums or benefits under the policy vary according to
a person's age, a provision specifying an equitable adjustment of:
(A) premiums;
(B) benefits; or
(C) both premiums and benefits;
to be made if the age of a covered person has been misstated. A
provision under this subdivision must contain a clear statement of
the method of adjustment to be used.
(7) (8) A provision that the insurer will issue to the policyholder,
for delivery to each person insured, a certificate setting forth a
statement that:
(A) explains the insurance protection to which the person
insured is entitled;
(B) indicates to whom the insurance benefits are payable; and
(C) explains any family member's or dependent's coverage
under the policy.
(8) (9) A provision stating that written notice of a claim must be
given to the insurer within twenty (20) days after the occurrence
or commencement of any loss covered by the policy, but that a
failure to give notice within the twenty (20) day period does not
invalidate or reduce any claim if it can be shown that it was not
reasonably possible to give notice within that period and that
notice was given as soon as was reasonably possible.
(9) (10) A provision stating that:
(A) the insurer will furnish to the person making a claim, or to
the policyholder for delivery to the person making a claim,
forms usually furnished by the insurer for filing proof of loss;
and
(B) if the forms are not furnished within fifteen (15) days after
the insurer received notice of a claim, the person making the
claim will be deemed to have complied with the requirements
of the policy as to proof of loss upon submitting, within the
time fixed in the policy for filing proof of loss, written proof
covering the occurrence, character, and extent of the loss for
which the claim is made.
(10) (11) A provision stating that:
(A) in the case of a claim for loss of time for disability, written
proof of the loss must be furnished to the insurer within ninety
(90) days after the commencement of the period for which the
insurer is liable, and that subsequent written proofs of the
continuance of the disability must be furnished to the insurer
at reasonable intervals as may be required by the insurer;
(B) in the case of a claim for any other loss, written proof of
the loss must be furnished to the insurer within ninety (90)
days after the date of the loss; and
(C) the failure to furnish proof within the time required under
clause (A) or (B) does not invalidate or reduce any claim if it
was not reasonably possible to furnish proof within that time,
and if proof is furnished as soon as reasonably possible but
(except in case of the absence of legal capacity of the
claimant) no later than one (1) year from the time proof is
otherwise required under the policy.
will first be applied to reduce or extinguish the indebtedness.
(16) (17) If the policy provides that hospital or medical expense
coverage of a dependent child of a group member terminates upon
the child's attainment of the limiting age for dependent children
set forth in the policy, a provision that the child's attainment of the
limiting age does not terminate the hospital and medical coverage
of the child while the child is:
(A) incapable of self-sustaining employment because of
mental retardation or mental or physical disability; and
(B) chiefly dependent upon the group member for support and
maintenance.
A provision under this subdivision may require that proof of the
child's incapacity and dependency be furnished to the insurer by
the group member within one hundred twenty (120) days of the
child's attainment of the limiting age and, subsequently, at
reasonable intervals during the two (2) years following the child's
attainment of the limiting age. The policy may not require proof
more than once per year in the time more than two (2) years after
the child's attainment of the limiting age. This subdivision does
not require an insurer to provide coverage to a mentally retarded
or mentally or physically disabled child who does not satisfy the
requirements of the group policy as to evidence of insurability or
other requirements for coverage under the policy to take effect. In
any case, the terms of the policy apply with regard to the coverage
or exclusion from coverage of the child.
(17) (18) A provision that complies with the group portability and
guaranteed renewability provisions of the federal Health
Insurance Portability and Accountability Act of 1996
(P.L.104-191).
(19) Notwithstanding subdivision (5), a provision specifying a
multiple year waiver of coverage that does not exceed ten (10)
years for a specified condition applicable under the policy. A
multiple year waiver of coverage for a specified condition that
must be specified under this subdivision may be included in a
policy of group accident and sickness insurance under which
a certificate of coverage is issued to an individual member of
an association or a discretionary group if:
(A) the insurer provides to the applicant before issuance of
the policy written notice explaining the waiver of coverage
for the specified condition and any complications that arise
from the specified condition;
(B) the offer of coverage includes the waiver in a separate
section stating in bold print that the applicant is receiving
coverage with an exception for the waived condition;
(C) the offer of coverage does not include more than two
(2) waivers;
(D) the waiver period is concurrent with and not in
addition to any applicable preexisting condition limitation
or exclusionary period;
(E) the insurer agrees to review a waiver upon request if
the individual has not received or had recommended to the
individual medical advice, diagnosis, care, or treatment
related to the waived condition for at least two (2) years;
and
(F) the insurer discloses to the applicant that the applicant
may decline the offer of coverage and apply for coverage
under an Indiana comprehensive health insurance
association policy under
IC 27-8-10.
The insurer shall require an applicant to initial the notice
under clause (A) and the waiver under clause (B) to
acknowledge acceptance of the waiver of coverage. An offer
of coverage under a policy that includes a waiver does not
preclude eligibility for coverage under an Indiana
comprehensive health insurance association policy if the
applicant meets all other criteria under
IC 27-8-10.
(d) Subsection (c)(5), (c)(7), (c)(8), and (c)(12) (c)(13) do not apply
to policies insuring the lives of debtors. The standard provisions
required under section 3(a) of this chapter for individual accident and
sickness insurance policies do not apply to group accident and sickness
insurance policies.
(e) If any policy provision required under subsection (c) is in whole
or in part inapplicable to or inconsistent with the coverage provided by
an insurer under a particular form of policy, the insurer, with the
approval of the commissioner, shall delete the provision from the
policy or modify the provision in such a manner as to make it
consistent with the coverage provided by the policy.