A.The coverage for an insured under individual health insurance coverage shall be subject to the provisions of this Section.
B.The provisions of this Section shall not preclude the standard twelve-month preexisting condition exclusions when the covered person initially becomes covered under a health and accident insurance policy or health maintenance organization subscriber agreement or when a covered person lacks continuous health insurance coverage for a period in excess of sixty-three days. In determining whether a preexisting condition exclusion applies to a covered person, any health and accident insurance policy or health maintenance organization subscriber agreement covered by this Section shall credit the time the person was covered under a previous policy covered by this Section
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A. The coverage for an insured under individual health insurance coverage shall be subject to the provisions of this Section.
B. The provisions of this Section shall not preclude the standard twelve-month preexisting condition exclusions when the covered person initially becomes covered under a health and accident insurance policy or health maintenance organization subscriber agreement or when a covered person lacks continuous health insurance coverage for a period in excess of sixty-three days. In determining whether a preexisting condition exclusion applies to a covered person, any health and accident insurance policy or health maintenance organization subscriber agreement covered by this Section shall credit the time the person was covered under a previous policy covered by this Section, if the previous coverage was continuous to a date not more than sixty-three days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such policy.
C. Notwithstanding the provisions of Subsections B and D of this Section, individual health insurance coverage offered to any individual may exclude coverage for medical care for specific medical conditions that existed prior to the issuance of coverage, subject to the following conditions:
(1) The exclusion of coverage for medical care shall not apply to any services, benefits, or options mandated by state or federal law to be included in a policy or certificate of coverage.
(2) The exclusion of coverage for medical care shall be for a specified period of time longer than twelve months and shall cover a specific medical condition.
(3) Before or at the time of issuance of the policy or subscriber agreement, the health insurance issuer shall provide the applicant with a written notice explaining the exclusion of coverage for the specific medical condition. Such exclusion of coverage shall not be applied to any other medical condition not arising directly as the result of the specific medical condition being excluded.
(4) The offer of coverage shall state that the applicant is receiving coverage with an exclusion of coverage for a specific medical condition. Such statement shall be printed in bold print as a separate section of the policy or subscriber agreement or on a separate form.
(5) The offer of coverage shall not include more than two specific medical conditions being excluded from coverage per individual covered under the policy or subscriber agreement.
(6) The exclusion period shall be concurrent with any other applicable preexisting condition limitation or exclusion period.
(7) The health insurance issuer shall agree to review the underwriting basis for the exclusion from coverage upon written request by the insured no more often than once in a twelve-month period. The issuer shall remove the exclusion, effective upon renewal, if the insurer determines that the evidence of insurability is satisfactory.
(8) The insured's benefit card shall disclose the telephone number where exclusions can be verified.
D. Any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, health and accident insurance policy, or any other insurance contract of this type, or a self-insurance plan, which is delivered, issued for delivery, or renewed in this state shall not deny, exclude, or limit benefits for a covered individual for losses due to a preexisting condition incurred more than twelve months following the effective date of the covered person's coverage unless an exclusion of coverage is established pursuant to Subsection C of this Section. The provisions of this Section shall not apply to limited benefit health insurance policies and short-term policies or contracts of a duration of six months or less. Any policy, contract, or plan subject to the provisions of this Section shall not contain a definition of a preexisting condition more restrictive than the following:
(1) A condition that would have caused an ordinary prudent person to seek medical advice, diagnosis, care, or treatment during the twelve months immediately preceding the effective date of coverage.
(2) A condition for which medical advice, diagnosis, care or treatment was recommended or received during the twelve months immediately preceding the effective date of coverage.
(3) A pregnancy existing on the effective date of coverage.
E. Any individual policyholder or individual subscriber shall be authorized to add a newborn child to his individual policy or subscriber agreement at any time prior to birth or at birth as set forth in R.S. 22:1075(A), effective upon birth. Coverage for a newborn child added to a policy or subscriber agreement pursuant to this Subsection shall be subject to adjustment for the additional coverage provided.
F. Individual health insurance coverage shall be subject to coordination of benefits with other health insurance coverage and treated as secondary to any group health insurance coverage in effect. In no instance shall a health insurance issuer be required to pay any amount in excess of the benefit amount that would have been paid under a policy or subscriber agreement if no other group health insurance coverage was in effect.
NOTE: Former R.S. 22:1072 redesignated as R.S. 22:846 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
Acts 1997, No. 1138, §1, eff. July 14, 1997; Acts 1999, No. 445, §1, eff. June 18, 1999; Acts 2001, No. 133, §1, eff. May 25, 2001; Acts 2004, No. 269, §1, eff. June 15, 2004; Redesignated from R.S. 22:250.11 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011.