§ 26-22-202 — Issuance of a converted policy; conditions

(a) Issuance of a converted policy is subject to the
following conditions:
(i) Written application for the converted policy
shall be made and the first premium paid to the insurer not
later than thirty-one (31) days after termination of the
insured's coverage by the group policy and termination of the
subsequent continuation rights offered by the group policy;
(ii) The effective date of the converted policy is
the day following the termination of the insured's coverage
under the group policy and termination of the subsequent
continuation rights offered by the group policy;
(iii) The converted policy shall:
(A) Cover the employee or member and his
dependents who were covered by the group policy on the date of
termination of insurance, and at the insurer's option, a
separate converted policy may be issued to cover any dependent;
(B) Be issued without evidence of insurability;
(C) Not exclude a preexisting condition not
excluded by the group policy.
(iv) The insurer is not required to issue a converted
policy:
(A) Covering any person if the person is or
could be covered by Medicare (Title XVIII of the United States
Social Security Act as added by the Social Security Amendments
of 1965 or as later amended or superseded);
(B) Covering any person if:
(I) The person is covered for similar
benefits by another hospital, surgical, medical or major medical
expense insurance policy or hospital or medical service
subscriber contract or medical practice or other prepayment plan
or by any other plan or program; or
(II) The person is eligible for similar
benefits, whether or not covered therefor, under any arrangement
of coverage for individuals in a group, whether on an insured or
uninsured basis; or
(III) Similar benefits are provided for or
available to the person, pursuant to or in accordance with the
requirements of any state or federal law; and
(IV) The benefits provided under the
sources referred to in subdivision (B)(I) of this paragraph for
the person or benefits provided or available under the sources
referred to in subdivisions (B)(II) and (III) of this paragraph
for the person, together with the benefits provided by the
converted policy, would result in overinsurance according to the
insurer's standards. The insurer's standards must bear some
reasonable relationship to actual health care costs in the area
in which the insured lives at the time of conversion and must be
filed with the commissioner prior to their use in denying
coverage;
(V) Which provides benefits in excess of
those provided under the group policy from which conversion is
made.
(v) A converted policy may:
(A) Include a provision whereby the insurer may
request information in advance of any premium due date of the
policy of any person covered thereunder as to whether:
(I) He is covered for similar benefits by
another hospital, surgical, medical or major medical expense
insurance policy or hospital or medical service subscriber
contract or medical practice or other prepayment plan or by any
other plan or program;
(II) He is covered for similar benefits
under any arrangement of coverage for individuals in a group,
whether on an insured or uninsured basis; or
(III) Similar benefits are provided for or
available to the person, pursuant to or in accordance with the
requirements of any state or federal law.
(B) Provide that the insurer may refuse to renew
the policy or the coverage of any person insured thereunder for
the following reasons only:
(I) Either the benefits provided under the
sources referred to in subdivisions (A)(I) and (II) of this
paragraph for the person or benefits provided or available under
the sources referred to in subdivision (A)(III) of this
paragraph for the person, together with the benefits provided by
the converted policy, would result in overinsurance according to
the insurer's standards on file with the commissioner, or the
converted policyholder fails to provide the requested
information;
(II) Fraud or material misrepresentation in
applying for any benefits under the converted policy;
(III) Eligibility of the insured person for
coverage under Medicare (Title XVIII of the United States Social
Security Act as added by the Social Security Amendments of 1965
or as later amended or superseded) or under any other state or
federal law providing for benefits similar to those provided by
the converted policy;
(IV) Other reasons the commissioner
approves.
(C) Provide that any hospital, surgical or
medical benefits payable thereunder may be reduced by the amount
of any such benefits payable under the group policy after the
termination of the individual's insurance under the group
policy;
(D) Provide that during the first policy year
the benefits payable under the converted policy, together with
the benefits payable under the group policy, shall not exceed
those that would have been payable had the individual's
insurance under the group policy remained in force and effect;
(E) Provide for reduction of coverage on any
person upon his eligibility for coverage under Medicare (Title
XVIII of the United States Social Security Act as added by the
Social Security Amendments of 1965 or as later amended or
superseded) or under any other state or federal law providing
for benefits similar to those provided by the converted policy.
(vi) Subject to the provisions and conditions of this
section:
(A) If the group insurance policy from which
conversion is made insures the employee or member for:
(I) Basic hospital or surgical expense
insurance, the employee or member is entitled to obtain a
converted policy providing, at his option, coverage on an
expense incurred basis under any one (1) of the plans meeting
the following requirements:
(1) Plan A:
a. Hospital room and board daily
expense benefits in a maximum dollar amount approximating the
average semiprivate rate charged in metropolitan areas of this
state, for a maximum duration of seventy (70) days;
b. Miscellaneous hospital expense
benefits of a maximum amount of ten (10) times the hospital room
and board daily expense benefits; and
c. Surgical operation expense
benefits according to a surgical schedule consistent with those
customarily offered by the insurer under group or individual
health insurance policies and providing a maximum benefit of
eight hundred dollars ($800.00); or
(2) Plan B:
a. Hospital room and board daily
expense benefits in a maximum dollar amount equal to
seventy-five percent (75%) of the maximum dollar amount
determined for Plan A, for a maximum duration of seventy (70)
days;
b. Miscellaneous hospital expense
benefits of a maximum amount of ten (10) times the hospital room
and board daily expense benefits; and
c. Surgical operation expense
benefits according to a surgical schedule consistent with those
customarily offered by the insurer under group or individual
health insurance policies and providing a maximum benefit of six
hundred dollars ($600.00); or
(3) Plan C:
a. Hospital room and board daily
expense benefits in a maximum dollar amount equal to fifty
percent (50%) of the maximum dollar amount determined for Plan
A, for a maximum duration of seventy (70) days;
b. Miscellaneous hospital
benefits of a maximum amount of ten (10) times the hospital room
and board daily expense benefits; and
c. Surgical operation expense
benefits according to a surgical schedule consistent with those
customarily offered by the insurer under group or individual
health insurance policies and providing a maximum benefit of
four hundred dollars ($400.00);
d. The maximum dollar amounts in
Plan A shall be determined by the commissioner and may be
redetermined by him from time to time as to converted policies
issued subsequent to the redetermination, except that no
redetermination shall be made more often than once in three (3)
years and the maximum dollar amounts in Plans A, B and C shall
be rounded to the nearest multiple of ten dollars ($10.00).
(II) Major medical expense insurance, the
employee or member is entitled to obtain a converted policy
providing catastrophic or major medical coverage under a plan
meeting the following requirements:
(1) A maximum benefit at least equal
to either, at the insurer's option, subdivisions (1) or (2) of
this subdivision:
a. The smaller of the following
amounts:
i. The maximum benefit
provided under the group policy;
ii. A maximum payment of two
hundred fifty thousand dollars ($250,000.00) per covered person
for all covered medical expenses incurred during the covered
person's lifetime.
b. The smaller of the following amounts:
(2) Payment of benefits at the
rate of eighty percent (80%) of covered medical expenses which
are in excess of the deductible, until twenty percent (20%) of
those expenses in a benefit period reaches one thousand dollars
($1,000.00), after which benefits will be paid at the rate of
one hundred percent (100%) during the remainder of the benefit
period, except that payment of benefits for outpatient treatment
of mental illness, if provided in the converted policy, may be
at a lesser rate but not less than fifty percent (50%);
i. The maximum benefit
provided under the group policy;
ii. A maximum payment of two
hundred fifty thousand dollars ($250,000.00) for each unrelated
injury or sickness.
(3) A deductible for each benefit
period which, at the insurer's option, shall be either the sum
of the benefits deductible and one hundred dollars ($100.00), or
the corresponding deductible in the group policy.
(B) The conversion privilege shall also be
available to:
(I) The surviving spouse, if any, at the
death of the employee or member, with respect to the spouse and
the children whose coverage under the group policy terminates by
reason of the death, otherwise to each surviving child whose
coverage under the group policy terminates by reason of the
death, or if the group policy provides for continuation of
dependent's coverage following the employee's or member's death,
at the end of the continuation;
(II) The spouse of the employee or member
upon termination of coverage of the spouse, while the employee
or member remains insured under the group policy, by reason of
ceasing to be a qualified family member under the group policy,
with respect to the spouse and the children whose coverage under
the group policy terminates at the same time; or
(III) A child solely with respect to
himself upon termination of his coverage by reason of ceasing to
be a qualified member under the group policy, if a conversion
privilege is not otherwise provided in this section with respect
to the termination.
(vii) If the maximum benefit is determined by
subdivision (A)(II)(1)b. of this paragraph, the insurer may
require that the deductible be satisfied during a period of not
less than three (3) months if the deductible is one hundred
dollars ($100.00) or less, and not less than six (6) months if
the deductible exceeds one hundred dollars ($100.00);
(viii) The benefit period shall be each calendar year
when the maximum benefit is determined by subdivision (A)(II)(1)
of this paragraph or twenty-four (24) months when the maximum
benefit is determined by subdivision (A)(II)(1)b. of this
paragraph;
(ix) Any surgical schedule shall be consistent with
those customarily offered by the insurer under group or
individual health insurance policies and shall provide at least
a one thousand two hundred dollar ($1,200.00) maximum benefit;
(x) As used in paragraph (vi) of this subsection:
(A) "Benefits deductible" means the value of any
benefits provided on an expense incurred basis which are
provided with respect to covered medical expenses by any other
hospital, surgical or medical insurance policy or hospital or
medical service subscriber contract or medical practice or other
prepayment plan, or any other plan or program whether on an
insured or uninsured basis, or in accordance with the
requirements of any state or federal law and, if pursuant to
paragraph (viii) of this subsection, the converted policy
provides both basic hospital or surgical coverage and major
medical coverage, the value of the basic benefits;
(B) "Covered medical expenses" includes, at
least, in the case of hospital room and board charges, the
lesser of the dollar amount in Plan A and the average
semiprivate room and board rate for the hospital in which the
individual is confined and twice that amount for charges in an
intensive care unit.
(xi) The conversion privilege required by this
section shall, if the group insurance policy insures the
employee or member for basic hospital or surgical expense
insurance as well as major medical expense insurance, make
available the plans of benefits set forth in paragraph (vi) of
this subsection;
(xii) An insurer may:
(A) Provide the plans of benefits specified in
paragraph (vi) of this subsection under one (1) policy;
(B) Instead of the plans of benefits set forth
in paragraph (vi) of this subsection, provide a policy of
comprehensive medical expense benefits without first dollar
coverage, which policy shall conform to the requirements of
subparagraph (vi)(B) of this subsection, except that an insurer
electing to provide such a policy shall make available a low
deductible option, not to exceed one hundred dollars ($100.00),
a high deductible option between five hundred dollars ($500.00)
and one thousand dollars ($1,000.00) and a third deductible
option midway between the high and low deductible options;
(C) Offer alternative plans for group health
conversion in addition to those required by this section;
(D) Provide group insurance coverage instead of
issuing a converted individual policy.
(xiii) If coverage would be continued under the group
policy on an employee following his retirement prior to the time
he is or could be covered by Medicare, he may elect instead of
continuation of group insurance, to have the same conversion
rights as would apply if his insurance terminated at retirement
by reason of termination of employment or membership;
(xiv) If the benefit levels required in paragraph
(vi) of this subsection exceed the benefit levels provided under
the group policy, the conversion policy may offer benefits which
are substantially similar to those provided under the group
policy instead of those required in paragraph (vi) of this
subsection;
(xv) Maternity benefits may be included at the
insured's option and may be subject to the preexisting
conditions limitations as discussed under paragraph (v) of this
subsection;
(xvi) A notification of the conversion privilege
shall be included in each certificate of coverage;
(xvii) A converted policy which is delivered outside
this state must be on a form which could be delivered in the
other jurisdiction as a converted policy had the group policy
been issued in that jurisdiction.
ARTICLE 3
PREPAID HOSPITAL, MEDICAL-SURGICAL OR OTHER
HEALTH SERVICE PLANS