§ 110 — General or blanket policies; power to issue; non-applicability of Sec. 108

Massachusetts § 110

• Jurisdiction: Massachusetts
• Part I: ADMINISTRATION OF THE GOVERNMENT
• Title XXII: CORPORATIONS
• Ch. 175: INSURANCE

Text

Section 110. (A) Nothing in section 108 shall be construed to apply to or affect or prohibit the issue of any general or blanket policy of insurance to groups, including, but not limited to, the following:(a) any employer, whether an individual, association, co-partnership, or corporation, or the trustees of a fund established by the employer; or (b) any municipal corporation or any department thereof not referred to in (c);(c) any police, fire or governmental department or volunteer fire department or first aid or civil defense or other such department;(d) any college, school or other institution of learning, or a school district or districts or school jurisdictional unit, or the head or principal or governing board thereof;(e) any organization for health, recreational or military instruction or treatment;(f) any automobile club, underwriters' corps, salvage bureau or like organization;(g) any trade union or other association of wage workers described in section twenty-nine;(h) the trustees of a fund established by 2 or more employers in the same industry or by 1or more of such trade unions or associations of wage workers, or by 1 or more employers and 1 or more of such trade unions or associations;(i) any association of employers or employees in the same or related industry having a constitution and by-laws and formed in good faith for purposes other than that of obtaining insurance for its association members and employees, under which the officers, members of the union or unions, or of the association or associations, or employees of the employer or employers, or classes or departments thereof, or the students or patients thereof, as the case may be, are insured against loss or damage from disease or specified accidental bodily injuries, or death caused by such injuries, contracted or sustained while exposed to the hazards of the occupation, the course of instruction or treatment, or otherwise, for a premium intended to cover the risks of all persons insured under such policy;(j) a bank, association, financial or other institution, vendor, or to a parent holding company, or to the trustee, trustees or agent designated by one or more banks, associations, financial or other institutions, or vendors under which debtors, guarantors or purchasers are insured against loss of time resulting from disease or specified bodily injuries, in an amount with respect to each obligation not to exceed the lesser of the total of the scheduled payments on the obligation, or $125,000 of principal obligation plus finance charges; provided, however, that no person shall be insured under any said policy for a period of more than fifteen years with respect to each said obligation; provided, further, that where the coverage is for less than the full amount of said obligation, the periodic benefit payment shall cover either the full amount of each periodic payment on said obligation or the maximum periodic benefit set forth in said policy until the maximum aggregate benefit of said policy is reached; and provided, further, that said $125,000 limitation and said fifteen year period limitation contained in this clause shall not apply to said insurance for which no identifiable charge is made to the debtor, co-debtor or guarantor;(k) an incorporated or unincorporated religious, charitable, recreational, educational or civic organization, or branch thereof;(l) a restaurant, hotel, motel, resort, innkeeper, or other group with a high degree of potential customer liability;(m) a travel agency, or other organization that arranges travel related services;(n) a sports team, camp or sponsor thereof;(o) a common carrier or operator, owner or lessee of a means of transportation;(p) an incorporated or unincorporated association or persons having a common interest or calling forms for purposes other than obtaining insurance;(q) under a policy or contract issued to a bank, association, financial or other institution, vendor, or to a parent holding company, or to the trustee, trustees or agent designated by one or more banks, associations, financial or other institutions, or vendors, which shall be deemed the policyholder, covering accountholders, debtors, guarantors, or purchasers;(r) any other risk or class of risks which, in the discretion of the commissioner, may be properly eligible for a general or blanket policy. The discretion of the commissioner may be exercised on an individual risk basis or class of risks, or both. Any general or blanket policy which qualifies as creditable coverage pursuant to chapter 111M and is delivered or issued for delivery in the commonwealth, and any certificate and the schedule of premium charges issued in connection with such policy, shall be furnished to the commissioner upon his request. Any such policy on which the premiums are paid by the policyholder wholly from the employer's funds or funds contributed by him, insuring all eligible employees, shall be deemed a general or blanket policy within the meaning of this section. Any such policy on which the premiums are paid by the policyholder, either partly from the employer's funds or funds contributed by him and partly from funds contributed by the insured employees, or wholly from funds contributed by the insured employees, and the benefits of which are offered to all eligible employees, and insuring not less than 75 per cent of such employees or not less than 8,000 of such employees who are principally employed within the commonwealth, or the members of an association of such employees if the members so insured constitute not less than 75 per cent of all eligible employees or not less than 8,000 of such employees who are principally employed within the commonwealth, shall be deemed a general or blanket policy within the meaning of this section. Any general or blanket policy which does not qualify as creditable coverage pursuant to chapter 111M and is delivered or issued for delivery in the commonwealth, and any certificate and the schedule of premium charges issued in connection with that policy, shall be furnished to the commissioner upon request thereby. Any such policy on which the premiums are paid by the policyholder wholly from the employer's funds or funds contributed by him, insuring all eligible employees, shall be considered a general or blanket policy within the meaning of this section. Any such policy on which the premiums are paid by the policyholder, either partly from the employer's funds or funds contributed by him and partly from funds contributed by the insured employees, or wholly from funds contributed by the insured employees, and the benefits of which are offered to all eligible employees shall be considered a general or blanket policy within the meaning of this section. A policy which qualifies as creditable coverage pursuant to chapter 111M and on which the premiums are paid by the trustees of a fund, described in clause (h), wholly from funds contributed by the employer or employers of the employees, or by the union or association, or by the union or associations, or by both, or the premiums on which are paid by such trustees partly from such funds contributed by the employer or employers of the employees, or by the union or unions or association or associations, or both, and partly from funds contributed by the insured persons specifically for their insurance, and insuring all employees of the employer or employers or all the members of the union or unions or association or associations, or all of any class or classes thereof determined by conditions pertaining to their employment, or to membership in the union or unions, or association or associations, or to both, or a policy issued to the trustees of a fund established by 1 or more employers and 1 or more such trade unions or associations, the premiums on which are paid by such trustees partly from such funds contributed by the employers, unions or associations, or both, and partly from funds contributed by the insured persons specifically for their insurance, and the benefits of which are offered to all eligible persons, and insuring not less than 75 per cent of such eligible employees of the employer or employers or of such eligible members of the union or unions or association or associations, who remit funds for premium payments to the trustees, shall also be deemed a general or blanket policy within the meaning of this section. A policy which does not qualify as creditable coverage pursuant to chapter 111M and on which the premiums are paid by the trustees of a fund, described in clause (h), wholly from funds contributed by the employer or employers of the employees, or by the union or association, or by the unions or associations, or by both, or on which the premiums are paid by the trustees partly from funds contributed by the employer or employers of the employees, or by the union or unions or association or associations, or both, and partly from funds contributed by the insured persons specifically for their insurance, and insuring all eligible employees of the employer or employers or all the eligible members of the union or unions or association or associations, or all eligible employees or members of any class or classes thereof determined by conditions pertaining to their employment, or to membership in the union or unions, or association or associations, or to both, or such a policy on which the premiums are paid by the trustees partly or wholly from funds contributed by the insured persons specifically for their insurance the benefits of which are offered to all eligible employees of the employer or employers or all eligible members of the union or unions or association or associations, or all eligible employees or members of any class or classes thereof determined by conditions pertaining to their employment, or to membership in the union or unions, or association or associations, or to both, or such a policy issued to the trustees of a fund established by 1 or more employers and 1 or more trade unions or associations, the premiums on which are paid by the trustees partly from funds contributed by the employers, unions or associations, or both, and partly or wholly from funds contributed by the insured persons specifically for their insurance, and the benefits of which are offered to all eligible persons, who remit funds for premium payments to the trustees, shall also be considered a general or blanket policy within the meaning of this section. In the case of a policy which does not qualify as creditable coverage pursuant to chapter 111M and which is issued to a trade union or association under clause (g) on which the premiums are to be paid by the trade union or association, or the trade union, association and its members jointly, or wholly by its members, and the benefits of the policy are offered to all eligible members, shall also be considered a general or blanket policy within the meaning of this section. In case of a policy which qualifies as creditable coverage pursuant to chapter 111M and is issued to a trade union or association under clause (g) on which the premium is to be paid by the trade union or association and its members jointly, or by its members, and the benefits of the policy are offered to all eligible members, not less than 75 per cent or not less than 8,000 of such members principally employed within the commonwealth may be so insured. In any general or blanket policy issued under clause (a), the word ''employees'' may include the officers, managers and employees of subsidiary or affiliated corporations, and the individual proprietors, partners and employees of affiliated individuals and firms, if the business of the employer and of such subsidiary or affiliated corporations, firms or individuals is under common control, through stock ownership, contract or otherwise. Any general or blanket policy issued under this section may provide that the term ''employees'' shall include retired employees, former employees, the partners or individual proprietors, if an employer is a partnership or an individual proprietor, and if such partners or proprietors are actively engaged in and devote a substantial part of their time to the conduct of the business of the proprietor or partnership; and the trustees or their employees, or both, if their duties are principally connected with such trusteeship.(B)(1) The employer, whether an individual, corporation, co-partnership or association, or a municipal corporation or department thereof, including a police or fire department or volunteer fire department, in case of such a general or blanket policy issued by a domestic mutual life or other domestic mutual company to such employer; or (2) the college, school or other institution of learning, in case of such a policy so issued to such institution; or (3) the head or principal of the college, school or other institution of learning, in case of such a policy so issued to the head or principal of such institution; or (4) such person as the organization for health, recreation or military instruction or treatment, the automobile club, the underwriters' corps, salvage bureau or like organization or the trade union or association of workers, or an association described in subdivision (C) of this section shall designate, in case of such a policy issued to such organization or union or association; or (5) such person as the trustees of a fund established as described in clause (a) or clause (h) of subdivision (A) of this section shall designate, in case of such a policy so issued to such trustees; or (6) a newspaper or newspaper distributor described in subdivision (D); or (7) a bank, association, financial or other institution or vendor described in clause (j) of subdivision (A) or, in the case of such a policy issued to the trustee or trustees designated by two or more banks, associations, financial or other institutions or vendors such person as the trustee or trustees shall designate, shall alone be a member of the company and entitled to one vote by virtue of such policy at the meetings of the company.(C) Nothing in sections one hundred and eight and one hundred and nine shall be construed to apply to or affect or prohibit the issue of any general or blanket policy of insurance to any association of state, county or municipal employees who are regularly and permanently employed by the commonwealth, a county or a municipality and, if employed by the commonwealth or the city of Boston are paid by a common paymaster, as defined in section one hundred and thirty-three, and are eligible for membership in the retirement association for the employees of the commonwealth or of the city of Boston, or to an association of employees of two or more municipalities within one county who are regularly and permanently employed by one or more such municipalities, insuring the members of the association against loss or damage from disease or specified accidental bodily injuries or death caused by such injuries, contracted or sustained while exposed to the hazards of their occupation, for a premium intended to cover the risks of all the persons insured under such policy. No person shall be eligible for coverage under such a policy as a member of more than one such association. A policy which qualifies as creditable coverage pursuant to chapter 111M and on which the premium is paid by the members of the association and the benefits of which are offered to all its members, and insuring not less than fifty members and seventy-five per cent of all persons eligible for membership in the association or not less than eight thousand such persons principally employed within the commonwealth shall be deemed to be a general or blanket policy within the meaning of this section. A policy which does not qualify as creditable coverage pursuant to chapter 111M and on which the premiums are paid by the members of the association and the benefits of which are offered to all of its members shall be considered to be a general or blanket policy within the meaning of this section. The provisions of section one hundred and thirty-eight A shall apply to deductions on pay-roll schedules from the salary of any state, county or municipal employee for the payment of premiums on a general or blanket policy issued to such an association of state, county or municipal employees.(D) Nothing in section one hundred and eight shall be construed to apply to or affect or prohibit the issue of any general or blanket policy of insurance to any newspaper or newspaper distributor employing independent contractor newspaperboys under which the independent contractor newspaperboys associated therewith, are insured against loss or damage from disease or specified accidental bodily injuries or death caused by such injuries, contracted or sustained while exposed to the hazards of their occupation, for a premium intended to cover the risks of all persons insured under such policy which qualifies as creditable coverage pursuant to chapter 111M. A policy which qualifies as creditable coverage pursuant to chapter 111M and on which the premiums are paid by a newspaper or newspaper distributor wholly from funds of or contributed by such newspaper or newspaper distributor insuring all eligible employees, shall be deemed a general or blanket policy within the meaning of this section. A policy on which the premiums are paid by the policy holder, either partly from funds of or contributed by such policy holder and partly from funds contributed by the insured independent contractor newspaperboys or wholly from funds contributed by such newspaperboys and the benefits of which are offered to all eligible newspaperboys, and insuring not less than seventy-five per cent of all eligible newspaperboys shall be deemed to be a general or blanket policy within the meaning of this section. A policy which does not qualify as creditable coverage pursuant to chapter 111M and on which the premiums are paid by the policy holder, either partly from funds of or contributed by the policy holder and partly from funds contributed by the insured independent contractor newspaperboys or wholly from funds contributed by the newspaperboys and the benefits of which are offered to all eligible newspaperboys shall be considered to be a general or blanket policy within the meaning of this section.(E) Any blanket or general policy issued under subdivision (A), (C) or (D) of this section may also insure the dependents of employees or members or other persons insured thereunder in respect to medical, surgical and hospital expenses, and the employees or members or other persons may contribute part or all of the premium for such insurance.(F) Notwithstanding any provision of any policy of insurance issued by a company, whenever such a policy provides for reimbursement for any visual services which are within the lawful scope of the practice of a duly registered optometrist, reimbursement thereunder shall be made to either the registered optometrist or the registered physician of the insured's selection. Visual services, as such term appears in the preceding sentence, shall mean the optometric services ordinarily provided by registered optometrists and physicians as set forth in chapter one hundred and twelve.(G) For purposes of this section the term ''notice of a claim'' shall mean any notification whether in writing or otherwise, to an insurer or its authorized agent, by any person, firm, association, or corporation asserting right to payment under a policy of insurance which reasonably apprises the insurer of the existence of a claim.Within fifteen days after an insurer's receipt of notice of claim by a claimant under a general or blanket policy of accident and sickness insurance which is delivered or issued for delivery in the commonwealth, and which provides hospital expense, medical expense, surgical expense or dental expense insurance, the insurer shall furnish such forms as are usually furnished by it for filing proofs of loss. Within forty-five days from said receipt of notice if payment is not made the insurer shall notify the claimant in writing specifying the reasons for the nonpayment or whatever further documentation is necessary for payment of said claim within the terms of the policy. If the insurer fails to comply with the provisions of this paragraph, said insurer shall pay, in addition to any benefits which inure to such claimant or provider, interest on such benefits, which shall accrue beginning forty-five days after the insurer's receipt of notice of claim at the rate of one and one-half percent per month, not to exceed eighteen percent per year. The provisions of this paragraph relating to interest payments shall not apply to a claim which an insurer is investigating because of suspected fraud.[There is no subdivision (H).]

(I) Whenever any general or blanket policy of insurance delivered or issued for delivery in the commonwealth under the provisions of this section provides for reimbursement for any podiatric service which is within the lawful scope of practice of a duly licensed podiatrist, a policyholder shall be entitled to reimbursement for such service, whether the service is performed by a physician or duly licensed podiatrist.

(J) For the purposes of computing any percentage participation requirement established by this section, eligible persons in a group who are enrollees under a group health maintenance contract, as defined in section one of chapter one hundred and seventy-six G, shall be deemed to be persons insured under a blanket or general policy authorized by this section.

(K) No group medical benefits contract shall be delivered or issued or renewed for delivery by an insurance company, to any group of persons in this Commonwealth and no employees health and welfare funds shall be promulgated or renewed to any group of persons in this Commonwealth unless persons covered under such group contract or fund will be eligible for benefits for expenses arising from the provisions of home care services. As used in this subdivision, the words ''Home care services'' shall mean health care services for a patient provided by a public or private home health agency which meets the standards of service of the purchaser of service, provided in a patient's residence; provided, however, that such residence is neither a hospital nor an institution primarily engaged in providing skilled nursing or rehabilitation services. Said services shall include, but not be limited to, nursing and physical therapy. Additional services such as occupational therapy, speech therapy, medical social work, nutritional consultation, the services of a home health aid and the use of durable medical equipment and supplies shall be provided to the extent such additional services are determined to be a medically necessary component of said nursing and physical therapy. Benefits for home care services shall apply only when such services are medically necessary and provided in conjunction with a physician approved home health services plan.

(L) Any blanket or general policy of insurance described in subdivision (A), (C) or (D) of this section, which is delivered or issued for delivery within or without the commonwealth and which covers residents of the commonwealth and any employees health and welfare fund which is promulgated or renewed to any person or group of persons in the commonwealth shall provide benefits for expense of cytologic screening and mammographic examinations which are at least equal to the following minimum requirements: (a) in the case of benefits for cytologic screening, said benefit shall provide for an annual cytologic screening for women eighteen years of age and older; and (b), in the case of benefits for mammographic examination, said benefits shall provide for a baseline mammogram for women between the ages of thirty-five and forty and for a mammogram on an annual basis for women forty years of age and older.

(M) An insurer authorized to issue or deliver within the commonwealth any general or blanket policy of insurance under the provisions of this section shall not refuse to contract with or compensate for covered services an otherwise eligible provider or nonparticipating provider solely because such provider has in good faith communicated with one or more of his current, former or prospective patients regarding the provisions, terms or requirements of the insurer's products as they relate to the needs of such provider's patients. In contracting with a provider of home health services or a licensed hospice agency, an insurer shall not require the provider or agency to be accredited by the Joint Commission on Accreditation of Healthcare Organizations or other national accrediting body if the provider is certified for participation in the Medicare program, Title XVIII of the federal Social Security Act, 42 U.S.C. Sections 1395 et seq.

(N)(1) For purposes of this subdivision, the following words shall, unless the context clearly requires otherwise, have the following meanings:—

''Carrier'', a health maintenance organization authorized under chapter 176G, an insurance company authorized to provide accident and health insurance under this chapter, a nonprofit hospital service corporation authorized under chapter 176A, a nonprofit medical service corporation authorized under chapter 176B, or any other entity responsible for the payment of benefits or provision of services under a group contract.

''Replacement'', the benefits provided by a succeeding carrier.

''Discontinuance'', the termination of the contract between the group contract holder and a health maintenance organization authorized under chapter 176G due to the insolvency of the health maintenance organization. The word ''discontinuance'' does not refer to the termination of any agreement between any individual enrollee and the health maintenance organization.

(2)(a) In the event of an insolvency of a health maintenance organization, upon order of the commissioner, all other carriers that participated in the enrollment process with the insolvent health maintenance organization at a group's last regular enrollment period shall offer such group's enrollees of the insolvent health maintenance organization a 30 day enrollment period commencing upon the date of insolvency. Each carrier shall offer such enrollees of the insolvent health maintenance organization the same coverages and rates that it had offered to the enrollees of the group at its last regular enrollment period.

(b) If no other carrier had been offered to some groups whose members were enrolled in the insolvent health maintenance organization, or if the commissioner determines that the other carriers lack sufficient health care delivery resources to assure that health care services will be available and accessible to all of the group's enrollees of the insolvent health maintenance organization, then the commissioner shall allocate equitably the insolvent health maintenance organization's group contracts for such groups among all health maintenance organizations that operate within a portion of the insolvent health maintenance organization's service area as provided in paragraph (2) of subsection (b) of section 23 of chapter 176G.

(3)(a) Any carrier providing replacement coverage with respect to group hospital, medical or surgical expense or service benefits within 60 days from the date of discontinuance of a prior health maintenance organization contract or policy providing such hospital, medical or surgical expense or service benefits shall immediately cover all enrollees who were validly covered under the previous health maintenance organization contract or policy at the date of discontinuance and who would otherwise be eligible for coverage under the succeeding carrier's contract, regardless of any provisions of the contract relating to active employment or hospital confinement or pregnancy.

(b) Except to the extent benefits for the condition would have been reduced or excluded under the prior carrier's contract or policy, no provision in a succeeding carrier's contract 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 contract shall be applied with respect to those enrollees validly covered under the prior carrier's contract or policy on the date of discontinuance.

(O) An insurer authorized to issue or deliver within the commonwealth any general or blanket policy of insurance under this section may only contract to sell any general or blanket policy of insurance, except policies or certificates that are not health benefit plans, as defined in section 1 of chapter 176J, with an employer if the insurance is offered by that employer to all full-time employees who live in the commonwealth; provided, however, the employer shall not make a smaller health insurance premium contribution percentage amount to an employee than the employer makes to any other employee who receives an equal or greater total hourly or annual salary for each specific or general blanket policy of insurance for all employees. Notwithstanding the foregoing, a carrier may enter into a general or blanket policy of insurance with an employer that establishes separate contribution percentages for employees covered by collective bargaining agreements.

(P) A blanket or general policy of insurance described in subdivision (A), (C) or (D), except policies or certificates that are not health benefit plans, as defined in section 1 of chapter 176J, or coverage to Medicare or other governmental programs which shall be delivered, issued or renewed in the commonwealth, shall provide, as benefits to all group members having a place of employment in the commonwealth, coverage to dependent persons under 26 years of age or without regard to age, so long as the dependent, who is covered under the membership of their parent as a member of a family group, is mentally or physically incapable of earning their own living due to disability.