§ 27-18-79 — § 27-18-79. Discretionary clauses.

§ 27-18-79. Discretionary clauses.

(a) No new or existing policy or certificate issued by an insurer or healthcare entity may contain any provision:

(1) Purporting to reserve sole discretion to the insurer or healthcare entity to determine eligibility for benefits or interpret the terms of a policy or certificate; or

(2) Specifying or affecting a standard of review upon which a court may review denial of a claim or any other decision made by an insurance company with respect to a policyholder or certificate holder.

(b) For purposes of this section, "healthcare entity� means a health insurance company or nonprofit hospital or medical or dental service corporation or plan or health maintenance organization that operates or administers a health plan in this state.

(c) Any such clause or language included in a contract, policy, or certificate issued to or covering a resident of this state that is contrary to or inconsistent with the provisions of this section is void and unenforceable.

(d) Nothing in this section prohibits an insurer from including a provision in a contract that informs an insured that as part of its routine operations the insurer applies the terms of its contracts for making decisions, including making determinations regarding eligibility, receipt of benefits and claims, or explaining policies, procedures, and processes, so long as the provision could not give rise to a deferential standard of review by any reviewing court.

Legislative History

P.L. 2013, ch. 85, § 2; P.L. 2013, ch. 94, § 2.