This text of Indiana § 22-3-5-5.5 (Deductibles and co-insurance) is published on Counsel Stack Legal Research, covering Indiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
5.
(a)Each insurer entering into or issuing an
insurance policy under IC 22-3-2 through IC 22-3-7 may, as a part of
the policy or as an optional endorsement to the policy, offer deductibles
or co-insurance, or both, that are optional to the insured for benefits
under IC 22-3-2 through IC 22-3-7. Each insurer may do the following:
(1)Offer deductibles in multiples of five hundred dollars ($500),
up to a maximum of five thousand dollars ($5,000) per
compensable claim.
(2)Offer co-insurance for each compensable claim. The following
apply to co-insurance provided under this subdivision:
(A)The co-insurance must require the insurer to pay eighty
percent (80%) and the insured to pay twenty percent (20%) of
the amount of benefits due to an employee for an injury
compensable under IC 22-3-2 th
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5. (a) Each insurer entering into or issuing an
insurance policy under IC 22-3-2 through IC 22-3-7 may, as a part of
the policy or as an optional endorsement to the policy, offer deductibles
or co-insurance, or both, that are optional to the insured for benefits
under IC 22-3-2 through IC 22-3-7. Each insurer may do the following:
(1) Offer deductibles in multiples of five hundred dollars ($500),
up to a maximum of five thousand dollars ($5,000) per
compensable claim.
(2) Offer co-insurance for each compensable claim. The following
apply to co-insurance provided under this subdivision:
(A) The co-insurance must require the insurer to pay eighty
percent (80%) and the insured to pay twenty percent (20%) of
the amount of benefits due to an employee for an injury
compensable under IC 22-3-2 through IC 22-3-7.
(B) An insured employer may not be required to pay more than
four thousand two hundred dollars ($4,200) in co-insurance
under this subdivision for each compensable claim.
(b) An insurer shall fully disclose in writing to prospective
policyholders the deductibles and co-insurance offered under
subsection (a). An insured employer who chooses a deductible under
subsection (a):
(1) may choose only one (1) deductible amount; and
(2) is liable for the amount of the deductible for benefits paid for
each compensable claim of an employee under IC 22-3-2 through
IC 22-3-7.
(c) An insurer shall do the following:
(1) Where a policy provides for a deductible, the insurer shall:
(A) pay all or a part of the deductible amount, whichever is
applicable to a compensable claim, to the person or medical
service provider entitled to the benefits under IC 22-3-2
through IC 22-3-7; and
(B) seek reimbursement from the employer from the applicable
deductible.
(2) Where a policy provides a deductible or co-insurance, the
insurance company shall pay the full cost of the claim. The
insurance company shall seek reimbursement from the insured
employer for its portion of the liability following closing of the
claim or when twenty percent (20%) of the benefits paid exceed
four thousand two hundred dollars ($4,200).
(d) The payment or nonpayment of a deductible or co-insurance
amount by an insured employer to the insurer shall be treated under the
policy insuring the liability for worker's compensation in the same
manner as payment or nonpayment of premiums is treated.
(e) The premium reduction for deductibles or for co-insurance shall
be determined before the application of any experience modifications,
premium surcharges, or premium discounts. The applicable premium
reduction percentage is the percentage corresponding to the appropriate
deductible or co-insurance amount. The premium reduction is obtained
by the application of the appropriate reduction percentage, shown
under miscellaneous values in the rate pages, to the premium
determined before application of any experience or schedule
modification, premium discounts, or any retrospective rating plan.
(f) This section does not apply to the following:
(1) An employer that is authorized to self-insure against liability
for claims under IC 22-3-2 through IC 22-3-6.
(2) Group self-insurance funds for claims under IC 22-3-2
through IC 22-3-6.
(g) A deductible or co-insurance provided under this section applies
against the total of all benefits paid for a compensable claim, including
benefits paid under the following:
(1) IC 22-3-3-4.
(2) IC 22-3-3-8 through IC 22-3-3-10.
(3) IC 22-3-3-17.
(4) IC 22-3-3-22.
(h) An employer may not use the employer's election of a deductible
or co-insurance under this section or the payment of a deductible or
co-insurance under this section in negotiating with the employer's
employees on any terms of employment. An employee of an employer
that knowingly violates this subsection may file a complaint with the
department of labor. The department of labor may impose a civil
penalty of not more than one thousand dollars ($1,000) against an
employer that knowingly violates this subsection.
(i) This subsection applies to an employee of an employer that has
paid a deductible or co-insurance under this section and to the
employee's dependents. If an employee or a dependent recovers
damages against a third party under IC 22-3-2-13, the insurer shall
provide reimbursement to the insured equal to a pro-rata share of the
net recovery by the insurer.