§ 26-13-305 — 26-13-304. Discretionary clause prohibited

Wyoming § 26-13-305

• Jurisdiction: Wyoming
• Title 26: Insurance Code
• Ch. 13: TRADE PRACTICES AND FRAUDS

Text

(a) No policy, contract, certificate or agreement offered
or issued in this state by a health carrier to provide, deliver,
arrange for, pay for or reimburse any of the costs of health
care services may contain a provision purporting to reserve
discretion to the health carrier to interpret the terms of the
contract, or to provide standards of interpretation or review
that are inconsistent with the laws of this state. This
subsection shall not apply to a policy, contract, certificate or
agreement subject to and meeting the requirements of subsections
(b) and (c) of this section.
(b) Any group policy, contract, certificate or agreement
subject to the federal Employee Retirement Income Security Act
and offered or issued in this state by a health carrier to
provide, deliver, arrange for, pay for or reimburse any of the
costs of health care services and which contains a provision
purporting to reserve discretion to the health carrier to
interpret the terms of the contract or to provide standards of
interpretation or review shall contain the following language
highlighted in bold in not less than twelve (12) point type:
This benefit plan contains a discretionary clause.
Determinations made by (insurer name) pursuant to the
discretionary clause do not prohibit or prevent a claimant from
seeking judicial review in court of (insurer name's) decisions.
By including this discretionary clause (insurer's name) agrees
to allow a court to review its determinations anew when a
claimant seeks judicial review of (insurer name's)
determinations of eligibility of benefits, the payment of
benefits or interpretations of the terms and conditions
applicable to the benefit plan.
(c) Any group policy, contract, certificate or agreement
containing a discretionary clause as authorized in subsection
(b) of this section shall contain a provision entitling any
person denied benefits in whole or in part to have the
determination reviewed de novo in any court with jurisdiction.