§1000. Group, family group, blanket, and association health and accident insurance
A. Any insurer authorized to write health and accident insurance in this state shall
have the power to issue policies described in this Section, provided that no policy issued
pursuant to this Section shall conflict with other provisions of this Title or with federal law
including but not limited to relevant provisions of law governing major medical health and
accident policies.
(1) Group health and accident insurance is any policy of health and accident
insurance, or similar coverage issued by a health maintenance organization, covering more
than one person, except family group, and blanket policies hereinafter specifically provided
for, which shall conform to the following requirements:
(a)(i) The policy shall be issued to an employer or association, or trustees of a fund
established by an employer, association or a trust for multiple associations who shall be
deemed the policyholder, covering one or more employees of such employer or one or more
members or employees of members of such association or multiple associations, for the
benefit of persons other than the employer, the association or the multiple associations, as
well as their officers or trustees, upon some plan which will preclude individual selection.
(ii) The premium may be paid by the employer, association or multiple associations,
by the employees, members or employees of members, or by the two parties jointly. An
insurer may but shall not be required to establish a percentage of eligible employees who are
required to enroll and participate in a group health and accident policy if the entire premium
is not paid by the employer, association or multiple associations.
(iii) If the policy is issued to any employer, any class or classes of employees eligible
for coverage must be determined by conditions pertaining to their employment or age.
(iv) No such policy issued under individual certificates and considered as individual
insurance coverage for purposes of this Subpart and R.S. 22:984, 1061 through 1079, and
2247 may be issued to an association or trust for multiple associations unless such
association or each participating association in the multiple associations, having had an
active existence for at least five years, has a constitution and bylaws and has been organized
and is maintained in good faith for purposes other than those of obtaining insurance, does not
condition membership in the association or multiple associations on any health status-related
factor relating to an individual, including an employee of an employer or a dependent of an
employee, and does not make health insurance coverage offered through the association or
multiple associations available other than in connection with a member of the association or
multiple associations. No such policy, issued and considered as group health insurance, as
defined under R.S. 22:1061(2)(c), may be issued to an association, trust for an association,
or multiple associations unless it or each participating association has been actively in
existence for at least five years, has been formed and maintained in good faith for purposes
other than obtaining insurance, does not condition membership in the association or multiple
associations on any health status-related factor relating to an individual, including an
employee of an employer or a dependent of an employee, and does not make health insurance
coverage offered through the association or multiple associations available other than in
connection with a member of the association. Such individual or group policy may be issued
to a trust established by an association or associations to allow multiple associations to
participate.
(v) The insurer shall issue to the employer, association, or the multiple associations
for delivery to each employee or member insured under such group policy, an individual
certificate containing a statement as to the insurance protection to which he is entitled and
to whom payable.
(vi)(aa) The policy may be issued to an employer, association, a trust for multiple
associations, or to the trustees of a fund established by two or more employers in the same
industry or by one or more labor unions, by one or more employers, and one or more labor
unions or by an association, or multiple associations, or to a multiple employer trust or
multiple association trust established by an insurer on behalf of participating employers or
participating associations, in the multiple associations, provided all participating employers
and employees or members, or employees of members of one of the multiple participating
associations have the same statutory protections that would apply if such policy was
purchased by the employer, association, or multiple associations directly from the insurer,
which trustees shall be deemed the policyholder, to insure with or without any eligible family
members including spouse, children until the age of twenty-six, and grandchildren who are
in the legal custody of and residing with the grandparent until the age of twenty-six pursuant
to R.S. 22:1003 and 1003.1, employees of the employers, members of the association or
employees of members of a multiple association, or of the unions for the benefit of persons
other than the employers or the unions.
(bb) Notwithstanding any other provision of law to the contrary, coverage of
dependent children or grandchildren for excepted benefits and for benefits of short-term,
limited duration insurance as defined pursuant to 45 CFR 144.103 shall be controlled by this
Subitem with regard to requirements for age. For excepted benefits, as defined in R.S.
22:1061(3)(b) and (c) and for benefits of short-term, limited duration insurance as defined
pursuant to 45 CFR 144.103, the following requirements for coverage of dependent children
or grandchildren shall apply:
(I) To an unmarried dependent child or grandchild but who is not a full-time student
until the age of twenty-one. A dependent grandchild shall be in the legal custody of and
residing with the grandparent.
(II) To an unmarried dependent child or grandchild who is enrolled as a full-time
student until the age of twenty-four. This enrollment may be at an accredited college or
university or at a vocational, technical, vocational-technical, or trade school or institute. A
dependent grandchild shall be in the legal custody of and residing with the grandparent.
(III) To an unmarried dependent child or grandchild who is a full-time student and
who develops a mental or nervous condition, problem, or disorder which renders the child
or grandchild, in the opinion of a qualified psychiatrist, subject to a second opinion if deemed
necessary by the health insurance issuer or health maintenance organization, unable to attend
school as a full-time student and from holding self-sustaining employment, until the age of
twenty-four. A dependent grandchild shall be in the legal custody of and residing with the
grandparent.
(IV) To an unmarried dependent child or grandchild who is incapable of
self-sustaining employment by reason of intellectual or physical disability, who became
incapable prior to attainment of the age of twenty-one, there may be continuous coverage for
excepted benefits regardless of age. A dependent grandchild shall be in the legal custody of
and residing with the grandparent.
(b) The benefits payable under any policy or contract of group health and accident
insurance shall be payable to the employee, members or employees of members of multiple
associations or to some beneficiary or beneficiaries designated by him, other than the
employer or association or multiple associations, but if there is no designated beneficiary as
to all or any part of the insurance at the death of the employee, member or employee of
members, then the amount of insurance payable for which there is no designated beneficiary
shall be payable to the estate of the employee, member or employee of members, except that
the insurer may in such case, at its option, pay such insurance to any one or more of the
following surviving relatives of the employee, member or employee of members: wife,
husband, mother, father, child, or children, brothers or sisters; and except that payment of
benefits for expenses incurred on account of hospitalization or medical or surgical aid, may
be made by the insurer to the hospital or other person or persons furnishing such aid.
Payment so made shall discharge the insurer's obligations with respect to the amount of
insurance so paid.
(c) Except as may otherwise be provided in the policy or contract of group health and
accident insurance or by R.S. 22:1012, the policyholder and the insurer may agree to modify,
amend, or cancel the group policy, and such agreement shall be binding upon the employee,
member, or employee of members insured under the group policy, provided that the
modification, amendment, or cancellation shall be without prejudice to any claim for benefits
accrued, or for expenses incurred for services rendered, prior to such modification,
amendment, or cancellation. Benefits and expenses incurred shall be as defined and limited
by the terms of the policy; however, upon cancellation by the insurer, the insurer shall only
be liable for any claim for benefits accrued, or for expenses incurred for services rendered,
subsequent to the cancellation date if the subsequent claim is for an illness or condition
which was the basis of any claim prior to cancellation and for which the insurer had notice.
Any cancellation pursuant to this Paragraph shall also comply with the provisions of R.S.
22:887(F).
(d) Except as may otherwise be provided in the policy or contract of group health and
accident insurance, the insurer shall not be liable for benefits accrued, or for expenses
incurred for services rendered, subsequent to the termination date where the policy of
insurance terminates for failure of the group policyholder to pay premiums or where the
employee's, member's, or member's employee's coverage terminated for failure of the
employee, member, or employee of members to maintain eligibility as provided in the policy
or contract of group health and accident insurance.
(2)(a) Family group health and accident insurance or similar coverage issued by a
health maintenance organization is an individual policy covering any one person, with or
without any eligible members, including spouse and children until the age of twenty-six, and
grandchildren until the age of twenty-six who are in the legal custody of and residing with
the grandparent pursuant to R.S. 22:1003 and 1003.1, except that the policy may provide for
continuing coverage for any child or grandchild in the legal custody of and residing with the
grandparent who is incapable of self-sustaining employment by reason of intellectual or
physical disability, who became so incapable prior to attainment of age twenty-six, and any
other person dependent upon the policyholder, written under a master policy issued to the
head of such family. The policy shall contain a provision that the policy, and the application
of the head of the family if attached to the policy, shall constitute the entire contract between
the parties.
(b) Notwithstanding any other provision of law to the contrary, coverage of
dependent children or grandchildren for excepted benefits and for benefits of short-term,
limited duration insurance as defined pursuant to 45 CFR 144.103 shall be controlled by this
Subparagraph with regard to requirements for age. For excepted benefits, as defined in R.S.
22:1061(3)(b) and (c) and for benefits of short-term, limited duration insurance as defined
pursuant to 45 CFR 144.103, the following requirements for coverage of dependent children
or grandchildren shall apply:
(i) To an unmarried dependent child or grandchild who is not a full-time student until
the age of twenty-one. A dependent grandchild shall be in the legal custody of and residing
with the grandparent.
(ii) To an unmarried dependent child or grandchild who is enrolled as a full-time
student until the age of twenty-four. This enrollment may be at an accredited college or
university or at a vocational, technical, vocational-technical, or trade school or institute. A
dependent grandchild shall be in the legal custody of and residing with the grandparent.
(iii) To an unmarried dependent child or grandchild who is a full-time student and
who develops a mental or nervous condition, problem, or disorder which renders the child
or grandchild, in the opinion of a qualified psychiatrist, subject to a second opinion if deemed
necessary by the health insurance issuer or health maintenance organization, unable to attend
school as a full-time student and from holding self-sustaining employment, until the age of
twenty-four. A dependent grandchild shall be in the legal custody of and residing with the
grandparent.
(iv) To an unmarried dependent child or grandchild who is incapable of
self-sustaining employment by reason of intellectual or physical disability, who became so
incapable prior to attainment of the age of twenty-one, there may be continuous coverage for
excepted benefits regardless of age. A dependent grandchild shall be in the legal custody
of and residing with the grandparent.
(3) Blanket health and accident insurance is any policy covering special groups of
persons as enumerated in any of the following:
(a) Under a policy or contract issued to any common carrier or to any operator,
owner, or lessee of a means of transportation that operates as a common carrier, which shall
be deemed the policyholder, covering a group defined as all persons who may become
passengers on such common carrier or means of transportation.
(b) Under a policy issued to an employer, who shall be deemed the policyholder,
covering any group of employees, dependents, or guests defined by reference to hazards
incident to activities or operations of the policyholder.
(c) Under a policy issued to a college, school, or other institution of learning, a
school district or districts or school jurisdictional unit, or to the head, principal, or governing
board thereof, who or which shall be deemed the policyholder, covering students, teachers,
employees, or volunteers.
(d) Under a policy issued in the name of any volunteer or governmental fire
department, first aid, civil defense, or other such volunteer group, which shall be deemed the
policyholder, covering any group of members, participants, or volunteers incident to any
activities or operations sponsored or supervised by such department or group.
(e) Under a policy or contract issued to a creditor who shall be deemed the
policyholder to insure debtors of the creditor.
(f) Under a policy or contract issued to a sports team, camp, or sponsor thereof,
which shall be deemed the policyholder, covering members, campers, employees, officials,
supervisors, or volunteers.
(g) Under a policy or contract issued to a religious, charitable, recreational,
educational, or civic organization or branch thereof, which shall be deemed the policyholder,
covering any group of members, participants, or volunteers defined by reference to specified
hazards incident to any activities or operations sponsored or supervised by or on the premises
of such policyholder.
(h) Under a policy or contract issued to a newspaper or other publisher, which shall
be deemed the policyholder, covering its carriers.
(i) Under a policy or contract issued to a restaurant, hotel, motel, resort, innkeeper,
or other group with a high degree of potential customer liability, which shall be deemed the
policyholder, covering patrons, guests, or volunteers.
(j) Under a policy or contract issued to a health maintenance organization, a health
care provider, or other arranger of health services, which shall be deemed the policyholder,
covering subscribers, patients, donors, and surrogates, provided that the coverage is not made
a condition of receiving care or that major medical health and accident coverage may not be
provided to subscribers or other enrollees pursuant to this Section.
(k) Under a policy or contract issued to a bank or other financial association or
institution, vendor, or to a parent holding company or to the trustee, trustees, or agent
designated by one or more banks or other financial associations or institutions or vendors
under which account holders, credit card holders, debtors, guarantors, or purchasers are
insured.
(l) Under a policy or contract issued to an incorporated or unincorporated association
of persons having a common interest or calling, formed for purposes other than obtaining
insurance, which association shall be deemed the policyholder, covering members or
participants of such association.
(m) Under a policy or contract issued to a travel agency or other organization that
provides travel related services, which organization shall be deemed the policyholder, to
cover all persons for which travel related services are provided.
(n) Under a policy issued to any other risk or class of risks that, in the discretion of
the commissioner of insurance, may be subject to the issuance of a blanket health and
accident policy. The discretion of the commissioner may be exercised on an individual risk
basis or class of risks, or both.
(o) Under a policy or contract issued to the Louisiana Department of Health, which
shall be deemed the policyholder, covering a group defined as all persons who are eligible
for medical assistance pursuant to a coverage program implemented pursuant to approval of
the secretary of the United States Department of Health and Human Services using authority
granted under Section 1115 of the Social Security Act.
(4) An individual application shall not be required from a person covered under such
a blanket policy. The insurer shall furnish to the policyholder for delivery to the insured a
certificate of insurance that shall disclose the benefits, limitations, exclusions, and reductions
contained in the policy and the provisions relating to notice of claim, proof of loss, time of
payment of claim, and any other relevant information, including the name and address of the
insurer. All benefits under any such blanket policy shall be payable to the person insured,
or to his designated beneficiary or beneficiaries, if the policy permits the designation of
named beneficiaries, or to his estate, except that if the person insured is a minor such benefits
may be made payable to his parent, guardian, or other person actually supporting him.
B.(1) The term "employees" as used in this Section shall be deemed to include, for
the purposes of insurance under this Section, as employees of a single employer, the officers,
managers, and employees of the employer and of subsidiary or affiliated corporations of a
corporation employer, and the individual proprietors, partners, and employees of individuals
and firms of which the business is controlled by the insured employer through stock
ownership, contract or otherwise. The term "employer" as used herein may be deemed to
include any governmental corporation, unit, agency or department thereof, or the proper
officers, as such, of any unincorporated governmental organization.
(2) As used in this Section, "participating association" shall mean an association that
has, by virtue of an affirmative vote, consensus, or similar decision in accordance with the
association's bylaws or conventions, acted overtly through its staff or elected leaders, acting
within the scope of their authority, to enter into an agreement with one or more other
associations to be a partner in a multiple association trust on terms mutually agreeable to all
associations participating in the multiple association trust.
C. Insurers issuing policies under this Section shall be subject to all the other
applicable provisions of this Subpart and R.S. 22:984, 1061 through 1079, and 2247. In
addition, policies issued under this Section shall also contain a provision that to the group
or class thereof originally insured shall be added:
(1) All new persons becoming eligible for and applying for insurance in such group
or class, including new members of a family group; and
(2) Any persons required to be provided coverage under federal law who apply for
insurance in such group or class.
D. Any policy issued under this Section may provide for the readjustment of the rate
of premium based on the experience at the end of the first year or of any subsequent year of
insurance, and such readjustment may be made retroactive only for such policy year. Any
refund under any plan for readjustment of the rate of premium based on the experience under
group policies issued, and any dividend paid under such policies may be issued to reduce the
employer's share of the cost of the coverage, except that if the aggregate refunds or dividends
under such group policy and any other group policy or contract issued to the policyholder
exceed the aggregate contributions of the employer toward the cost of the coverages, such
excess shall be applied by the policyholder for the sole benefit of insured employees.
E. Any group, family group, blanket, or association health and accident insurer,
including a group health plan as defined by Section 607(1) of the Employee Retirement
Income Security Act of 1974, self-insurance plan, health maintenance organization, nonprofit
hospital or medical service organization, or the Office of Group Benefits, shall be prohibited
from any consideration of the availability or eligibility for medical assistance in this or any
other state, as mandated under federal law, as a requirement of eligibility for coverage or
payment under its policy, plan, certificate, or agreement for its policyholders, enrollees,
members, certificate holders, or their dependents.