§ 3216. Individual accident and health insurance policy provisions. Show (1) "Policy of accident and health insurance" includes any individual (2) "Indemnity" means benefits promised. (3) "Family" may include the policyholder's spouse, or dependent (4) "Dependent children" (A) shall include any children under a (i) Any unmarried dependent child, regardless of age, who is incapable (ii) Any unmarried student at an accredited institution of learning (iii) Any married or unmarried child shall be considered a dependent (B) may include, at the option of the insurer, any unmarried child (C) In addition to the requirements of subparagraphs (A) and (B) of (b) No policy of accident and health insurance, including (c) No policy of accident and health insurance shall be delivered or (1) The entire money and other considerations therefor are expressed (2) The time at which the insurance takes effect and terminates is (3) It purports to insure only one person, except that a policy may (4) (A) Coverage of an unmarried dependent child who is incapable of (B) Coverage of a dependent spouse or named insured which would (C) Any family coverage shall provide that coverage of newborn (5) (A) Any family policy providing hospital or surgical expense (B) Written notice of entitlement to a conversion policy shall be (C) Such individual conversion policy shall be subject to the (i) The premium shall be that applicable to the form and amount of (ii) The benefits provided under such policy shall become effective (iii) No insurer shall be required to issue a conversion policy if it (6) The style, arrangement and overall appearance of the policy give (7) The exceptions and reductions of indemnity are set forth in the (8) Each such form, including riders and endorsements, shall be (9) It contains no provision purporting to make any portion of the (10) There is prominently printed on the first page thereof or there (11) The age limit or date or period, if any, after which the coverage (12) Any policy, other than one issued in fulfillment of the "NOTICE - THIS POLICY DOES NOT MEET THE REQUIREMENTS OF A CONTINUING (13) Any persons covered by the policy who are also members of a (A) the condition arose during the period of active duty and the (B) a waiting period was imposed and had not been completed prior to (14) To be entitled to the right defined in paragraph thirteen of this (A) voluntarily or involuntarily enters upon active duty (other than (B) has his or her active duty voluntarily or involuntarily extended (C) serves no more than four years of active duty. (d) Each policy of accident and health insurance delivered or issued (1) Each policy shall, except with respect to designation by numbers (A) ENTIRE CONTRACT; CHANGES: This policy, including the endorsements (B) TIME LIMIT ON CERTAIN DEFENSES: (i) After two years from the date of issue of this policy no (The foregoing policy provision shall not be so construed as to affect (A policy which the insured has the right to continue in force subject After this policy has been in force for a period of two years during (ii) No claim for loss incurred or disability (as defined in the (C) GRACE PERIOD: A grace period of ........................ (insert a (A policy in which the insurer reserves the right to refuse renewal "Unless not less than thirty days prior to the renewal date the Furthermore, such a policy, except an accident only policy, shall also (D) REINSTATEMENT: If any renewal premium be not paid within the time (The last sentence of the above provision may be omitted from any (E) NOTICE OF CLAIM: Written notice of claim must be given to the (F) CLAIM FORMS: The insurer, upon receipt of a notice of claim, will (G) PROOFS OF LOSS: Written proof of loss must be furnished to the (H) TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy (I) PAYMENT OF CLAIMS: Any indemnity for loss of life will be payable Subject to any written direction of the insured in the application or (J) PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense (K) LEGAL ACTIONS: No action at law or in equity shall be brought to (L) CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable (M) "CONVERSION PRIVILEGE" (under this caption) a provision which (2) Other provisions. No such policy delivered or issued for delivery (A) CHANGE OF OCCUPATION: If the insured be injured or contract (B) MISSTATEMENT OF AGE: If the insured's age has been misstated, all (C) OTHER INSURANCE IN THIS INSURER: If an accident or sickness or making the aggregate indemnity for ------------(insert type of Insurance effective at any one time on the insured under a like policy (D) INSURANCE WITH OTHER INSURERS: If there be other valid coverage, (If the foregoing policy provision is included in a policy which also (E) INSURANCE WITH OTHER INSURERS: If there be other valid coverage, (If the foregoing policy provision is included in a policy which also (F) RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of (The foregoing policy provision may be inserted only in a policy which (G) UNPAID PREMIUM: Upon the payment of a claim under this policy, any (H) CANCELLATION: Within the first ninety days after the date of (Nothing in this subsection shall be construed to prohibit an insurer (I) CONFORMITY WITH STATE STATUTES: Any provision of this policy (J) ILLEGAL OCCUPATION: The insurer shall not be liable for any loss (K) INTOXICANTS AND NARCOTICS: The insurer shall not be liable for any (3) If any provision of this subsection is in whole or in part (4) The provisions which are the subject of paragraphs one and two of (5) The word "insured", as used in this section, shall not be (6) The superintendent may make such reasonable rules and regulations (e) The acknowledgment by any insurer of the receipt of notice given (f) If any such policy contains a provision establishing, as an age (g)(1) No insurer shall refuse to renew a policy of hospital, surgical (A) nonpayment of premiums, (B) fraud in applying for the policy or in applying for any benefits (C) discontinuance of a class of policies in accordance with paragraph (i) Coverage shall be reinstated only for such insureds terminated on (ii) In the event any such insured becomes eligible to purchase (iii) Within sixty days of this item taking effect, the insurer or (D) discontinuance of all hospital, surgical and medical expense (E) in the case of an insurer that offers coverage in the individual (F) for such other reasons as are acceptable to the superintendent and In no event shall any insurer refuse to renew any such policy because (2) In any case in which an insurer decides to discontinue offering a (A) the insurer gives at least ninety days prior written notice of (B) the insurer provides written notice of such discontinuance to each (C) the insurer offers to each covered individual the option to (D) in exercising the option to discontinue coverage of a class of (E) The superintendent may, after giving due consideration to the (3) In any case in which an insurer elects to discontinue offering all (A) the insurer gives at least one hundred eighty days prior written (B) the insurer provides written notice of such discontinuance to each (C) all hospital, surgical and medical expense coverage issued or (D) in addition to the notice referred to in subparagraph (A) of this (4) In the case of a discontinuance under paragraph three of this (5) At the time of coverage renewal, an insurer may modify the health (6) For purposes of this subsection the term "network plan" shall mean (h) This section shall not apply to or affect: (1) Any contract of non-cancellable disability insurance which is (2) Any policy or contract of reinsurance. (3) Any policy of group or blanket insurance which is governed by (4) Any policy providing disability benefits pursuant to article nine (5) Any policy of a co-operative life and accident insurance company (6) Life insurance, endowment or annuity contracts, or contracts (i) Every person insured under a policy of accident and health (1) If a policy provides for reimbursement for any optometric service (2) If a policy provides for reimbursement for any podiatrical service (3) If a policy provides for reimbursement for any dental service (4) If a policy provides for reimbursement for psychiatric or (5) Every policy providing for reimbursement for laboratory tests or (6) Every policy which provides coverage for in-patient hospital care (A) Home care means the care and treatment of a covered person who is (i) Part-time or intermittent home nursing care by or under the (ii) Part-time or intermittent home health aide services which consist (iii) Physical, occupational or speech therapy if provided by the home (iv) Medical supplies, drugs and medications prescribed by a (B) Coverage may be subject to an annual deductible of not more than (7) Every policy which provides coverage for in-patient hospital care (A) the tests are ordered by a physician as a planned preliminary to (B) tests are necessary for and consistent with the diagnosis and (C) reservations for a hospital bed and for an operating room shall (D) the surgery actually takes place within seven days of such (E) the patient is physically present at the hospital for the tests. (8) Every policy which provides coverage for in-patient surgical care (9)(A) Every policy that provides coverage for inpatient hospital care (i) without the need for any prior authorization determination; (ii) regardless of whether the health care provider furnishing such (iii) if the emergency services are provided by a non-participating (iv) if the emergency services are provided by a non-participating (B) Any requirements of section 2719A(b) of the Public Health Service (C) For purposes of this paragraph, an "emergency condition" means a (D) For purposes of this paragraph, "emergency services" means, with (E) For purposes of this paragraph, "to stabilize" means, with respect (10) (A) (i) Every policy which provides hospital, surgical or medical (ii) Maternity care coverage shall also include, at minimum, parent (iii) The mother shall have the option to be discharged earlier than (B) Coverage provided under this paragraph for care and treatment (11) (A) Every policy that provides coverage for hospital, surgical or (i) upon the recommendation of a physician, a mammogram, which may be (ii) a single baseline mammogram, which may be provided by breast (iii) an annual mammogram, which may be provided by breast (B) Such coverage required pursuant to subparagraph (A) or (C) of this (C) For purposes of subparagraphs (A) and (B) of this paragraph, (D) In addition to subparagraph (A), (B) or (C) of this paragraph, (i) evidence-based items or services for mammography that have in (ii) with respect to women, such additional preventive care and (E) For purposes of this paragraph, "grandfathered health plan" means (F) Screening and diagnostic imaging for the detection of breast (11-a) (A) Every policy delivered or issued for delivery in this state (i) standard diagnostic testing including, but not limited to, a (ii) an annual standard diagnostic examination including, but not (B) Such coverage shall not be subject to annual deductibles or (12) (A) Every policy which provides coverage for prescribed drugs (i) the American Hospital Formulary Service-Drug Information (ii) National Comprehensive Cancer Networks Drugs and Biologics (iii) Thomson Micromedex DrugDex; (iv) Elsevier Gold Standard's Clinical Pharmacology; or other (B) Notwithstanding the provisions of this paragraph, coverage shall (12-a) (A) Every policy delivered or issued for delivery in this state (B) An insurer providing coverage under this paragraph and any (i) vary the terms of the policy for the purpose or with the effect of (ii) provide incentives (monetary or otherwise) to encourage a covered (iii) penalize in any way or reduce or limit the compensation of a (iv) provide incentives (monetary or otherwise) to a health care (v) achieve compliance with this paragraph by imposing an increase in (13) (A) Every policy which provides coverage for hospital care shall (B) Every policy which provides coverage for surgical and medical care (C) Every policy that provides medical, major medical or similar (i) For purposes of this subparagraph, "iatrogenic infertility" means (ii) No insurer providing coverage under this paragraph shall (13-a) Every policy that provides coverage for prescription fertility (14) If a policy provides for reimbursement for the services of (15) (A) Every policy that provides hospital, surgical or medical care (B) For purposes of subparagraphs (A) and (C) of this paragraph, (C) Such coverage required pursuant to subparagraph (A) or (B) of this (D) In addition to subparagraph (A), (B) or (C) of this paragraph, (i) evidence-based items or services for cervical cytology that have (ii) with respect to women, such additional preventive care and (E) For purposes of this paragraph, "grandfathered health plan" means (15-a) (A) Every policy which provides medical coverage that includes (B) Such coverage may be subject to annual deductibles and coinsurance (16) If a policy provides for reimbursement for speech-language (17) (A) Every policy that provides medical, major-medical or similar (B) For the purposes of subparagraphs (A), (C) and (D) of this (i) an initial hospital check-up and well-child visits scheduled in (ii) at each visit, services in accordance with the prevailing (iii) necessary immunizations, as determined by the superintendent in (C) Such coverage required pursuant to subparagraph (A) or (B) of this (D) Such coverage required pursuant to subparagraph (A) or (B) of this (E) In addition to subparagraph (A), (B), (C) or (D) of this (i) evidence-based items or services for preventive care and (ii) immunizations that have in effect a recommendation from the (iii) with respect to children, including infants and adolescents, (iv) with respect to women, such additional preventive care and (v) all FDA-approved contraceptive drugs, devices, and other products, (F) For purposes of this paragraph, "grandfathered health plan" means (18) (A) Every policy which provides coverage for inpatient hospital (B) An insurer providing coverage under this paragraph and any (i) deny to a covered person eligibility, or continued eligibility, to (ii) provide incentives (monetary or otherwise) to encourage a covered (iii) penalize in any way or reduce or limit the compensation of a (iv) provide incentives (monetary or otherwise) to a health care (v) restrict coverage for any portion of a period within a hospital (C) The prohibitions in subparagraph (B) of this paragraph shall be in (19) (A) Every policy which provides medical, major medical, or (i) In the case of a policy that requires, or provides financial (ii) In the case of a policy that does not provide financial (iii) Such coverage may be subject to annual deductibles and Nothing in this paragraph shall eliminate or diminish an insurer's (B) An insurer providing coverage under this paragraph and any (i) deny to a covered person eligibility, or continued eligibility, to (ii) provide incentives (monetary or otherwise) to encourage a covered (iii) penalize in any way or reduce or limit the compensation of a (iv) provide incentives (monetary or otherwise) to a health care (C) The prohibitions in subparagraph (B) of this paragraph shall be in (20) * (A) Every policy which provides medical, major medical, or (i) all stages of reconstruction of the breast on which the mastectomy (ii) surgery and reconstruction of the other breast to produce a * NB Effective until January 12, 2023 * (A) Every policy which provides medical, major medical, or similar (i) all stages of reconstruction of the breast or chest wall on which (ii) surgery and reconstruction of the other breast or chest wall to * NB Effective January 12, 2023 (B) An insurer providing coverage under this paragraph and any (i) deny to a covered person eligibility, or continued eligibility, to (ii) provide incentives (monetary or otherwise) to encourage a covered (iii) penalize in any way or reduce or limit the compensation of a (iv) provide incentives (monetary or otherwise) to a health care (v) restrict coverage for any portion of a period within a hospital (C) The prohibitions in this paragraph shall be in addition to the * (21) Every policy that provides coverage for prescription drugs * NB There are 2 par (21)'s * (21)(A) Every policy which is a "managed care product" as defined in (C) Every policy which includes coverage for physician services in a (D) For purposes of this paragraph, a "managed care product" shall (E) The coverage required by this paragraph shall not be abridged by * NB There are 2 par (21)'s (22) No policy shall exclude coverage of a health care service, as (23) If a policy provides for reimbursement for physical and (24)(A) Every policy which provides major medical or similar (B) Payment by an insurer pursuant to this section shall be payment in (C) An insurer shall provide reimbursement for those services (D) The provisions of this paragraph shall have no application to (E) As used in this paragraph: (i) "Prehospital emergency medical services" means the prompt (ii) "Emergency condition" means a medical or behavioral condition (25) (A) Every policy which provides coverage for hospital or surgical (B) Every policy that provides physician services, medical, major (C) For purposes of this paragraph: (i) "autism spectrum disorder" means any pervasive developmental (ii) "applied behavior analysis" means the design, implementation, and (iii) "behavioral health treatment" means counseling and treatment (iv) "diagnosis of autism spectrum disorder" means assessments, (v) "pharmacy care" means medications prescribed by a licensed health (vi) "psychiatric care" means direct or consultative services provided (vii) "psychological care" means direct or consultative services (viii) "therapeutic care" means services provided by licensed or (ix) "treatment of autism spectrum disorder" shall include the (1) behavioral health treatment; (2) psychiatric care; (3) psychological care; (4) medical care provided by a licensed health care provider; (5) therapeutic care, including therapeutic care which is deemed (6) pharmacy care in the event that the policy provides coverage for (D) Coverage may be denied on the basis that such treatment is being (E) Nothing in this paragraph shall be construed to affect any (G) Nothing in this paragraph shall be construed to prevent a policy (H) Coverage under this paragraph shall not apply financial (I) The criteria for medical necessity determinations under the policy (J) For purposes of this paragraph: (i) "financial requirement" means deductible, copayments, coinsurance (ii) "predominant" means that a financial requirement or treatment (iii) "treatment limitation" means limits on the frequency of (K) An insurer shall provide coverage under this paragraph, at a (26)(A) No managed care health insurance policy that provides coverage (B) No managed care health insurance policy that provides coverage for (C) For purposes of this paragraph, a "health care provider" is a (D) For purposes of this paragraph, a "managed care health insurance * (27) No policy delivered or issued for delivery in this state which * NB There are 2 par (27)'s * (27)(A) Every policy that includes coverage for dialysis treatment (i) The out-of-network provider is duly licensed to practice and (ii) The out-of-network provider is located outside the service area (iii) The in-network healthcare provider treating the insured for the (iv) The insured has notified, in writing, the insurer at least thirty (v) The insurer shall have the right to pre-approve the dialysis (vi) Such coverage is limited to no greater than ten out-of-network (B) Where coverage for out-of-network dialysis treatment is provided (C) Such coverage of out-of-network dialysis services required by * NB There are 2 par (27)'s * (28) Notwithstanding title eleven of article five of the social * NB There are 2 par (28)'s * (28) (A) Definitions. For the purpose of this paragraph: (i) "Same reimbursement amount" shall mean that any coverage described (ii) "Mail order pharmacy" means a pharmacy whose primary business is (B) Any policy that provides coverage for prescription drugs shall * NB There are 2 par (28)'s (29) Every individual policy which provides medical, major medical or * (30)(A) Every policy that provides hospital, major medical or (B) Coverage provided under this paragraph may be limited to (C) Coverage provided under this paragraph may be subject to annual (D) This subparagraph shall apply to facilities in this state that are (E) An insurer shall make available to any insured, prospective (F) For purposes of this paragraph: (i) "financial requirement" means deductible, copayments, coinsurance (ii) "predominant" means that a financial requirement or treatment (iii) "treatment limitation" means limits on the frequency of (iv) "substance use disorder" shall have the meaning set forth in the (G) An insurer shall provide coverage under this paragraph, at a * NB There are 2 par (30)'s * (30) Every policy that provides medical coverage that includes * NB There are 2 par (30)'s (31) (A) Every policy that provides medical, major medical or similar (B) Coverage under this paragraph may be limited to facilities in this (C) Coverage provided under this paragraph may be subject to annual (D) A policy providing coverage for substance use disorder services (i) does not exceed the allowable number of family visits provided by (ii) is otherwise entitled to coverage pursuant to this paragraph and (E) This subparagraph shall apply to facilities in this state that are (F) The criteria for medical necessity determinations under the policy (G) For purposes of this paragraph: (i) "financial requirement" means deductible, copayments, coinsurance (ii) "predominant" means that a financial requirement or treatment (iii) "treatment limitation" means limits on the frequency of (iv) "substance use disorder" shall have the meaning set forth in the (H) An insurer shall provide coverage under this paragraph, at a (I) This subparagraph shall apply to crisis stabilization centers in (31-a) (A) No policy that provides medical, major medical or similar (B) Coverage provided under this paragraph may be subject to (32) No policy delivered or issued for delivery in this state that * (33) Every policy delivered or issued for delivery in this state * NB There are 2 par (33)'s * (33) Whenever in this section an insurer is required to provide * NB There are 2 par (33)'s * (34) Health care forensic examinations performed pursuant to section * NB There are 2 par (34)'s * (34) Every policy that provides coverage for hospital, surgical or * NB There are 2 par (34)'s (35) (A) Every policy delivered or issued for delivery in this state (i) where the policy provides coverage for inpatient hospital care, (ii) where the policy provides coverage for physician services, (B) Coverage required by this paragraph may be subject to annual (C) Coverage under this paragraph shall not apply financial (D) The criteria for medical necessity determinations under the policy (E) For purposes of this paragraph: (i) "financial requirement" means deductible, copayments, coinsurance (ii) "predominant" means that a financial requirement or treatment (iii) "treatment limitation" means limits on the frequency of (iv) "mental health condition" means any mental health disorder as (F) An insurer shall provide coverage under this paragraph, at a (G) This subparagraph shall apply to hospitals in this state that are (H) This subparagraph shall apply to crisis stabilization centers in * (36) (A) Every policy which provides hospital, surgical, or medical (B) Coverage for abortion shall not be subject to annual deductibles * NB Effective January 1, 2023 (j) (1) Every insurer issuing a policy of accident and health (A) In this paragraph nursing home care means the continued care and (B) Ambulatory care means care in hospital out-patient facilities, as (2) Every insurer issuing a policy of accident and health insurance (3) Consistent with federal law, every insurer issuing a policy of (A) Coverage shall be subject to a copayment of twenty-five dollars (B) Brochures describing such coverage must be provided to all (C) The commensurate rate for the coverage must be approved by the (D) Such insurers shall report to the superintendent each year the (k) Any person, partnership or corporation willfully violating any (l) An insurer shall not offer individual hospital, medical or (m) An insurer shall not be required to offer the policyholder any What should an insured do if the insurer does not send claims?If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party. You can ask that your insurance company reconsider its decision.
What is a cancelable insurance policy?Cancelable — refers to the fact that most insurance contracts can be terminated by the insurer or the insured at any time. If an individual policy is not a cancelable policy, then it will probably be designated guaranteed renewable or noncancelable.
What type of changes can be made to a guarantee renewable health insurance policy?Guaranteed renewable means that you have the right to continue the policy as long as the premiums are paid on a timely basis. An insurer cannot terminate the policy if your health declines. The insurer also cannot make any change in any provision of the policy while the insurance is in force without your agreement.
What type of policy allows the insurance company to cancel a policy at any time quizlet?The renewability provision in a cancelable policy allows the insurer to cancel or terminate the policy at any time, simply by providing written notification to the insured and refunding any advance premium that has been paid.
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