Citations Affected: IC 27-1; IC 27-8; IC 27-13.
Synopsis: Insurance mandate review task force and coverage
documents. Adds one member and provides for per diem payment and
cost reimbursement for members of the task force to review mandated
benefits and mandated benefit proposals. Specifies certain
requirements for the task force. Expires the task force on December 31,
2010. Provides that certain accident and sickness insurers, health
maintenance organizations, and limited service health maintenance
organizations: (1) may provide certain documents in electronic or paper
form; (2) must provide certain information concerning obtaining
evidence of coverage; and (3) must provide documents in paper form
Effective: July 1, 2005.
January 6, 2005, read first time and referred to Committee on Health and Provider
February 24, 2005, amended, reported favorably _ Do Pass.
February 28, 2005, read second time, ordered engrossed. Engrossed.
March 1, 2005, read third time, passed. Yeas 48, nays 0.
A BILL FOR AN ACT to amend the Indiana Code concerning
benefit proposal each year.
(l) In assessing a mandated benefit or mandated benefit proposal, and to the extent that information is available, the task force shall consider:
(1) social impacts, including:
(A) the extent to which the service that is the subject of the mandated benefit or mandated benefit proposal is generally used by a significant part of the population;
(B) the extent to which the health coverage is already generally available;
(C) if the health coverage is not generally available, the extent to which the lack of health coverage results in unreasonable financial hardship;
(D) the level of public demand for the service that is the subject of the mandated benefit or mandated benefit proposal;
(E) the level of public demand for the health coverage; and
(F) the extent to which the service that is the subject of the mandated benefit or mandated benefit proposal is covered under self-funded health coverage provided by Indiana employers that employ at least five hundred (500) employees;
(2) medical impacts, including the extent to which the service that is the subject of the mandated benefit or mandated benefit proposal is generally:
(A) recognized by the medical community as effective in patient treatment;
(B) demonstrated by a review of scientific and peer review literature to be recognized by the medical community; and
(C) available and used by treating physicians; and
(3) financial impacts, including the:
(A) extent to which the health coverage will increase or decrease the cost of the service that is the subject of the mandated benefit or mandated benefit proposal;
(B) extent to which the health coverage will increase the appropriate use of the service that is the subject of the mandated benefit or mandated benefit proposal;
(C) extent to which the service that is the subject of the mandated benefit or mandated benefit proposal will be a substitute for a more expensive service;
(D) extent to which the health coverage will increase or decrease the:
implement this section.
(l) (s) Information that identifies a person and that is obtained by the
task force under this section is confidential.
(t) This section expires December 31, 2010.
left-hand corner of the first page of the policy.
(7) The policy contains no provision purporting to make any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of or reference to a statement of rates or classification of risks, or short-rate table filed with the commissioner.
(8) If an individual accident and sickness insurance policy or hospital service plan contract or medical service plan contract provides that hospital or medical expense coverage of a dependent child terminates upon attainment of the limiting age for dependent children specified in such policy or contract, the policy or contract must also provide that attainment of such limiting age does not operate to terminate the hospital and medical coverage of such child while the child is and continues to be both:
(A) incapable of self-sustaining employment by reason of mental retardation or mental or physical disability; and
(B) chiefly dependent upon the policyholder for support and maintenance.
Proof of such incapacity and dependency must be furnished to the insurer by the policyholder within thirty-one (31) days of the child's attainment of the limiting age. The insurer may require at reasonable intervals during the two (2) years following the child's attainment of the limiting age subsequent proof of the child's disability and dependency. After such two (2) year period, the insurer may require subsequent proof not more than once each year. The foregoing provision shall not require an insurer to insure a dependent who is a mentally retarded or mentally or physically disabled child where such dependent does not satisfy the conditions of the policy provisions as may be stated in the policy or contract required for coverage thereunder to take effect. In any such case the terms of the policy or contract shall apply with regard to the coverage or exclusion from coverage of such dependent.
This subsection applies only to policies or contracts delivered or issued for delivery in this state more than one hundred twenty (120) days after August 18, 1969.
(b) If any policy is issued by an insurer domiciled in this state for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the commissioner that any such policy is not subject to approval or disapproval by such official, the commissioner may by ruling require that such policy meet the standards set forth in subsection (a) and in section 3 of this chapter.
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.
(7) If premiums or benefits under the policy vary according to a person's age, a provision specifying an equitable adjustment of:
(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.
(8) A provision that the insurer will issue to the policyholder, for delivery to each person insured, a certificate, in electronic or paper form, 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.
The provision must specify that the certificate will be provided in paper form upon the request of the insured.
(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.
(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.
(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.
(12) A provision that:
(A) all benefits payable under the policy (other than benefits for loss of time) will be paid in accordance with IC 27-8-5.7; and
(B) subject to due proof of loss, all accrued benefits under the policy for loss of time will be paid not less frequently than monthly during the continuance of the period for which the insurer is liable, and any balance remaining unpaid at the
termination of the period for which the insurer is liable will be
paid as soon as possible after receipt of the proof of loss.
(13) A provision that benefits for loss of life of the person insured are payable to the beneficiary designated by the person insured. However, if the policy contains conditions pertaining to family status, the beneficiary may be the family member specified by the policy terms. In either case, payment of benefits for loss of life is subject to the provisions of the policy if no designated or specified beneficiary is living at the death of the person insured. All other benefits of the policy are payable to the person insured. The policy may also provide that if any benefit is payable to the estate of a person or to a person who is a minor or otherwise not competent to give a valid release, the insurer may pay the benefit, up to an amount of five thousand dollars ($5,000), to any relative by blood or connection by marriage of the person who is deemed by the insurer to be equitably entitled to the benefit.
(14) A provision that the insurer has the right and must be allowed the opportunity to:
(A) examine the person of the individual for whom a claim is made under the policy when and as often as the insurer reasonably requires during the pendency of the claim; and
(B) conduct an autopsy in case of death if it is not prohibited by law.
(15) A provision that no action at law or in equity may be brought to recover on the policy less than sixty (60) days after proof of loss is filed in accordance with the requirements of the policy and that no action may be brought at all more than three (3) years after the expiration of the time within which proof of loss is required by the policy.
(16) In the case of a policy insuring debtors, a provision that the insurer will furnish to the policyholder, for delivery to each debtor insured under the policy, a certificate of insurance describing the coverage and specifying that the benefits payable will first be applied to reduce or extinguish the indebtedness.
(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
organizations, such accident and sickness insurance claim forms as the
commissioner determines will provide for uniformity and simplicity in
insurance reporting. The forms shall include, but need not be limited
to, information regarding the medical diagnosis, treatment and
prognosis of the patient, together with the details of charges incident to
the providing of care, treatment or services, sufficient for the purpose
of meeting the proof requirements of an accident or sickness insurance
policy or a hospital, medical, or dental service contract.
(b) An accident and sickness insurer may not refuse to accept a claim submitted on duly promulgated uniform claim forms. However, an insurer may accept claims submitted on any other form.
(c) Accident and sickness insurer explanation of benefits paid statements or claims summary statements sent to an insured by the accident and sickness insurer may be sent in electronic or paper form and shall be in a format and written in a manner that promotes understanding by the insured by setting forth:
(1) the total dollar amount submitted to the insurer for payment;
(2) any reduction in the amount paid due to the application of any co-payment or deductible, along with an explanation of the amount of the co-payment or deductible applied under the insured's policy;
(3) any reduction in the amount paid due to the application of any other policy limitation or exclusion as set forth in the insured's policy along with an explanation thereof;
(4) the total dollar amount paid; and
(5) the total dollar amount remaining unpaid.
In addition, the explanation shall clearly set forth a toll free number that the insured may call to obtain additional information about any of the items contained in the explanation of benefits paid or claims summary statement.
(d) The commissioner may issue an order under IC 27-1-3-19(a) directing an accident and sickness insurer to comply with subsection (c).
(e) An accident and sickness insurer does not violate subsection (c) by using a document that the accident and sickness insurer has been required to use by the federal government or the state.
(f) An accident and sickness insurer shall:
(1) inform an insured that the insured may request that the statements described in subsection (c) be sent in paper form; and
(2) send the statements in paper form upon the request of the insured.