Section 23-86-108 - Group accident and health insurance - Required provisionsEach group accident and health insurance policy shall contain in substance the following provisions:
(1) A provision that, in the absence of fraud, all statements made by applicants or the policyholder or by an insured person shall be deemed representations and not warranties and that no statement made for the purpose of effecting insurance shall void the insurance or reduce benefits unless contained in a written instrument signed by the policyholder of the insured person, a copy of which has been furnished to the policyholder or to the person or his or her beneficiary;(2)(A) A provision that the insurer will furnish to the policyholder for delivery to each employee or member of the insured group a statement in summary form of the essential features of the insurance coverage of the employee or member and to whom benefits under the policy are payable.(B) If dependents are included in the coverage, only one (1) certificate need be issued for each family unit;(3) A provision that to the group originally insured may be added from time to time eligible new employees or members or dependents, as the case may be, in accordance with the terms of the policy;(4)(A) In any contract that contains a provision whereby coverage of a dependent in a family group terminates at a specified age, there shall also be a provision that coverage of an unmarried dependent who is incapable of sustaining employment by reason of intellectual and developmental disability or physical disability, who became so incapacitated prior to the attainment of nineteen (19) years of age and who is chiefly dependent upon the employee for support and maintenance, shall not terminate, but coverage shall continue so long as the coverage of the employee or member remains in force and so long as the dependent remains in such condition.(B) At the request and expense of the insurer, proof of the incapacity or dependency must be furnished to the insurer by the policyholder, except in no event shall this requirement preclude eligible dependents under Acts 1975, No. 649, § 5, as amended, regardless of age.(C) If the incapacity or dependency is thereafter removed or terminated, the policyholder shall so notify the insurer;(5)(A) No policy or contract of group accident and health insurance, including contracts issued by hospital and medical service corporations, that provides coverage for any of the following services when delivered on an inpatient basis shall hereafter be sold, delivered, or issued for delivery or offered for sale in this state unless the identical coverage for such services is provided when delivered on an outpatient basis:(i) Laboratory and pathological tests;(iv) Radiation treatment; and(B) However, the coverage required by subdivision (5)(A) of this section shall not be required when any policyholder or contract holder shall reject the coverage in writing.(C) The definition of the services referred to in this subdivision (5) shall be the same as found in § 23-85-133.(D) All existing group contracts, including existing group contracts issued by hospital and medical service corporations, shall conform to the provisions of this subdivision (5) upon the first anniversary of the issue date, after March 12, 1981;(6) A provision that: (A) All benefits payable under the policy other than benefits for loss of time will be payable immediately upon receipt of written proof of such loss;(B) Subject to proof of loss, all accrued benefits payable under the policy for loss of time will be paid not later than at the expiration of each period of thirty (30) days during the continuance of the period for which the insurer is liable; and(C) Any balance remaining unpaid at the termination of that period will be paid immediately upon receipt of due proof; and(7)(A) Every insurer, hospital or medical service corporation, fraternal benefit society, self-funded healthcare plan, or health maintenance organization providing replacement coverage, with respect to group accident and health benefits within a period of sixty (60) days from the date of discontinuance of a prior plan, shall immediately cover all employees and dependents: (i) If each employee or dependent was validly covered under the previous plan at the date of the discontinuance;(ii) If each employee or dependent is a member of the class of individuals eligible for coverage under the succeeding carrier's plan, regardless of any of the plan's limitations or exclusions relating to "actively at work" or hospital confinement; and(iii) Only if the group accident and health benefits were provided to a group consisting of more than fifteen (15) members.(B) The succeeding carrier shall be entitled to deduct from its benefits any benefits payable by the previous carrier pursuant to an extension of benefits provision.(C) No provision in a succeeding carrier's plan of replacement coverage that would operate to reduce or exclude benefits on the basis that the condition giving rise to benefits preexisted the effective date of the succeeding carrier's plan shall be applied with respect to those employees and dependents validly insured under the previous carrier's policy on the date of discontinuance if benefits for the condition would have been payable under the previous carrier's plan.(D) The provisions of this section shall apply upon the issuance of an insurance policy or healthcare plan: (i) To a group whose benefits had previously been self-insured;(ii) To a self-insurer providing coverage to a group that had been previously covered by an insurer; and(iii) To a group that had previously been covered by an insurer.Amended by Act 2019, No. 1035,§ 53, eff. 7/24/2019.Acts 1959, No. 148, § 420; 1967, No. 418, § 3; 1969, No. 263, § 3; 1975, No. 404, §§ 2, 8; 1975, No. 649, §§ 2, 8; 1981, No. 810, § 1; 1983, No. 522, §§ 31, 32; A.S.A. 1947, § 66-3702; Acts 1987, No. 456, § 17; 1987, No. 478, § 1; 1997, No. 208, § 28; 2001, No. 1063, § 8.