Table of Contents
Sec. 38a-469. Definitions.
Sec. 38a-470. (Formerly Sec. 38-174n). Lien on workers' compensation awards for insurers.
Notice of lien.
Sec. 38a-471. (Formerly Sec. 38-174o). Third party prescription programs. Notice of cancellation. Applicability of section.
Sec. 38a-472. (Formerly Sec. 38-174a). Assignment of insurance proceeds to doctor, hospital or state agency. Lien for state care. Notice of lien.
Sec. 38a-472a. Medical provider indemnification agreements prohibited.
Sec. 38a-472b. Medical provider indemnification contracts. Professional actions and related liability.
Sec. 38a-473. Medicare supplement expense factors. Age, gender, previous claim or medical
history rating prohibited. Exceptions.
Sec. 38a-474. Rate increases: Procedure. Age, gender, previous claim or medical history
rating prohibited. Exceptions.
Sec. 38a-475. Precertification of policies under the Connecticut Partnership for Long-
Term Care. Regulations.
Sec. 38a-476. Preexisting condition coverage.
Sec. 38a-476a. Compliance with the Health Insurance Portability and Accountability Act.
Guaranteed renewability. Discrimination based on health status, newborns' and mothers'
health prohibited. Parity of mental health benefits. Disclosure of information for employers. Construction. Application. Regulations.
Sec. 38a-477. Standardized claim forms. Regulations.
Sec. 38a-478. Definitions.
Sec. 38a-478a. Commissioner's report to the Governor and the General Assembly.
Sec. 38a-478b. Penalty for managed care organization's failure to file data and reports.
Commission's report to the Governor and the General Assembly on organizations that fail to
file data and reports.
Sec. 38a-478c. Managed care organization's report to the commissioner: Data, reports and
information required.
Sec. 38a-478d. List of providers required. Notification to enrollee of removal from list
of enrollee's primary care physician.
Sec. 38a-478e. Medical protocols. Procedure prior to change. Physician input. Notification of change.
Sec. 38a-478f. Provider profile development requirements.
Sec. 38a-478g. Managed care contract requirements. Plan description requirements.
Sec. 38a-478h. Removal of providers. Notice requirements. Retaliatory action prohibited.
Sec. 38a-478i. Limitation on enrollee rights prohibited.
Sec. 38a-478j. Coinsurance payments based on negotiated discounts.
Sec. 38a-478k. Gag clauses prohibited.
Sec. 38a-478l. Consumer report card required. Content.
Sec. 38a-478m. Internal grievance procedure. Duty to establish and notify enrollees of
procedure. Deadline for resolving complaints.
Sec. 38a-478n. Internal grievances. Appeal to the commissioner. Fees. Public education
outreach program.
Sec. 38a-478o. Confidentiality and antidiscrimination procedures required.
Sec. 38a-478p. Expedited utilization review. Standardized form required.
Sec. 38a-478q. Use of laboratories covered by plan required.
Sec. 38a-478r. Emergency rooms. Prudent layperson standard. Presenting symptoms or final
diagnosis as basis for coverage.
Sec. 38a-478s. ERISA. Workers' compensation. Nonapplicability.
Sec. 38a-478t. Commissioner of Public Health to receive data.
Sec. 38a-478u. Regulations.
Sec. 38a-478v. Applicability of Unfair and Prohibited Insurance Practices Act. Examination by Insurance Commissioner. Regulations.
Sec. 38a-479.
Sec. 38a-480. (Formerly Sec. 38-174). Nonapplication to certain policies or contracts.
Sec. 38a-481. (Formerly Sec. 38-165). Approval of individual health application and policy form by commissioner. Exception re Medicare supplement policy. Filing, form and minimum provisions of loss ratio guarantee. Regulations. Age, gender, previous claim or medical history rating prohibited. Exceptions. Optional life insurance riders.
Sec. 38a-482. (Formerly Sec. 38-166). Form of policy.
Sec. 38a-483. (Formerly Sec. 38-167). Standard provisions of individual health policy.
Sec. 38a-483a. Exclusionary riders for individual health insurance policies. Regulations.
Sec. 38a-483b. Time limits for coverage determinations. Notice requirements.
Sec. 38a-483c. Coverage and notice re experimental treatments. Appeals.
Sec. 38a-484. (Formerly Sec. 38-168). Policy provisions not to be less favorable than
standard. Validity of policy issued in violation of law.
Sec. 38a-485. (Formerly Sec. 38-169). Copy of application to be part of new policy or to
be furnished with renewal. Alteration of application.
Sec. 38a-486. (Formerly Sec. 38-170). Certain acts not to operate as waiver of rights.
Sec. 38a-487. (Formerly Sec. 38-171). Coverage after termination date of policy.
Sec. 38a-488. (Formerly Sec. 38-172). Discrimination.
Sec. 38a-488a. Mandatory coverage for the diagnosis and treatment of mental or nervous
conditions. Exceptions. Benefits payable re type of provider or facility. State's claim
against proceeds.
Sec. 38a-489. (Formerly Sec. 38-174e). Continuation of coverage of mentally or physically
handicapped children.
Sec. 38a-490. (Formerly Sec. 38-174g). Coverage for newborn infants in health insurance
policies. Notice. Application.
Sec. 38a-490a. Coverage for birth-to-three program.
Sec. 38a-491. (Formerly Sec. 38-174h). Coverage for services performed by dentists in
certain instances.
Sec. 38a-491a. Coverage for in-patient, outpatient or one-day dental services in certain
instances.
Sec. 38a-491b. Assignment of benefits to a dentist or oral surgeon.
Sec. 38a-492. (Formerly Sec. 38-174i). Coverage for accidental ingestion or consumption
of controlled drugs. Benefits prescribed.
Sec. 38a-492a. Mandatory coverage for hypodermic needles and syringes.
Sec. 38a-492b. Coverage for off-label drug prescriptions.
Sec. 38a-492c. Coverage for amino acid modified preparations and low protein modified
food products.
Sec. 38a-492d. Mandatory coverage for diabetes testing and treatment.
Sec. 38a-492e. Mandatory coverage for diabetes outpatient self-management training.
Sec. 38a-492f. Mandatory coverage for certain prescription drugs removed from formulary.
Sec. 38a-492g. Mandatory coverage for prostate cancer screening.
Sec. 38a-492h. Mandatory coverage for certain Lyme disease treatments.
Sec. 38a-492i. Mandatory coverage for pain management.
Sec. 38a-492j. Mandatory coverage for ostomy-related supplies.
Sec. 38a-493. (Formerly Sec. 38-174k). Mandatory coverage required in health insurance
for home health care.
Sec. 38a-494. (Formerly Sec. 38-174l). Home health care by recognized nonmedical systems.
Sec. 38a-495. (Formerly Sec. 38-174m). Medicare supplement policies. Coverage of home
health aid services and mammography. Prescription drug riders.
Sec. 38a-495a. Medicare supplement policies and certificates. Minimum required policy
benefits and standards. Regulations.
Sec. 38a-495b. Medicare supplement policies and certificates. Definitions.
Sec. 38a-495c. Premium rates charged on a community rate basis. Age, gender, previous
claim or medical history rating prohibited. Exceptions. Medicare supplement policies for
the disabled.
Sec. 38a-496. (Formerly Sec. 38-174q). Coverage for occupational therapy. Definitions.
Benefits.
Sec. 38a-497. (Formerly Sec. 38-174r). Termination of coverage of children in individual
policies.
Sec. 38a-497a. Group coverage and benefits of a noncustodial parent. Notification of new
employer by IV-D agency. Notification to custodial parent. Enrollment of child.
Sec. 38a-498. (Formerly Sec. 38-174t). Mandatory coverage for medically necessary ambulance services. Direct payment to ambulance provider.
Sec. 38a-498a. Preauthorization prohibited for certain 9-1-1 emergency calls.
Sec. 38a-499. (Formerly Sec. 38-174v). Mandatory coverage for services of physician assistants and certain nurses.
Sec. 38a-500. (Formerly Sec. 38-174w). Mandatory coverage for partners, sole proprietors
and corporate officers for work-related injuries. Subrogation rights.
Sec. 38a-501. (Formerly Sec. 38-174x). Long-term care policies.
Sec. 38a-502. (Formerly Sec. 38-174ff). Mandatory coverage for services provided by the
Veterans' Home and Hospital.
Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for mammography.
Sec. 38a-503a. Mandatory coverage for breast cancer survivors.
Sec. 38a-503b. Carriers to permit direct access to obstetrician-gynecologist.
Sec. 38a-503c. Mandatory coverage for maternity care. Notice required.
Sec. 38a-503d. Mandatory coverage for mastectomy care. Termination of provider contract
prohibited.
Sec. 38a-503e. Mandatory coverage for prescription contraceptives.
Sec. 38a-504. (Formerly Sec. 38-262i). Mandatory coverage for treatment of tumors and
leukemia. Mandatory coverage for reconstructive surgery, prosthesis and chemotherapy. Mandatory coverage for breast reconstruction after mastectomy.
Sec. 38a-505. (Formerly Sec. 38-378). Insurance Commissioner's powers concerning comprehensive health care plans. Notification to purchasers of policy.
Sec. 38a-506. (Formerly Sec. 38-173). Penalty.
Sec. 38a-507. Coverage for services performed by chiropractors.
Sec. 38a-508. Coverage for adopted children.
Secs. 38a-509 to 38a-511.
Sec. 38a-512. Applicability.
Sec. 38a-513. Approval of group health insurance policy forms. Age, gender, previous
claim or medical history rating prohibited. Exceptions. Optional life insurance riders.
Sec. 38a-513a. Time limits for coverage determinations. Notice requirements.
Sec. 38a-513b. Coverage and notice re experimental treatments. Appeals.
Sec. 38a-514. (Formerly Sec. 38-174d). Mandatory coverage for the diagnosis and treatment
of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State's claim against proceeds.
Sec. 38a-514a. Biologically-based mental illness. Coverage required.
Sec. 38a-515. Continuation of coverage of mentally retarded or physically handicapped dependent children.
Sec. 38a-516. Coverage for newborn infants in health insurance policies. Notice. Application.
Sec. 38a-516a. Coverage for birth-to-three program.
Sec. 38a-517. Coverage for services performed by dentist in certain instances.
Sec. 38a-517a. Coverage for in-patient, outpatient or one-day dental services in certain
instances.
Sec. 38a-517b. Assignment of benefits to a dentist or oral surgeon.
Sec. 38a-518. Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed.
Sec. 38a-518a. Mandatory coverage for hypodermic needles and syringes.
Sec. 38a-518b. Coverage for off-label drug prescriptions.
Sec. 38a-518c. Coverage for amino acid modified preparations and low protein modified
food products.
Sec. 38a-518d. Mandatory coverage for diabetes testing and treatment.
Sec. 38a-518e. Mandatory coverage for diabetes outpatient self-management training.
Sec. 38a-518f. Mandatory coverage for certain prescription drugs removed from formulary.
Sec. 38a-518g. Mandatory coverage for prostate cancer screening.
Sec. 38a-518h. Mandatory coverage for certain Lyme disease treatments.
Sec. 38a-518i. Mandatory coverage for pain management.
Sec. 38a-518j. Mandatory coverage for ostomy-related supplies.
Sec. 38a-519. (Formerly Sec. 38-174j). Offset proviso prohibited in certain policies.
Sec. 38a-520. Mandatory coverage required in health insurance for home health care.
Sec. 38a-521. Home health care by recognized nonmedical systems.
Sec. 38a-522. Medicare supplement policies. Coverage of home health aide service.
Sec. 38a-523. (Formerly Sec. 38-174p). Group hospital or medical insurance coverage for
comprehensive rehabilitation services.
Sec. 38a-524. Coverage for occupational therapy. Definitions. Benefits.
Sec. 38a-525. Mandatory coverage for emergency ambulance services. Direct payment to ambulance provider.
Sec. 38a-525a. Preauthorization prohibited for certain 9-1-1 emergency calls.
Sec. 38a-526. Mandatory coverage for services of physician assistants and certain nurses.
Sec. 38a-527. Mandatory coverage for partners, sole proprietors and corporate officers
for work-related injuries.
Sec. 38a-528. Long-term care policies.
Sec. 38a-529. Mandatory coverage for service provided by the Veterans' Home and Hospital.
Sec. 38a-530. Mandatory coverage for mammography.
Sec. 38a-530a. Mandatory coverage for breast cancer survivors.
Sec. 38a-530b. Carriers to permit direct access to obstetrician-gynecologist.
Sec. 38a-530c. Mandatory coverage for maternity care. Notice required.
Sec. 38a-530d. Mandatory coverage for mastectomy care. Termination of provider contract
prohibited.
Sec. 38a-530e. Mandatory coverage for prescription contraceptives.
Sec. 38a-531. (Formerly Sec. 38-174hh). Required coverage for certain employees. Approval
of policy forms.
Sec. 38a-532. (Formerly Sec. 38-262a). Assignment of incidents of ownership under group
life, health or accident policy.
Sec. 38a-533. (Formerly Sec. 38-262b). Mandatory coverage for the treatment of medical
complications of alcoholism.
Sec. 38a-534. Mandatory coverage for chiropractic services.
Sec. 38a-535. Mandatory coverage for preventive pediatric care.
Sec. 38a-535a. Notification of individual coverage and benefits of a noncustodial parent
to a custodial parent, when. Regulations.
Sec. 38a-536. Group hospital or medical expense insurance policy coverage for infertility.
Sec. 38a-537. (Formerly Sec. 38-262c). Notice of cancellation or discontinuation to covered employees. Fine. Notice of transfer of coverage. Failure to procure coverage. Retroactive coverage.
Sec. 38a-538. (Formerly Sec. 38-262d). Continuation of benefits under group employee
health plans.
Sec. 38a-539. (Formerly Sec. 38-262f). Group hospital or medical expense insurance policy
coverage for treatment of alcoholism on an outpatient basis.
Sec. 38a-540. (Formerly Sec. 38-262g). Duplication of coverage under group health insurance policies.
Sec. 38a-541. (Formerly Sec. 38-262h). Group health policy to allow spouse coverage as
both employee and dependent, when. Effect of collective bargaining agreements.
Sec. 38a-542. Mandatory coverage for treatment of tumors and leukemia. Mandatory coverage
for reconstructive surgery, prothesis and chemotherapy. Mandatory coverage for breast reconstruction after mastectomy.
Sec. 38a-543. (Formerly Sec. 38-262j). Age discrimination in group insurance coverage
prohibited.
Sec. 38a-544. Prescription drug coverage. Mail order pharmacies.
Sec. 38a-545. (Formerly Sec. 38-262k). Group dental health insurance plans. Alternative
coverage option.
Sec. 38a-546. (Formerly Sec. 38-379). Continuation of benefits under group health policies.
Sec. 38a-547. Termination of policy or contract due to insurer ceasing to offer health
insurance in this state; maternity benefits to continue for six weeks following termination of the pregnancy, when.
Sec. 38a-548. Penalty.
Sec. 38a-549. Coverage for adopted children.
Sec. 38a-550.
Sec. 38a-551. (Formerly Sec. 38-371). Definitions.
Sec. 38a-552. (Formerly Sec. 38-372). Applicability. Individual and group comprehensive
health care plans.
Sec. 38a-553. (Formerly Sec. 38-373). Minimum standard benefits of comprehensive health
care plans. Optional and excludable benefits. Managed care plans.
Sec. 38a-554. (Formerly Sec. 38-374). Additional requirements and eligibility under group
comprehensive health care plans. Continuation of benefits under group plans. Insurance
Commissioner's authority to coordinate benefits.
Sec. 38a-555. (Formerly Sec. 38-375). Additional requirements for individual comprehensive health care plans. Carrier obligations concerning termination of coverage.
Sec. 38a-556. (Formerly Sec. 38-376). Health Reinsurance Association. Classes of risk.
Audits. Insurance Commissioner's powers. Qualification as an acceptable alternative mechanism.
Sec. 38a-557. (Formerly Sec. 38-377). Hospital and medical service corporations. Residual
market mechanism. Insurance Commissioner's powers concerning such mechanisms.
Sec. 38a-558. (Formerly Sec. 38-380). Office of Health Care Access.
Sec. 38a-559. (Formerly Sec. 38-381). Commissioner of Social Services. Contract authority
concerning Medicaid programs.
Secs. 38a-560. Small employer grouping for health insurance coverage.
Secs. 38a-561 to 38a-563.
Sec. 38a-564. Definitions.
Sec. 38a-565. Special health care plans.
Sec. 38a-566. Health insurance plans or insurance arrangements covering employees of a
small employer. Trusts. Trade associations. Self-employed individuals.
Sec. 38a-567. Provisions of small employer plans and arrangements.
Sec. 38a-568. Coverage under small employer health care plans and arrangements. Approval
by commissioner.
Sec. 38a-569. Connecticut Small Employer Health Reinsurance Pool.
Sec. 38a-570. Issuance of special health care plans by the Health Reinsurance Association
to small employers.
Sec. 38a-571. Issuance of individual special health care plans by the Health Reinsurance
Association.
Sec. 38a-572. Requirement to provide service to certain low income persons.
Sec. 38a-573. Validity of separate provisions.
Sec. 38a-574. Standard underwriting form.
Secs. 38a-575 and 38a-576.
Sec. 38a-577. (Formerly Sec. 38-174ii). Consumer dental health plans. Definitions.
Sec. 38a-578. (Formerly Sec. 38-174jj). Certificate of authority. Application requirements.
Sec. 38a-579. (Formerly Sec. 38-174kk). Certificate of authority. Standards for issuance
and renewal.
Sec. 38a-580. (Formerly Sec. 38-174ll). General surplus required.
Sec. 38a-581. (Formerly Sec. 38-174mm). Evidence of coverage to be provided to enrollees.
Approval by commissioner.
Sec. 38a-582. (Formerly Sec. 38-174nn). Schedule of charges. Approval by commissioner.
Appeal of disapproval.
Sec. 38a-583. (Formerly Sec. 38-174oo). Records. Commissioner's power to examine; maintenance; preservation.
Sec. 38a-584. (Formerly Sec. 38-174pp). Complaint system.
Sec. 38a-585. (Formerly Sec. 38-174qq). Requirements re filing of annual reports with
commissioner.
Sec. 38a-586. (Formerly Sec. 38-174rr). False or misleading advertising or solicitation
and deceptive evidence of coverage prohibited.
Sec. 38a-587. (Formerly Sec. 38-174ss). Suspension or revocation of certificate of authority. Hearing. Appeal.
Sec. 38a-588. (Formerly Sec. 38-174tt). Penalty. Insolvency.
Sec. 38a-589. (Formerly Sec. 38-174uu). Confidentiality.
Sec. 38a-590. (Formerly Sec. 38-174vv). Commissioner's power to adopt regulations.
Secs. 38a-591 to 38a-594.
HEALTH INSURANCE: IN GENERAL
Sec. 38a-469. Definitions. As used in title 38a, unless the context otherwise requires or a different meaning is specifically prescribed, "health insurance" policy means
insurance providing benefits due to illness or injury, resulting in loss of life, loss of
earnings, or expenses incurred, and includes the following types of coverage: (1) Basic
hospital expense coverage; (2) basic medical-surgical expense coverage; (3) hospital
confinement indemnity coverage; (4) major medical expense coverage; (5) disability
income protection coverage; (6) accident only coverage; (7) long term care coverage;
(8) specified accident coverage; (9) Medicare supplement coverage; (10) limited benefit
health coverage; (11) hospital or medical service plan contract; (12) hospital and medical
coverage provided to subscribers of a health care center; (13) specified disease coverage. Sec. 38a-470. (Formerly Sec. 38-174n). Lien on workers' compensation
awards for insurers. Notice of lien. (a) For purposes of this section, "controverted
claim" means any claim in which compensation is denied either in whole or in part by
the workers' compensation carrier or the employer, if self-insured. Sec. 38a-471. (Formerly Sec. 38-174o). Third party prescription programs.
Notice of cancellation. Applicability of section. (a) As used in this section, a "third
party prescription program" means a system of providing for reimbursement for the
cost of drugs or pharmaceutical services under a contractual arrangement or agreement
with a provider of such drugs or services. Such programs shall include, but not be limited
to, employee benefit plans under which a consumer receives prescription drugs or pharmaceutical services and such drugs or services are paid for in part by an agent of the
consumer's employer or others. An "administrator" means the program administrator
of a third party prescription program. Sec. 38a-472. (Formerly Sec. 38-174a). Assignment of insurance proceeds to
doctor, hospital or state agency. Lien for state care. Notice of lien. (a) Whenever a
contract by a third party agency provides for payment to a beneficiary under the contract
on account of bills incurred by him for medical, surgical or hospital care received by
him, the assignment of the benefits of the contract by that beneficiary to the department
head, as defined in section 4-5, of a state agency, or any doctor or hospital rendering
such care, when sent by registered or certified mail to the third party agency, with a
copy to the insured, shall be authority for the payment directly by the third party agency
to the assignee. The state shall have a lien, in an amount equal to the care rendered, on
the proceeds of such contracts for care rendered by any state hospital, institution or other
facility, written notice of which shall be authority for the payment directly by the third
party agency to the state. Sec. 38a-472a. Medical provider indemnification agreements prohibited. No
contract between a managed care company, other organization or insurer authorized to
do business in this state and a medical provider practicing in this state for the provision
of services may require that the medical provider indemnify the managed care company,
other organization or insurer for any expenses and liabilities including, without limitation, judgments, settlements, attorneys' fees, court costs and any associated charges
incurred in connection with any claim or action brought against a managed care company, other organization or insurer on the basis of its determination of medical necessity
or appropriateness of health care services if the information provided by said medical
provider used in making the determination was accurate and appropriate at the time it
was given. As used in this section and section 38a-472b, "medical provider" means any
person licensed pursuant to chapters 370 to 373, inclusive, or chapter 375, 379, 380
or 383. Sec. 38a-472b. Medical provider indemnification contracts. Professional actions and related liability. Notwithstanding the provisions of section 38a-472a, every
medical provider participating in a contract pursuant to said section shall be responsible
for his professional actions and related liability. Sec. 38a-473. Medicare supplement expense factors. Age, gender, previous
claim or medical history rating prohibited. Exceptions. (a) No insurance company,
fraternal benefit society, hospital service corporation, medical service corporation,
health care center or any other entity which delivers or issues for delivery Medicare
supplement insurance policies or certificates, written, delivered, continued or renewed
in this state during the previous calendar year, shall incorporate in its rates for Medicare
supplement insurance calculated in accordance with sections 38a-495, 38a-495a and
38a-522 and any regulations adopted thereunder, factors for expenses which exceed one
hundred fifty per cent of the average expense ratio for the entire written premium for
all lines of health insurance of such company, society, corporation, center or other entity
for the previous calendar year. Sec. 38a-474. Rate increases: Procedure. Age, gender, previous claim or medical history rating prohibited. Exceptions. (a) On or after October 1, 1990, any insurance company, fraternal benefit society, hospital service corporation or medical service
corporation, and on and after January 1, 1994, any health care center or any other entity
which delivers, issues for delivery, continues or renews in this state any Medicare supplement policy or certificate, as defined in sections 38a-495, 38a-495a and 38a-522, seeking
to change its rates, shall file a request for such change with the insurance department
at least sixty days prior to the proposed effective date of such change. The Insurance
Department shall review the request and, with respect to requests for an increase in rates,
shall hold a public hearing on such increase. The Insurance Commissioner shall approve
or deny the request within forty-five days of its receipt. The Insurance Commissioner
shall adopt regulations, in accordance with the provisions of chapter 54, to set requirements for the submission of data pertaining to a request to change rates and to define
the policies utilized in making a decision on such change in rates. Sec. 38a-475. Precertification of policies under the Connecticut Partnership
for Long-Term Care. Regulations. The Insurance Department shall only precertify
long-term care insurance policies which (1) alert the purchaser to the availability of
consumer information and public education provided by the Department of Social Services pursuant to section 17a-307; (2) offer the option of home and community-based
services in addition to nursing home care; (3) in all home care plans, include case management services delivered by an access agency approved by the Office of Policy and
Management and the Department of Social Services as meeting the requirements for
such agency as defined in regulations adopted pursuant to subsection (e) of section 17b-
342, which services shall include, but need not be limited to, the development of a
comprehensive individualized assessment and care plan and, as needed, the coordination
of appropriate services and the monitoring of the delivery of such services; (4) provide
inflation protection; (5) provide for the keeping of records and an explanation of benefit
reports on insurance payments which count toward Medicaid resource exclusion; and
(6) provide the management information and reports necessary to document the extent
of Medicaid resource protection offered and to evaluate the Connecticut Partnership for
Long-Term Care. No policy shall be precertified if it requires prior hospitalization or a
prior stay in a nursing home as a condition of providing benefits. The commissioner
may adopt regulations, in accordance with chapter 54, to carry out the precertification
provisions of this section. Sec. 38a-476. Preexisting condition coverage. (a)(1) For the purposes of this section, "health insurance plan" means any hospital and medical expense incurred policy,
hospital or medical service plan contract and health care center subscriber contract and
does not include (A) short-term health insurance issued on a nonrenewable basis with a
duration of six months or less, accident only, credit, dental, vision, Medicare supplement,
long-term care or disability insurance, hospital indemnity coverage, coverage issued as
a supplement to liability insurance, insurance arising out of a workers' compensation
or similar law, automobile medical payments insurance, or insurance under which beneficiaries are payable without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance, or (B) policies of
specified disease or limited benefit health insurance, provided that the carrier offering
such policies files on or before March first of each year a certification with the Insurance
Commissioner that contains the following: (i) A statement from the carrier certifying
that such policies are being offered and marketed as supplemental health insurance and
not as a substitute for hospital or medical expense insurance; (ii) a summary description
of each such policy including the average annual premium rates, or range of premium
rates in cases where premiums vary by age, gender or other factors, charged for such
policies in the state; and (iii) in the case of a policy that is described in this subparagraph
and that is offered for the first time in this state on or after October 1, 1993, the carrier
files with the commissioner the information and statement required in this subparagraph
at least thirty days prior to the date such policy is issued or delivered in this state. Sec. 38a-476a. Compliance with the Health Insurance Portability and Accountability Act. Guaranteed renewability. Discrimination based on health status,
newborns' and mothers' health prohibited. Parity of mental health benefits. Disclosure of information for employers. Construction. Application. Regulations. (a)
Each insurance company, fraternal benefit society, hospital service corporation, medical
service corporation and health care center shall comply with sections 2742, 2743, and
2747 of the Public Health Service Act, as set forth in the Health Insurance Portability
and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to
time, concerning guaranteed renewability of individual health insurance coverage and
certification of coverage. Sec. 38a-477. Standardized claim forms. Regulations. (a) Except where there
is an agreement to the contrary between a third-party payer and the health care provider,
as defined in section 19a-17b, all health care providers shall submit all third-party claims
for payment on the current standard Health Care Financing Administration Fifteen Hundred (HCFA1500) health insurance claim form or its successor, or in the case of a hospital
or other health care institution, a UB-82 or its successor, or in accordance with other
forms which may be prescribed by the Insurance Commissioner. Sec. 38a-478. Definitions. As used in sections 38a-478 to 38a-478o, inclusive, and
subsection (a) of section 38a-478s: Sec. 38a-478a. Commissioner's report to the Governor and the General Assembly. On March 1, 1999, and annually thereafter, the Insurance Commissioner shall
submit a report, to the Governor and to the joint standing committees of the General
Assembly having cognizance of matters relating to public health and relating to insurance, concerning the commissioner's responsibilities under the provisions of sections
19a-647, 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, and 38a-993.
The report shall include: (1) A summary of the quality assurance plans submitted by
managed care organizations pursuant to section 38a-478c along with suggested changes
to improve such plans; (2) suggested modifications to the consumer report card developed under the provisions of section 38a-478l; (3) a summary of the commissioner's
procedures and activities in conducting market conduct examinations of utilization review companies, including, but not limited to: (A) The number of desk and field audits
completed during the previous calendar year; (B) a summary of findings of the desk
and field audits, including any recommendations made for improvements or modifications; (C) a description of complaints concerning managed care companies, including
a summary and analysis of any trends or similarities found in the managed care complaints filed by enrollees; (4) a summary of the complaints received by the Insurance
Department's Consumer Affairs Division and the commissioner under section 38a-
478n, including a summary and analysis of any trends or similarities found in the complaints received; (5) a summary of any violations the commissioner has found against
any managed care organization; and (6) a summary of the issues discussed related to
health care or managed care organizations at the Insurance Department's quarterly forums throughout the state. Sec. 38a-478b. Penalty for managed care organization's failure to file data
and reports. Commission's report to the Governor and the General Assembly on
organizations that fail to file data and reports. (a) Each managed care organization,
as defined in section 38a-478, that fails to file the data, reports or information required
by sections 19a-647, 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive,
and 38a-993 shall pay a late fee of one hundred dollars per day for each day from the
due date of such data, reports or information to the date of filing. Each managed care
organization that files incomplete data, reports or information shall be so informed by
the commissioner, shall be given a date by which to remedy such incomplete filing and
shall pay said late fee commencing from the new due date. Sec. 38a-478c. Managed care organization's report to the commissioner:
Data, reports and information required. (a) On or before May 1, 1998, and annually
thereafter, each managed care organization shall submit to the commissioner: Sec. 38a-478d. List of providers required. Notification to enrollee of removal
from list of enrollee's primary care physician. For any contract delivered, issued for
delivery, renewed, amended or continued in this state on or after October 1, 1997, each
managed care organization shall provide: (1) Annually to each enrollee a listing of all
providers available under the provisions of the enrollee's enrollment agreement; and
(2) notification, as soon as possible, to each enrollee upon the termination or withdrawal
of the enrollee's primary care physician. Sec. 38a-478e. Medical protocols. Procedure prior to change. Physician input.
Notification of change. (a) Each managed care organization shall, prior to implementing new medical protocols or substantially or materially altering existing medical protocols, obtain input from physicians actively practicing in Connecticut and practicing in
the relevant specialty areas. The managed care organization shall also seek input from
physicians who are not employees of or consultants, other than to the extent a person
is an employee or consultant solely for the purposes of this subsection, to the managed
care organization provided the input is not unreasonably withheld. The managed care
organization shall obtain the input in a manner permitting verification by the commissioner and shall document the process by which it obtained the input. For the purpose
of this section, "medical protocols" shall include, but not be limited to, drug formularies
or lists of covered drugs. Sec. 38a-478f. Provider profile development requirements. Each managed care
organization, in developing provider profiles or otherwise measuring health care provider performance, shall: (1) Make allowances for the severity of illness or condition
of the patient mix; (2) make allowances for patients with multiple illnesses or conditions;
(3) make available to the commissioner documentation of how the managed care organization makes such allowances; and (4) inform enrollees and participating providers,
upon request, how the managed care organization considers patient mix when profiling
or evaluating providers. Sec. 38a-478g. Managed care contract requirements. Plan description requirements. (a) Each managed care contract delivered, issued for delivery, renewed,
amended or continued in this state on or after October 1, 1997, shall be in writing and
a copy thereof furnished to the group contract holder or individual contract holder, as
appropriate. Each such contract shall contain the following provisions: (1) Name and
address of the managed care organization; (2) eligibility requirements; (3) a statement
of copayments, deductibles or other out-of-pocket expenses the enrollee must pay; (4)
a statement of the nature of the health care services, benefits or coverages to be furnished
and the period during which they will be furnished and, if there are any services, benefits
or coverages to be excepted, a detailed statement of such exceptions; (5) a statement of
terms and conditions upon which the contract may be cancelled or otherwise terminated
at the option of either party; (6) claims procedures; (7) enrollee grievance procedures;
(8) continuation of coverage; (9) conversion; (10) extension of benefits, if any; (11)
subrogation, if any; (12) description of the service area, and out-of-area benefits and
services, if any; (13) a statement of the amount the enrollee or others on his behalf must
pay to the managed care organization and the manner in which such amount is payable;
(14) a statement that the contract includes the endorsement thereon and attached papers,
if any, and contains the entire contract; (15) a statement that no statement by the enrollee
in his application for a contract shall void the contract or be used in any legal proceeding
thereunder, unless such application or an exact copy thereof is included in or attached
to such contract; and (16) a statement of the grace period for making any payment due
under the contract, which shall not be less than ten days. The commissioner may waive
the requirements of this subsection for any managed care organization subject to the
provisions of section 38a-182. Sec. 38a-478h. Removal of providers. Notice requirements. Retaliatory action
prohibited. (a) Each contract delivered, issued for delivery, renewed, amended or continued in this state on and after October 1, 1997, between a managed care organization
and a participating provider shall require the provider to give at least sixty days' advance
written notice to the managed care organization and shall require the managed care
organization to give at least sixty days' advance written notice to the provider in order
to withdraw from or terminate the agreement. Sec. 38a-478i. Limitation on enrollee rights prohibited. No contract delivered,
issued for delivery, renewed, amended or continued in this state on and after October
1, 1997, between a managed care organization and a participating provider shall prohibit
or limit any cause of action or contract rights an enrollee otherwise has. Sec. 38a-478j. Coinsurance payments based on negotiated discounts. Each
managed care plan that requires a percentage coinsurance payment by the insured shall
calculate the insured's coinsurance payment on the lesser of the provider's or vendor's
charges for the goods or services or the amount payable by the managed care organization
for such goods or services, except as otherwise required by the laws of a foreign state
when applicable to providers, vendors or patients in such foreign state. Sec. 38a-478k. Gag clauses prohibited. (a) No contract delivered, issued for delivery, renewed, amended or continued in this state on and after October 1, 1997, between
a managed care organization and a participating provider shall prohibit the provider
from discussing with an enrollee any treatment options and services available in or out
of network, including experimental treatments. Sec. 38a-478l. Consumer report card required. Content. (a) Not later than
March 15, 1999, and annually thereafter, the Insurance Commissioner, after consultation
with the Commissioner of Public Health, shall develop and distribute a consumer report
card on all managed care organizations. The commissioner shall develop the consumer
report card in a manner permitting consumer comparison across organizations. Sec. 38a-478m. Internal grievance procedure. Duty to establish and notify enrollees of procedure. Deadline for resolving complaints. (a) Each managed care organization shall establish and maintain an internal grievance procedure to assure that enrollees may seek a review of any grievance that may arise from a managed care
organization's action or inaction, other than action or inaction based on utilization review, and obtain a timely resolution of any such grievance. Such grievance procedure
shall comply with the following requirements: Sec. 38a-478n. Internal grievances. Appeal to the commissioner. Fees. Public
education outreach program. (a) On or after January 1, 1998, any enrollee, or any
provider acting on behalf of an enrollee with the enrollee's consent, who has exhausted
the internal mechanisms provided by a managed care organization or utilization review
company to appeal a determination not to certify an admission, service, procedure or
extension of stay, may appeal such determination to the commissioner. Sec. 38a-478o. Confidentiality and antidiscrimination procedures required.
(a) Each managed care organization shall conform to all applicable state and federal
antidiscrimination and confidentiality statutes, shall ensure that the confidentiality of
specified enrollee patient information and records in its custody is protected, and shall
have written confidentiality policies and procedures. Sec. 38a-478p. Expedited utilization review. Standardized form required. (a)
On or before October 1, 1997, the Insurance Commissioner shall develop a standardized
process for use in seeking expedited utilization review approval pursuant to section 38a-
226c. In developing such standardized process, the commissioner may convene and
consult with a working group composed of a representative of: The Connecticut Medical
Society, the Connecticut Hospital Association, Blue Cross Blue Shield of Connecticut,
and the Association of Connecticut HMOs. Sec. 38a-478q. Use of laboratories covered by plan required. Each provider, as
defined in section 38a-478, in utilizing laboratories or testing facilities for enrollees in
managed care plans that provide coverage for laboratories and testing facilities, shall
utilize laboratories or testing facilities covered by the enrollee's managed care plan or
notify the enrollee if the provider intends to utilize a laboratory or testing facility not
covered by the plan. Sec. 38a-478r. Emergency rooms. Prudent layperson standard. Presenting
symptoms or final diagnosis as basis for coverage. (a) Each provider, as defined in
section 38a-478, shall code for the presenting symptoms of all emergency claims and
each hospital shall record such code for such claims on locator 76 on the UB92 form
or its successor. Sec. 38a-478s. ERISA. Workers' compensation. Nonapplicability. (a) Nothing
in sections 38a-478 to 38a-478o, inclusive, shall be construed to apply to the arrangements of managed care organizations offered to individuals covered under self-insured
employee welfare benefit plans established pursuant to the federal Employee Retirement
Income Security Act of 1974. Sec. 38a-478t. Commissioner of Public Health to receive data. The Commissioner of Public Health may request and shall receive any data, report or information
filed with the Insurance Commissioner pursuant to the provisions of sections 19a-647,
38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, and 38a-993. Sec. 38a-478u. Regulations. The Insurance Commissioner shall adopt regulations
in accordance with the provisions of chapter 54 to implement the provisions of sections
19a-647, 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, and 38a-993. Sec. 38a-478v. Applicability of Unfair and Prohibited Insurance Practices
Act. Examination by Insurance Commissioner. Regulations. (a) Each managed care
organization, as defined in section 38a-478, shall be subject to the provisions of sections
38a-815 to 38a-819, inclusive. Sec. 38a-479. Reserved for future use. Sec. 38a-480. (Formerly Sec. 38-174). Nonapplication to certain policies or
contracts. (a) Nothing in sections 38a-481 to 38a-488, inclusive, shall apply to or affect
(1) any policy of liability or workers' compensation insurance; (2) any group health
insurance policy as defined by the commissioner; (3) life insurance, endowment or
annuity contracts or contracts supplemental thereto which contain only such provisions
relating to health insurance as (A) provide additional benefits in case of death by accidental means and (B) operate to safeguard such contracts against lapse, or to give a special
surrender value or special benefit or an annuity in the event that the insured or annuitant
becomes totally and permanently disabled as defined by the contract or supplemental
contract; (4) fraternal benefit societies, except as provided by section 38a-640; (5) insurance, issued in conjunction with an automobile liability policy subject to sections 38a-
19 and 38a-363 to 38a-388, inclusive, providing reimbursement for medical, surgical,
ambulance, hospital, nursing or funeral expenses, or indemnity for other loss, resulting
from injuries sustained by any person, including the named insured, arising out of the
ownership, maintenance or use of an automobile, or issued in conjunction with other
kinds of liability insurance providing reimbursement for medical, surgical, ambulance,
hospital, nursing or funeral expenses resulting from injuries sustained by any person,
including the named insured, in connection with the premises or operations insured. Sec. 38a-481. (Formerly Sec. 38-165). Approval of individual health application and policy form by commissioner. Exception re Medicare supplement policy.
Filing, form and minimum provisions of loss ratio guarantee. Regulations. Age,
gender, previous claim or medical history rating prohibited. Exceptions. Optional
life insurance riders. (a) No individual health insurance policy shall be delivered or
issued for delivery to any person in this state, nor shall any application, rider or endorsement be used in connection therewith, until a copy of the form thereof and of the classification of risks and the premium rates have been filed with the commissioner. The commissioner shall adopt regulations in accordance with the provisions of chapter 54,
establishing a procedure for review of such policies. The commissioner shall disapprove
the use of such form at any time if it does not comply with the requirements of law, or
if it contains a provision or provisions which are unfair or deceptive or which encourage
misrepresentation of the policy. The commissioner shall notify, in writing, the insurer
which has filed any such form of his disapproval, specifying his reasons therefor, and
ordering that no such insurer shall deliver or issue for delivery to any person in this state
a policy on or containing such form. The provisions of section 38a-19 shall apply to
such orders. Sec. 38a-482. (Formerly Sec. 38-166). Form of policy. No individual health insurance policy shall be delivered or issued for delivery to any person in this state unless:
(1) The entire money and other considerations therefor are expressed therein; (2) the
time at which the insurance takes effect and terminates is expressed therein; (3) such
policy purports to insure only one person, except that a policy may insure, originally or
by subsequent amendment, upon the application of an adult member of a family, who
shall be deemed the policyholder, any two or more eligible members of such family,
including husband, wife, dependent children or any children under a specified age, which
shall not exceed eighteen years, and any other person dependent upon the policyholder;
(4) the style, arrangement and overall appearance of the policy give no undue prominence to any portion of the text, and every printed portion of the text of the policy and
of any endorsements or attached papers is plainly printed in light-faced type of a style
in general use, the size of which shall be uniform and not less than ten-point with a
lowercase unspaced alphabet length not less than one hundred and twenty-point, the
word "text" as herein used including all printed matter except the name and address of
the insurer, name or title of the policy, the brief description, if any, and captions and
subcaptions; (5) the exceptions and reductions of indemnity are set forth in the policy
and, except as provided in section 38a-483, are printed, at the insurer's option, either
included with the benefit provision to which they apply, or under an appropriate caption
such as "EXCEPTIONS" or "EXCEPTIONS AND REDUCTIONS", provided, if an
exception or reduction specifically applies only to a particular benefit of the policy, a
statement of such exception or reduction shall be included with the benefit provision to
which it applies; (6) each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and (7)
such policy contains no provision purporting to make any portion of the charter, rules,
constitution or bylaws of the insurer a part of the policy unless such portion is set forth
in full in the policy, except in the case of the incorporation of, or reference to, a statement
of rates or classification of risks, or short-rate table filed with the commissioner. Sec. 38a-483. (Formerly Sec. 38-167). Standard provisions of individual
health policy. (a) Except as provided in subsection (c) of this section, each individual
health insurance policy delivered or issued for delivery to any person in this state shall
contain the provisions specified in this subsection in the words in which the same appear
in this section; provided the insurer may, at its option, substitute for one or more of such
provisions corresponding provisions of different wording approved by the commissioner which are in each instance not less favorable in any respect to the insured or the
beneficiary. Such provisions shall be preceded individually by the caption appearing in
this subsection or, at the option of the insurer, by such appropriate individual or group
captions or subcaptions as the commissioner may approve. Such provisions to be contained in such policy shall be: Sec. 38a-483a. Exclusionary riders for individual health insurance policies.
Regulations. Notwithstanding the provisions of section 38a-476, the Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to
allow exclusionary riders to be issued for individual health insurance policies that are
not subject to Section 2701 of the Public Health Service Act, as set forth in the Health
Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as
amended from time to time. Sec. 38a-483b. Time limits for coverage determinations. Notice requirements.
Except as otherwise provided in this title, each insurer, health care center, hospital and
medical service corporation or other entity delivering, issuing for delivery, renewing
or amending any individual health insurance policy in this state on or after January 1,
2000, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and
(12) of section 38a-469 shall complete any coverage determination with respect to such
policy and notify the insured or the insured's health care provider of its decision not
later than forty-five days after a request for such determination is received by the insurer,
health care center, hospital and medical service corporation or other entity. In the case
of a denial of coverage, such entity shall notify the insured and the insured's health care
provider of the reasons for such denial. Sec. 38a-483c. Coverage and notice re experimental treatments. Appeals. (a)
Each individual health insurance policy delivered, issued for delivery, renewed,
amended or continued in this state on or after January 1, 2000, shall define the extent
to which it provides coverage for experimental treatments. Sec. 38a-484. (Formerly Sec. 38-168). Policy provisions not to be less favorable
than standard. Validity of policy issued in violation of law. (a) No policy provision
which is not subject to section 38a-483 shall make a policy, or any portion thereof, less
favorable in any respect to the insured or the beneficiary than the provisions thereof
which are subject to sections 38a-481 to 38a-488, inclusive. Sec. 38a-485. (Formerly Sec. 38-169). Copy of application to be part of new
policy or to be furnished with renewal. Alteration of application. (a) The insured
shall not be bound by any statement made in an application for an individual health
insurance policy unless a copy of such application is attached to or endorsed on the
policy when issued as a part thereof. If any such policy delivered or issued for delivery
to any person in this state is reinstated or renewed, and the insured or the beneficiary
or assignee of such policy makes written request to the insurer for a copy of the application, if any, for such reinstatement or renewal, the insurer shall, within fifteen days after
the receipt of such request at its home office or any branch office of the insurer, deliver
or mail to the person making such request, a copy of such application. If such copy is
not so delivered or mailed, the insurer shall be precluded from introducing such application as evidence in any action or proceeding based upon or involving such policy or its
reinstatement or renewal. Sec. 38a-486. (Formerly Sec. 38-170). Certain acts not to operate as waiver of
rights. The acknowledgment by any insurer of the receipt of notice given under any
individual health insurance policy, or the furnishing of forms for filing proofs of loss,
or the acceptance of such proofs, or the investigation of any claim thereunder shall not
operate as a waiver of any of the rights of the insurer in defense of any claim arising
under such policy. Sec. 38a-487. (Formerly Sec. 38-171). Coverage after termination date of policy. If any individual health insurance policy contains a provision establishing, as an
age limit or otherwise, a date after which the coverage provided by the policy will not
be effective, and if such date falls within a period for which a premium is accepted by
the insurer or if the insurer accepts a premium after such date, the coverage provided
by the policy will continue in force subject to any right of cancellation until the end of
the period for which the premium has been accepted. If the age of the insured has been
misstated and if, according to the correct age of the insured, the coverage provided by
the policy would not have become effective, or would have ceased prior to the acceptance
of such premium or premiums, the liability of the insurer shall be limited to the refund,
upon request, of all premiums paid for the period not covered by the policy. Sec. 38a-488. (Formerly Sec. 38-172). Discrimination. Discrimination between
individuals of the same class in the amount of premiums or rates charged for any individual health insurance policy, or in the benefits payable thereon, or in any of the terms or
conditions of such policy, or in any other manner, is prohibited. Sec. 38a-488a. Mandatory coverage for the diagnosis and treatment of mental
or nervous conditions. Exceptions. Benefits payable re type of provider or facility.
State's claim against proceeds. (a) Each individual health insurance policy providing
coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-
469 delivered, issued for delivery, renewed, amended or continued in this state on or
after January 1, 2000, shall provide benefits for the diagnosis and treatment of mental
or nervous conditions. For the purposes of this section, "mental or nervous conditions"
means mental disorders, as defined in the most recent edition of the American Psychiatric
Association's "Diagnostic and Statistical Manual of Mental Disorders". "Mental or nervous conditions" does not include (1) mental retardation, (2) learning disorders, (3)
motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6)
relational problems, and (7) additional conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of
the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental
Disorders". Sec. 38a-489. (Formerly Sec. 38-174e). Continuation of coverage of mentally
or physically handicapped children. (a) Every individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and
(12) of section 38a-469, delivered or issued for delivery in this state more than one
hundred twenty days after July 1, 1971, which provides that coverage of a dependent
child shall terminate upon attainment of the limiting age for dependent children specified
in the policy shall also provide in substance that attainment of the limiting age shall not
operate to terminate the coverage of the child if at such date the child is and continues
thereafter to be both (1) incapable of self-sustaining employment by reason of mental
or physical handicap, as certified by the child's physician on a form provided by the
insurer, hospital or medical service corporation or health care center, and (2) chiefly
dependent upon the policyholder or subscriber for support and maintenance. Sec. 38a-490. (Formerly Sec. 38-174g). Coverage for newborn infants in health
insurance policies. Notice. Application. (a) Every individual health insurance policy
providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and
(12) of section 38a-469 for a family member of the insured or subscriber shall, as to such
family members' coverage, also provide that the health insurance benefits applicable for
children shall be payable with respect to a newly born child of the insured or subscriber
from the moment of birth.
(P.A. 90-243, S. 68; P.A. 96-227, S. 9.)
History: P.A. 96-227 added "specified disease coverage" as a type of "health insurance" policy.
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(b) Any insurer, hospital or medical service corporation, health care center or employee welfare benefit plan which furnished benefits or services under a health insurance
policy or a self-insured employee welfare benefit plan to any person suffering an injury
or illness covered by the Workers' Compensation Act has a lien on the proceeds of any
award or approval of any compromise made by a workers' compensation commissioner
less attorneys' fees approved by the district commissioner and reasonable costs related
to the proceeding, to the extent of benefits paid or services provided for the effects of
the injury or illness arising out of and in the course of employment as a result of a
controverted claim, provided such plan, policy or contract provides for reduction, exclusion, or coordination of benefits of the policy or plan on account of workers' compensation benefits.
(c) The lien shall arise at the time such benefits are paid or such services are rendered.
The person or entity furnishing such benefits or services shall serve written notice upon
the employee, the insurance company providing workers' compensation benefits or the
employer, if self-insured, and the workers' compensation commissioner for the district
in which the claim for workers' compensation has been filed, setting forth the nature
and extent of the lien allowable under subsection (b). The lien shall be effective against
any workers' compensation award made after the notice is received.
(d) The written notice shall be served upon the employee at his last-known address,
the insurance company at its principal place of business in this state or the employer, if
self-insured, at its principal place of business, and the workers' compensation commissioner, at the district office. Service shall be made to all parties by certified or registered
mail. The notice shall be in duplicate and shall contain, in addition to the information
set forth in subsection (c) of this section, the name of the injured or ill employee, the
name of the company providing workers' compensation benefits, the amount expended
and an estimate of the amount to be expended for benefits or services provided to such
injured or ill employee.
(e) The insurance company providing workers' compensation coverage or the employer, if self-insured, shall reimburse the insurance company, hospital or medical service corporation, health care center or employee welfare benefit plan providing benefits
or service directly, to the extent of any such lien. The receipt of such reimbursement by
such insurer, hospital or medical service corporation, health care center or employee
welfare benefit plan shall fully discharge such lien.
(f) The validity or amount of the lien may be contested by the workers' compensation carrier, the employer, if self-insured or the employee by bringing an action in the
superior court for the judicial district of Hartford or in the judicial district in which the
plaintiff resides. Such cases shall have the same privilege with respect to their assignment for trial as appeals from the workers' compensation review division but shall first
be claimed for the short calendar unless the court shall order the matter placed on the
trial list. An appeal may be taken from the decision of the Superior Court to the Appellate
Court in the same manner as is provided in section 51-197b. In any appeal in which one
of the parties is not represented by counsel and in which the party taking the appeal
does not claim the case for the short calendar or trial within a reasonable time after the
return day, the court may of its own motion dismiss the appeal, or the party ready to
proceed may move for nonsuit or default as appropriate. During the pendency of the
appeal any workers' compensation benefits due shall be paid into the court in accordance
with the rules relating to interpleader actions.
(P.A. 81-386, S. 1; June Sp. Sess. P.A. 83-29, S. 34, 82; P.A. 88-230, S. 1, 12; P.A. 90-98, S. 1, 2; 90-243, S. 69; P.A.
93-142, S. 4, 7, 8; P.A. 95-220, S. 4−6.)
History: June Sp. Sess. P.A. 83-29 deleted reference to supreme court and substituted appellate court in lieu thereof in
Subsec. (f); P.A. 88-230 replaced "judicial district of Hartford-New Britain" with "judicial district of Hartford", effective
September 1, 1991; P.A. 90-98 changed the effective date of P.A. 88-230 from September 1, 1991, to September 1, 1993;
P.A. 90-243 added references to "health care center" and substituted reference to "health insurance policies" for reference
to various health, disability and accident policies; Sec. 38-174n transferred to Sec. 38a-470 in 1991; P.A. 93-142 changed
the effective date of P.A. 88-230 from September 1, 1993, to September 1, 1996, effective June 14, 1993; P.A. 95-220
changed the effective date of P.A. 88-230 from September 1, 1996, to September 1, 1998, effective July 1, 1995.
See Secs. 38a-199 to 38a-209, inclusive, re hospital service corporations.
See Secs. 38a-214 to 38a-225, inclusive, re medical service corporations.
Annotations to former section 38-174n:
Cited. 216 C. 815. Cited. 219 C. 439−441, 444, 448, 449, 452, 458.
Cited. 22 CA 539, 544, 546−548; judgment reversed, see 219 C. 439 et seq.
Subsec. (b):
Cited. 217 C. 631, 640.
Cited. 22 CA 27, 35; judgment reversed, see 217 C. 631 et seq.
Subsec. (c):
Cited. 22 CA 539, 544, 546; judgment reversed, see 219 C. 439 et seq.
Annotations to present section:
Cited. 219 C. 439−441, 444, 448, 449, 452, 458.
Subsec. (b):
Cited. 217 C. 631, 640.
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(b) Any agreement or contract entered into in this state between an administrator
and a pharmacy shall include a statement of the method and amount of reimbursement
to the pharmacy for drugs or services provided to persons enrolled in the program, and
the frequency of payment by the administrator to the pharmacy for such drugs or services.
(c) (1) Each administrator of a program shall notify all pharmacies enrolled in such
program of any cancellation of coverage or benefits of any group enrolled in the program
at least thirty days prior to the effective date of such cancellation or within ten business
days following the date on which he receives notice of a cancellation, if he receives
such notice less than forty days prior to its effective date.
(2) Each employer shall give written notice to all persons enrolled in such program
of the cancellation of the plan and written notice to any person whose enrollment is
terminated. Such notice shall be given as soon as is practicable but in no case later than
thirty days after cancellation or termination. Such notice shall include a demand for the
return of any plan identification cards such persons may have been issued by reason of
their enrollment in such program.
(3) Any person who uses a program identification card to obtain drugs or services
from a pharmacy after having received notice of the cancellation of his program shall
be liable to the administrator for all moneys paid by the administrator for any drugs or
services obtained by the illegal use of such card.
(d) (1) No administrator shall deny payment to any pharmacy for drugs or services
which were provided as the result of the fraudulent or illegal use of an identification
card by any person to whom an identification card was issued, unless the pharmacy was
notified of the cancellation of such card.
(2) No administrator shall withhold payments for uncontested claims to any pharmacy beyond the time period specified in the payment schedule provisions of the
agreement.
(e) Each administrator shall mail to any pharmacist, upon written request, a copy
of each contract or agreement form in use in this state between such administrator and
a pharmacy.
(f) No administrator shall prohibit a pharmacy from enrolling in a program except
for cause, including, but not limited to, previous fraudulent use of program identification
cards.
(g) The provisions of this section shall not apply to the providing of drugs or services
under the provisions of Title XIX of the Social Security Act.
(P.A. 81-455, S. 1−8.)
History: Sec. 38-174o transferred to Sec. 38a-471 in 1991.
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(b) Whenever there is in existence a contract by an insurer for payment to, or on
behalf of, an applicant or recipient of medical assistance under the general assistance
program, the state-administered general assistance program or the Medicaid program
under said contract on account of bills incurred by the applicant or recipient for medical
services, including, but not limited to, physician services, nursing services, pharmaceutical services, surgical care and hospital care, the assignment of the benefits of the contract
by such applicant or recipient or his legally liable relative pursuant to section 17b-265
shall, upon receipt of notice from the assignee, be authority for payment by the insurer
directly to the assignee. If notice is provided by the assignee to the insurer in accordance
with the provisions of section 17b-265, the insurer shall be liable to the assignee for any
amount payable to the assignee under the contract.
(c) No insurer, health care center or issuer of any service plan contract for hospital
or medical expense coverage delivered, issued for delivery or renewed in this state shall
impose requirements on the Department of Social Services which have the effect of
denying or limiting benefits which have been assigned pursuant to this section. The
assignment of benefits shall be in accordance with the provisions of section 38a-472.
(1961, P.A. 124; P.A. 75-591; P.A. 90-243, S. 70; 90-283, S. 2; May Sp. Sess. P.A. 94-5, S. 8, 30; June 18 Sp. Sess.
P.A. 97-2, S. 101, 165.)
History: P.A. 75-591 clarified existing provision by substituting "sent by registered or certified mail" for "lodged with",
authorized assignment of benefits to department heads, required a copy to be sent to insured and added provision re state's
lien on contracts for care rendered by state hospitals, institutions, etc.; P.A. 90-243 made technical changes for statutory
consistency; P.A. 90-283 added Subsec. (b) re assignment of benefits of contract by an applicant or recipient of medical
assistance; Sec. 38-174a transferred to Sec. 38a-472 in 1991; May Sp. Sess. P.A. 94-5 added a new Subsec. (c) to prevent
insurers from imposing requirements on the department of social services which deny or limit benefits assigned pursuant
to this section, effective July 1, 1994; June 18 Sp. Sess. P.A. 97-2 amended Subsec. (b) to make technical and conforming
changes to references re assistance programs, effective July 1, 1997.
Annotations to former section 38-174a:
Subsec. (b):
Cited. 219 C. 439, 442.
Annotations to present section:
Cited. 219 C. 439, 442.
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(P.A. 95-199, S. 3.)
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(P.A. 95-199, S. 4.)
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(b) No insurance company, fraternal benefit society, hospital service corporation,
medical service corporation, health care center or any other entity which delivers or
issues for delivery, in this state, any Medicare supplement policies or certificates, shall
incorporate in its rates for Medicare supplement insurance policies or certificates any
factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate, except for plans "H" to "J",
inclusive, as provided in section 38a-495b. In plans "H" to "J", inclusive, previous
claims history and the medical condition of the applicant may be used in determining
rates and granting coverage under Medicare supplement policies and certificates.
(P.A. 90-243, S. 179, 181; P.A. 91-406, S. 9, 29; P.A. 92-60, S. 20; P.A. 93-239, S. 4; 93-390, S. 3, 8; May 25 Sp. Sess.
P.A. 94-1, S. 39, 130.)
History: P.A. 91-406 corrected an internal reference; P.A. 92-60 made provisions applicable to any Medicare supplement
policy continued or renewed during the previous calendar year, made provisions applicable to all lines of health insurance
and made technical corrections for statutory consistency; P.A. 93-239 made technical corrections for statutory consistency
and accuracy; P.A. 93-390 made technical changes for statutory consistency by adding references to "any other entity"
and "certificate" and added Subsec. (b) prohibiting the incorporation of factors for age, gender and previous claim or
medical condition history, into the insurer's rate schedule, effective January 1, 1994; May 25 Sp. Sess. P.A. 94-1 amended
Subsec. (a) by making technical change, effective July 1, 1994.
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(b) No insurance company, fraternal benefit society, hospital service corporation,
medical service corporation, health care center or any other entity which delivers or
issues for delivery, in this state, any Medicare supplement policies or certificates, shall
incorporate in its rates for Medicare supplement insurance policies or certificates any
factors or values based on the age, gender, previous claims history or the medical condition of the person covered by such policy or certificate, except for plans "H" to "J",
inclusive, as provided in section 38a-495b. In plans "H" to "J", inclusive, previous
claims history and the medical condition of the applicant may be used in determining
rates and granting coverage under Medicare supplement policies and certificates.
(P.A. 90-81; P.A. 91-406, S. 10, 29; P.A. 93-390, S. 4, 8; P.A. 94-39, S. 4.)
History: P.A. 91-406 corrected an internal reference; P.A. 93-390 added references to "health care centers" and "any
other entity" for statutory consistency and added Subsec. (b) prohibiting the incorporation of factors for age, gender and
previous claim or medical condition history, into insurer's rate schedule, effective January 1, 1994; P.A. 94-39 substituted
"change" for the references to "increase" and added a provision in Subsec. (a) that with respect to requests for an increase
in rates a public hearing must be held by the insurance department.
See Sec. 38a-481 re Medicare supplement policy rates.
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(P.A. 89-352, S. 3, 6; P.A. 91-187, S. 3, 4; P.A. 93-262, S. 1, 87; P.A. 95-160, S. 14, 69; P.A. 96-139, S. 12, 13.)
History: P.A. 91-187 amended Subdivs. (2), (3) and (4) to require all precertified policies to provide that the option of
home and community-based services be offered in addition to nursing home care, that all home care plans include case
management services and that all such policies provide inflation protection, deleting provision re option to furnish periodic
per diem upgrades until insured begins receiving long-term care benefits; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department on aging, effective July 1, 1993; P.A. 95-160
replaced a reference to coordination, assessment and monitoring agencies with access agencies, effective July 1, 1995
(Revisor's note: A reference to "Department of Insurance" was replaced editorially by the Revisors with "Insurance
Department" for consistency with customary statutory usage); P.A. 96-139 changed effective date of P.A. 95-160 but
without affecting this section.
See. Sec. 17b-251 re outreach program.
See Sec. 17b-252 re establishment of Connecticut Partnership for Long-Term Care pilot program.
See Sec. 17b-253 re amendments to Medicaid regulations and state plan, and regulations re determining eligibility of
applicants for Medicaid and coverage requirements for long-term care benefits.
See Sec. 17b-254 re foundation funds and federal approval and report to General Assembly.
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(2) "Insurance arrangement" means any "multiple employer welfare arrangement",
as defined in Section 3 of the Employee Retirement Income Security Act of 1974
(ERISA), as amended, except for any such arrangement which is fully insured within
the meaning of Section 514(b)(6) of said act, as amended.
(3) "Preexisting conditions provision" means a policy provision which limits or
excludes benefits relating to a condition based on the fact that the condition was present
before the effective date of coverage, for which any medical advice, diagnosis, care or
treatment was recommended or received before such effective date. Routine follow-up
care to determine whether a breast cancer has reoccurred in a person who has been
previously determined to be breast cancer free shall not be considered as medical advice,
diagnosis, care or treatment for purposes of this section unless evidence of breast cancer
is found during or as a result of such follow-up. Genetic information shall not be treated
as a condition in the absence of a diagnosis of the condition related to such information.
Pregnancy shall not be considered a preexisting condition.
(4) "Qualifying coverage" means (A) any group health insurance plan, insurance
arrangement or self-insured plan, (B) Medicare or Medicaid, or (C) an individual health
insurance plan that provides benefits which are actuarially equivalent to or exceeding
the benefits provided under the small employer health care plan, as defined in subdivision (12) of section 38a-564, whether issued in this state or any other state.
(5) "Applicable waiting period" means the period of time imposed by the group
policyholder or contractholder before an individual is eligible for participating in the
group policy or contract.
(b) (1) No group health insurance plan or insurance arrangement may impose a
preexisting conditions provision which excludes coverage for a period beyond twelve
months following the insured's effective date of coverage. Any preexisting conditions
provision may only relate to conditions, whether physical or mental, for which medical
advice, diagnosis or care or treatment was recommended or received during the six
months immediately preceding the effective date of coverage.
(2) No individual health insurance plan or insurance arrangement may impose a
preexisting conditions provision which excludes coverage beyond twelve months following the insured's effective date of coverage. Any preexisting conditions provision
may only relate to conditions, whether physical or mental, which manifest themselves, or
for which medical advice, diagnosis or care or treatment was recommended or received
during the twelve months immediately preceding the effective date of coverage.
(c) All health insurance plans and insurance arrangements shall provide coverage,
under the terms and conditions of its policies or contracts, for the preexisting conditions
of any newly insured individual who was previously covered for such preexisting condition under the terms of the individual's preceding qualifying coverage, provided the
preceding coverage was continuous to a date less than one hundred twenty days prior
to the effective date of the new coverage, exclusive of any applicable waiting period,
except in the case of a newly insured group member whose previous coverage was
terminated due to an involuntary loss of employment, the preceding coverage must have
been continuous to a date not more than one hundred fifty days prior to the effective
date of the new coverage, exclusive of any applicable waiting period, provided such
newly insured group member or dependent applies for such succeeding coverage within
thirty days of the member's or dependent's initial eligibility.
(d) With respect to a newly insured individual who was previously covered under
qualifying coverage, but who was not covered under such qualifying coverage for a
preexisting condition, as defined under the new health insurance plan or arrangement,
such plan or arrangement shall credit the time such individual was previously covered
by qualifying coverage to the exclusion period of the preexisting condition provision,
provided the preceding coverage was continuous to a date less than one hundred twenty
days prior to the effective date of the new coverage, exclusive of any applicable waiting
period under such plan, except in the case of a newly insured group member whose
preceding coverage was terminated due to an involuntary loss of employment, the preceding coverage must have been continuous to a date not more than one hundred fifty
days prior to the effective date of the new coverage, exclusive of any applicable waiting
period, provided such newly insured group member or dependent applies for such succeeding coverage within thirty days of the member's or dependent's initial eligibility.
(e) Each insurance company, fraternal benefit society, hospital service corporation,
medical service corporation or health care center which issues in this state group health
insurance subject to Section 2701 of the Public Health Service Act, as set forth in the
Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA),
as amended from time to time, shall comply with the provisions of said section with
respect to such group health insurance, except that the longer period of days specified
in subsections (c) and (d) of this section shall apply to the extent excepted from preemption in Section 2723(B)(2)(iii) of said Public Health Service Act.
(f) The provisions of this section shall apply to every health insurance plan or insurance arrangement issued, renewed or continued in this state on or after October 1, 1993.
For purposes of this section, the date a plan or arrangement is continued shall be the
anniversary date of the issuance of the plan or arrangement. The provisions of subsection
(e) of this section shall apply on and after the dates specified in Sections 2747 and 2792
of the Public Health Service Act as set forth in HIPAA.
(g) A short-term health insurance policy issued on a nonrenewable basis for six
months or less shall not be subject to this section, provided, any policy, application
or sales brochure issued for such short-term insurance which imposes a preexisting
conditions provision shall disclose that such preexisting conditions are not covered.
(h) The commissioner may adopt regulations, in accordance with the provisions of
chapter 54, to enforce the provisions of HIPAA concerning preexisting conditions and
portability.
(P.A. 93-345, S. 3; P.A. 96-87, S. 1−3; 96-177, S. 5; June 18 Sp. Sess. P.A. 97-8, S. 65, 88; P.A. 98-27, S. 14; P.A. 00-121.)
History: P.A. 96-87 amended Subsec. (a) and added Subsec. (f) to exempt "short-term" policies which provide the
prescribed disclosures, effective May 8, 1996; P.A. 96-177 redefined "preexisting conditions provision" to specify that
breast cancer check-ups are not medical advice, diagnosis, care or treatment unless evidence of breast cancer is found;
June 18 Sp. Sess. P.A. 97-8 redefined "preexisting conditions provision" in Subsec. (a), amended Subsec. (b) to delete
references to pregnancy, to substitute "whether physical or mental" for "manifesting themselves or" in Subdiv. (1) and to
substitute "whether physical or mental, which manifest themselves" for "manifesting themselves" in Subdiv. (2), amended
Subsecs. (c) and (d) to substitute "less than sixty-three days" for "not more than thirty days" and to substitute "sixty-three
days" for "thirty days", added new Subsec. (e) re compliance with the Public Health Service Act, designated former
Subsecs. (e) and (f) as Subsecs. (f) and (g) respectively, amending new Subsec. (f) re application dates of Subsec. (e), and
added new Subsec. (h) re regulations to enforce HIPAA, effective July 1, 1997; P.A. 98-27 amended Subsec. (d) to
substitute "time such individual" for "time such person" and substituted "such individual's initial eligibility" for "their
initial eligibility"; P.A. 00-121 amended Subsecs. (c) and (d) by amending time periods from sixty-three to one hundred
twenty days and ninety to one hundred fifty days, amending application deadline from sixty-three to thirty days, and making
technical changes for purposes of gender neutrality.
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(b) Each insurance company, fraternal benefit society, hospital service corporation,
medical service corporation and health care center shall comply with sections 2702,
2704, 2705 and 2712 of the Public Health Service Act, as set forth in the Health Insurance
Portability and Accountability Act of 1996 (P.L. 104-191 and 104-204) (HIPAA), as
amended from time to time, concerning discrimination based on health status, newborns'
and mothers' health, parity of mental health benefits and guaranteed renewability of
coverage for employers in the group market, with respect to health insurance coverage
offered in the small and large group markets as defined in said Public Health Service Act.
(c) Each insurance company, fraternal benefit society, hospital service corporation,
medical service corporation and health care center shall comply with sections 2711 and
2713 of the Public Health Service Act, as set forth in the Health Insurance Portability
and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to time,
concerning guaranteed availability and disclosure of information for employers with
respect to health insurance coverage offered in the small group market as defined in
said Public Health Service Act.
(d) No provision of the general statutes concerning a HIPAA requirement shall be
construed to supersede any other provision of the general statutes except to the extent
that such other provision prevents the application of a requirement of HIPAA.
(e) This section shall apply to insurance companies, fraternal benefit societies, hospital service corporations, medical service corporations and health care centers on and
after the dates specified in the Public Health Service Act, as set forth in the Health
Insurance Portability and Accountability Act of 1996, (P.L. 104-191 and 104-204) (HIPAA), as amended from time to time.
(f) The commissioner may adopt regulations, in accordance with the provisions of
chapter 54, to implement the provisions of this section and the provisions of the Public
Health Service Act, as set forth in the Health Insurance Portability and Accountability
Act of 1996, as amended from time to time.
(June 18 Sp. Sess. P.A. 97-8, S. 66, 88.)
History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997.
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(b) The commissioner may adopt regulations in accordance with the provisions of
chapter 54 to implement the provisions of subsection (a) of this section.
(P.A. 93-109.)
*See Sec. 19a-647 re preferred provider networks.
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HEALTH INSURANCE: MANAGED CARE
(1) "Commissioner" means the Insurance Commissioner.
(2) "Managed care organization" means an insurer, health care center, hospital or
medical service corporation or other organization delivering, issuing for delivery, renewing or amending any individual or group health managed care plan in this state.
(3) "Managed care plan" means a product offered by a managed care organization
that provides for the financing or delivery of health care services to persons enrolled in
the plan through: (A) Arrangements with selected providers to furnish health care services; (B) explicit standards for the selection of participating providers; (C) financial
incentives for enrollees to use the participating providers and procedures provided for by
the plan; or (D) arrangements that share risks with providers, provided the organization
offering a plan described under subparagraph (A), (B), (C) or (D) of this subdivision is
licensed by the Insurance Department pursuant to chapter 698, 698a or 700 and that the
plan includes utilization review pursuant to sections 38a-226 to 38a-226d, inclusive.
(4) "Provider" means a person licensed to provide health care services under chapters 370 to 373, inclusive, 375 to 383b, inclusive, 384a to 384c, inclusive, or chapter 400j.
(5) "Enrollee" means a person who has contracted for or who participates in a managed care plan for himself or his eligible dependents.
(P.A. 97-99, S. 1.)
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(P.A. 97-99, S. 2; June 18 Sp. Sess. P.A. 97-8, S. 57, 88; P.A. 99-284, S. 51, 60; P.A. 00-196, S. 22.)
History: June 18 Sp. Sess. P.A. 97-8 changed reporting date from January 15, 1999, to March 1, 1999, and in Subdiv.
(3)(C) changed "complaints" to "managed care complaints", effective July 1, 1997; P.A. 99-284 deleted obsolete reference
to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a technical change.
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(b) On June 1, 1998, and annually thereafter, the commissioner shall submit, to
the Governor and to the joint standing committees of the General Assembly having
cognizance of matters relating to public health and matters relating to insurance, a list of
those managed care organizations that have failed to file any data, report or information
required by sections 19a-647, 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u,
inclusive, and 38a-993.
(P.A. 97-99, S. 3; P.A. 99-284, S. 52, 60; P.A. 00-196, S. 23.)
History: P.A. 99-284 deleted obsolete references to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a
technical change in Subsec. (b).
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(1) A report on its quality assurance plan that includes, but is not limited to, information on complaints related to providers and quality of care, on decisions related to patient
requests for coverage and on prior authorization statistics. Statistical information shall
be submitted in a manner permitting comparison across plans and shall include, but not
be limited to: (A) The ratio of the number of complaints received to the number of
enrollees; (B) a summary of the complaints received related to providers and delivery
of care or services and the action taken on the complaint; (C) the ratio of the number of
prior authorizations denied to the number of prior authorizations requested; (D) the
number of managed care organization's utilization review determinations not to certify
an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the managed care organization's utilization review procedure;
(E) the percentage of those employers or groups that renew their contracts within the
previous twelve months; and (F) notwithstanding the provisions of this subsection, on
or before July 1, 1998, and annually thereafter, all data required by the National Committee for Quality Assurance (NCQA) for its Health Plan Employer Data and Information
Set (HEDIS). If an organization does not provide information for the National Committee for Quality Assurance for its Health Plan Employer Data and Information Set, then it
shall provide such other equivalent data as the commissioner may require by regulations
adopted in accordance with the provisions of chapter 54. The commissioner shall find
that the requirements of this subdivision have been met if the managed care plan has
received a one-year or higher level of accreditation by the National Committee for Quality Assurance and has submitted the Health Plan Employee Data Information Set data
required by subparagraph (F) of this subdivision.
(2) A model contract that contains the provisions currently in force in contracts
between the organization and participating providers in this state and, upon the commissioner's request, a copy of any individual contracts between such parties, provided the
contract may withhold or redact proprietary fee schedule information.
(3) A written statement of the types of financial arrangements or contractual provisions that the managed care organization has with hospitals, utilization review companies, physicians and any other health care providers including, but not limited to, compensation based on a fee-for-service arrangement, a risk-sharing arrangement or a
capitated risk arrangement.
(4) Such information as the commissioner deems necessary to complete the consumer report card he is required to develop and distribute pursuant to section 38a-478l.
Such information may include, but need not be limited to: (A) The organization's characteristics, including its model, its profit or nonprofit status, its address and telephone
number, the length of time it has been licensed in this and any other state, its number
of enrollees and whether it has received any national or regional accreditation; (B) a
summary of the information required by subdivision (3) of this section, including any
change in a plan's rates over the prior three years, its medical loss ratio or percentage
of the total premium revenues spent on medical care compared to administrative costs
and plan marketing, how it compensates health care providers and its premium level;
(C) a description of services, the number of primary care physicians and specialists, and
distribution and the number of hospitals, by county; (D) utilization review information,
including the name or source of any established medical protocols and the utilization
review standards; (E) medical management information, including the provider-to-patient ratio by primary care provider and speciality care provider, the percentage of primary and speciality care providers who are board certified, and how the medical protocols incorporate input as required in section 38a-478e; (F) the quality assurance
information required to be submitted under the provisions of subdivision (1) of subsection (a) of this section; (G) the status of the organization's compliance with the reporting
requirements of this section; (H) whether the organization markets to individuals and
Medicare recipients; (I) the number of hospital days per thousand enrollees; and (J) the
average length of hospital stays for specific procedures, as may be requested by the
commissioner.
(5) A summary of the procedures used by managed care organizations to credential
providers.
(b) The information required pursuant to subsection (a) of this section shall be consistent with the data required by the National Committee for Quality Assurance (NCQA)
for its Health Plan Employer Data and Information Set (HEDIS).
(c) The commissioner may accept electronic filing for any of the requirements under
this section.
(d) No managed care organization shall be liable for a claim arising out of the submission of any information concerning complaints concerning providers, provided the
managed care organization submitted the information in good faith.
(P.A. 97-99, S. 4; P.A. 98-27, S. 19.)
History: P.A. 98-27 amended Subpara. (a)(1)(F) to add "Notwithstanding the provisions of this subsection, on or before
July 1, 1998, and annually thereafter" re required data.
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(P.A. 97-99, S. 5.)
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(b) Each managed care organization shall (1) make available, upon the request of
a participating provider, its medical protocols for examination during regular business
hours at the principal Connecticut headquarters of the managed care organization, and
(2) if a managed care organization denies a treatment, service or procedure, the organization shall furnish, upon the request of a participating provider, a copy of the relevant
medical protocol to the participating provider, along with an explanation of the denial
at the time the denial is made.
(P.A. 97-99, S. 6; P.A. 00-216, S. 7, 28.)
History: P.A. 00-216 amended Subsec. (a) by making a technical change and adding provision defining "medical
protocols" to include drug formularies or lists of covered drugs, effective July 1, 2000.
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(P.A. 97-99, S. 7.)
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(b) Each managed care organization shall provide every enrollee with a plan description. The plan description shall be in plain language as commonly used by the
enrollees and consistent with chapter 699a. The plan description shall be made available
to each enrollee and potential enrollee prior to the enrollee's entering into the contract
and during any open enrollment period. The plan description shall not contain provisions
or statements that are inconsistent with the plan's medical protocols. The plan description shall contain:
(1) A clear summary of the provisions set forth in subdivisions (1) to (12), inclusive,
of subsection (a) of this section, subdivision (3) of subsection (a) of section 38a-478c
and sections 38a-478j to 38a-478l, inclusive;
(2) A statement of the number of managed care organization's utilization review
determinations not to certify an admission, service, procedure or extension of stay, and
the denials upheld and reversed on appeal within the managed care organization's utilization review procedure;
(3) A description of emergency services, the appropriate use of emergency services,
including to the use of E 9-1-1 telephone systems, any cost sharing applicable to emergency services and the location of emergency departments and other settings in which
participating physicians and hospitals provide emergency services and post stabilization care;
(4) Coverage of the plans, including exclusions of specific conditions, ailments or
disorders;
(5) The use of drug formularies or any limits on the availability of prescription drugs
and the procedure for obtaining information on the availability of specific drugs covered;
(6) The number, types and specialties and geographic distribution of direct health
care providers;
(7) Participating and nonparticipating provider reimbursement procedure;
(8) Preauthorization and utilization review requirements and procedures, internal
grievance procedures and internal and external complaint procedures;
(9) The medical loss ratio, or percentage of total premium revenue spent on medical
care compared to administrative costs and plan marketing;
(10) The plan's for-profit, nonprofit incorporation and ownership status;
(11) Telephone numbers for obtaining further information, including the procedure
for enrollees to contact the organization concerning coverage and benefits, claims grievance and complaint procedures after normal business hours;
(12) How notification is provided to an enrollee when the plan is no longer contracting with an enrollee's primary care provider;
(13) The procedures for obtaining referrals to specialists or for consulting a physician other than the primary care physician;
(14) The status of the National Committee for Quality Assurance (NCQA) accreditation;
(15) Enrollee satisfaction information; and
(16) Procedures for protecting the confidentially of medical records and other patient information.
(P.A. 97-99, S. 8; June 18 Sp. Sess. P.A. 97-8, S. 58, 88.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (a) by deleting requirement of conformance to federal Health
Maintenance Organization Act in Subdiv. (4) and deleting reference to filing in Subdiv. (16) and amended Subsec. (b) by
adding provision re procedure for obtaining information on the availability of specific drugs in Subdiv. (5), effective July
1, 1997.
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(b) The provisions of this section shall not apply: (1) When lack of such notice is
necessary for the health or safety of the enrollees; (2) when a provider has entered into
a contract with a managed care organization that is found to be based on fraud or material
misrepresentation; or (3) when a provider engages in any fraudulent activity related to
the terms of his contract with the managed care organization.
(c) No managed care organization shall take or threaten to take any action against
any provider in retaliation for such provider's assistance to an enrollee under the provisions of subsection (e) of section 38a-226c or section 38a-478n.
(P.A. 97-99, S. 9.)
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(P.A. 97-99, S. 10.)
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(P.A. 97-99, S. 11; June 18 Sp. Sess. P.A. 97-8, S. 59, 88.)
History: June 18 Sp Sess. P.A. 97-8 added exception re laws of a foreign state, effective July 1, 1997.
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(b) No contract delivered, issued for delivery, renewed, amended or continued in
this state on and after October 1, 1997, between a managed care organization and a
participating provider shall prohibit the provider from disclosing, to an enrollee who
inquires, the method the managed care organization uses to compensate the provider.
(P.A. 97-99, S. 12.)
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(b) The consumer report card shall include (1) all health care centers licensed pursuant to chapter 698a and (2) the fifteen largest licensed health insurers that use provider
networks and that are not included in subdivision (1) of this subsection. The insurers
selected pursuant to subdivision (2) of this subsection shall be selected on the basis of
Connecticut direct written health premiums from such network plans.
(c) The commissioner shall test market a draft of the consumer report card prior to
its publication and distribution. As a result of such test marketing, the commissioner
may make any necessary modification to its form or substance.
(P.A. 97-99, S. 13.)
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(1) Enrollees shall be informed of the grievance procedure at the time of initial
enrollment and at not less than annual intervals thereafter, which notification may be
met by inclusion in an enrollment agreement or update. Enrollees shall also be informed
of the grievance procedure when a decision has been made not to certify an admission,
service or extension of stay.
(2) Notices to enrollees describing the grievance procedure shall explain: (A) The
process for filing a grievance with the managed care organization, which may be communicated orally, electronically or in writing; (B) that the enrollee, a person acting on behalf
of an enrollee, including the enrollee's health care provider, may make a request for
review of a grievance; and (C) the time periods within which the managed care organization must resolve the grievance.
(b) All reviews conducted under this section shall be resolved not later than sixty
days from the date the enrollee commences the complaint, unless an extension is requested by the enrollee.
(P.A. 97-99, S. 14; P.A 99-284, S. 35.)
History: P.A. 99-284 designated existing provisions as Subsec. (a), amending Subdiv. (1) by requiring enrollees to be
informed of the grievance procedure and amending Subdiv. (2) by allowing other forms of communication, and added
new Subsec. (b) re reviews within sixty days.
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(b) (1) To appeal a decision under the provisions of this section, an enrollee or any
provider acting on behalf of an enrollee shall, within thirty days from receiving a final
written determination from the enrollee's managed care organization or utilization review company, file a written request with the commissioner. The appeal shall be on
forms prescribed by said commissioner and shall include the filing fee provided for in
subdivision (2) of this section and a general release executed by the enrollee for all
medical records pertinent to the appeal.
(2) The filing fee shall be twenty-five dollars and shall be deposited into the Insurance Fund established in section 38a-52. If the commissioner finds that an enrollee is
indigent or unable to pay the fee, the commissioner shall waive the fee.
(3) Upon receipt of the appeal together with the executed release and appropriate
fee, the commissioner shall assign the appeal for review to an entity as defined in subsection (c) of this section.
(4) Upon receipt of the request for appeal from the commissioner, the entity conducting the appeal shall conduct a preliminary review of the appeal and accept it if
such entity determines: (A) The individual was or is an enrollee of the managed care
organization; (B) the benefit or service that is the subject of the complaint or appeal
reasonably appears to be a covered service, benefit or service under the agreement provided by contract to the enrollee; (C) the enrollee has exhausted all internal appeal
mechanisms provided; (D) the enrollee has provided all information required by the
commissioner to make a preliminary determination including the appeal form, a copy of
the final decision of denial and a fully-executed release to obtain any necessary medical
records from the managed care organization and any other relevant provider.
(5) Upon completion of the preliminary review, the entity conducting such review
shall immediately notify the member or provider, as applicable, in writing as to whether
the appeal has been accepted for full review and, if not so accepted, the reasons therefor.
(6) If accepted for full review, the entity shall conduct such review in accordance
with the regulations adopted by the commissioner, after consultation with the Commissioner of Public Health, in accordance with the provisions of chapter 54.
(c) To provide for such appeal the Insurance Commissioner, after consultation with
the Commissioner of Public Health, shall engage impartial health entities to provide for
medical review under the provisions of this section. Such review entities shall include
(1) medical peer review organizations, (2) independent utilization review companies,
provided any such organizations or companies are not related to or associated with any
managed care organization and (3) nationally recognized health experts or institutions
approved by the commissioner.
(d) The commissioner shall accept the decision of the reviewing entity and the decision of the commissioner shall be binding.
(e) Not later than January 1, 2000, the Insurance Commissioner shall develop a
comprehensive public education outreach program to educate health insurance consumers of the existence of the appeals procedure established in this section. The program
shall maximize public information concerning the appeals procedure and shall include,
but not be limited to: (1) The dissemination of information through mass media, interactive approaches and written materials; (2) involvement of community-based organizations in developing messages and in devising and implementing education strategies;
and (3) periodic evaluations of the effectiveness of educational efforts. The Managed
Care Ombudsman shall coordinate the outreach program and oversee the education
process.
(P.A. 97-99, S. 20; June 18 Sp. Sess. P.A. 97-8, S. 60, 88; P.A. 99--284, S. 14, 60.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subdiv. (2) of Subsec. (b) to require that the fee be deposited in the
Insurance Fund, effective July 1, 1997; P.A. 99-284, which was added editorially by the Revisors as Subsec. (e), required
the commissioner to develop a public education outreach program and required the ombudsman to coordinate the program
and oversee the education process, effective July 7, 1999.
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(b) No managed care organization shall sell, for any commercial purpose the names
of its enrollees or any identifying information concerning enrollees.
(P.A. 97-99, S. 21; P.A. 98-27, S. 15.)
History: P.A. 98-27 amended Subsec. (a) to substitute "its" for "their".
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(b) The process developed pursuant to subsection (a) of this section shall be distributed to all acute care hospitals in this state and shall be revised as deemed necessary by
the commissioner.
(P.A. 97-99, S. 22, 32.)
History: P.A. 97-99 effective June 6, 1997.
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(P.A. 97-99, S. 25.)
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(b) The presenting symptoms, as coded by the provider and recorded by the hospital
on the UB92 form or its successor, or the final diagnosis, whichever reasonably indicates
an emergency medical condition, shall be the basis for reimbursement or coverage,
provided such symptoms reasonably indicated an emergency medical condition.
(c) For the purposes of this section, in accordance with the National Committee for
Quality Assurance, an emergency medical condition is a condition such that a prudent
lay-person, acting reasonably, would have believed that emergency medical treatment
is needed.
(d) The Insurance Commissioner, after consultation with the working group convened pursuant to section 38a-478p, may develop and disseminate to hospitals in this
state a claims form system that will ensure that all hospitals consistently code for the
presenting and diagnosis symptoms on all emergency claims.
(P.A. 97-99, S. 26; June 18 Sp. Sess. P.A. 97-8, S. 61, 88.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (b) to add provision re "the final diagnosis, whichever reasonably
indicates an emergency medical condition," effective July 1, 1997.
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(b) The provisions of sections 38a-478 to 38a-478o, inclusive, shall not apply to
any plan that provides for the financing or delivery of health care services solely for the
purposes of workers' compensation benefits pursuant to chapter 568.
(P.A. 97-99, S. 28, 30; June 18 Sp. Sess. P.A. 97-8, S. 64, 88; P.A. 99-284, S. 53, 60.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (a) by replacing the exemption for managed care organizations
with an exemption for the arrangements of managed care organizations offered to individuals covered under self-insured
plans, effective July 1, 1997; P.A. 99-284 deleted obsolete reference to Sec. 38a-514a from Subsec. (b), effective January
1, 2000.
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(P.A. 97-99, S. 31; P.A. 99-284, S. 54, 60.)
History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000.
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(P.A. 97-99, S. 29; P.A. 99-284, S. 55, 60.)
History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000.
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(b) The Insurance Commissioner may examine the affairs of any managed care
organization licensed to do business in this state in order to determine whether such
managed care organization has been or is engaged in any unfair method of competition
or in any unfair or deceptive act or practice prohibited by section 38a-816. The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.
(P.A. 99-284, S. 31.)
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INDIVIDUAL HEALTH INSURANCE
(b) The provisions of sections 38a-481 to 38a-488, inclusive, 38a-492, 38a-502 and
38a-505 shall not apply to any subscriber contract issued by a health care center.
(1949 Rev., S. 6188; 1951, 1953, S. 2842d; 1957, P.A. 448, S. 46; 1967, P.A. 326; P.A. 79-376, S. 59; P.A. 88-326, S.
5; P.A. 90-243, S. 71.)
History: 1967 act added proviso in Subdiv. (2) re furnishing of information which insurer would be required to certify
to plan administrator under federal Welfare and Pension Plans Disclosure Act; P.A. 79-376 added reference to Secs.
38-166 to 38-172 and substituted "workers' compensation" for "workmen's compensation"; P.A. 88-326 required the
commissioner to adopt regulations establishing a procedure for review of group health and accident policies, life insurance
policies and annuity contracts, and added a new Subsec. (b) concerning the commissioner's disapproval of any policy
form; P.A. 90-243 substituted reference to "group health insurance policy" for reference to accident and health policies,
deleted former provisions re commissioner's approval of forms and re group policies and added a new Subsec. (b) exempting
health care centers from certain statutory provisions; Sec. 38-174 transferred to Sec. 38a-480 in 1991.
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(b) No rate filed under the provisions of subsection (a) of this section shall be effective until the expiration of thirty days after it has been filed or unless sooner approved
by the commissioner in accordance with regulations promulgated by him, which regulations shall prescribe standards to insure that such rates shall not be excessive, inadequate
or unfairly discriminatory and the commissioner may disapprove such rate within thirty
days after it has been filed if it fails to comply with such standards, except that no rate
filed under the provisions of subsection (a) of this section for any Medicare supplement
policy shall be effective unless approved in accordance with section 38a-474.
(c) No insurance company, fraternal benefit society, hospital service corporation,
medical service corporation, health care center or any other entity which delivers or
issues for delivery, in this state, any Medicare supplement policies or certificates, shall
incorporate in its rates for Medicare supplement insurance policies or certificates any
factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate, except for plans "H" to "J",
inclusive, as provided in section 38a-495b. In plans "H" to "J", inclusive, previous
claims history and the medical condition of the applicant may be used in determining
rates and granting coverage under Medicare supplement policies and certificates.
(d) Rates on a particular policy form will not be deemed excessive if the insurer
has filed a loss ratio guarantee with the Insurance Commissioner which meets the requirements of subsection (e) provided the form of such loss ratio guarantee has been
explicitly approved by the Insurance Commissioner and provided further, the current
expected lifetime loss ratio is not more than five per cent less than the filed lifetime
loss ratio as certified by an actuary. The insurer shall withdraw the policy form if the
commissioner determines that the lifetime loss ratio will not be met. Rates also will not
be deemed excessive if the insurer complies with the terms of the loss ratio guarantee.
The Insurance Commissioner may, however, adopt regulations to assure that the use of
a loss ratio guarantee does not constitute an unfair practice.
(e) Premium rates shall be deemed approved upon filing with the Insurance Commissioner if the filing is accompanied by a loss ratio guarantee. The loss ratio guarantee
shall be in writing, signed by an officer of the insurer and shall contain as a minimum
the following:
(1) A recitation of the anticipated lifetime and durational target loss ratios contained
in the original actuarial memorandum filed with the policy form when it was originally
approved;
(2) A guarantee that the actual Connecticut loss ratios for the experience period in
which the new rates take effect and for each experience period thereafter until any new
rates are filed will meet or exceed the loss ratios referred to in subdivision (1) of this
subsection. If the annual earned premium volume in Connecticut under the particular
policy form is less than one million dollars and therefore not actuarially credible, the
loss ratio guarantee will be based on the actual nation-wide loss ratio for the policy
form. If the aggregate earned premium for all states is less than one million dollars, the
experience period will be extended until the end of the calendar year in which one million
dollars of earned premium is attained;
(3) A guarantee that the actual Connecticut or national, as the case may be, loss
ratio results for the experience period at issue will be independently audited by a certified
public accountant or a member of the American Academy of Actuaries at the insurer's
expense. The audit shall be done in the second quarter of the year following the end of
the experience period and the audited results must be reported to the Insurance Commissioner not later than June thirtieth following the end of the experience period;
(4) A guarantee that affected Connecticut policyholders will be issued a proportional refund, which will be based on the premiums earned, of the amount necessary to
bring the actual loss ratio up to the anticipated loss ratio referred to in subdivision (1)
of this subsection. If nation-wide loss ratios are used, the total amount refunded in
Connecticut will equal the dollar amount necessary to achieve the loss ratio standards
multiplied by the total premium earned from all Connecticut policyholders who will
receive refunds and divided by the total premium earned in all states on the policy form.
The refund shall be made to all Connecticut policyholders who are insured under the
applicable policy form as of the last day of the experience period and whose refund
would equal two dollars or more. The refund will include interest, at six per cent, from
the end of the experience period until the date of payment. Payment shall be made
during the third quarter of the year following the experience period for which a refund
is determined to be due;
(5) A guarantee that refunds less than two dollars will be aggregated by the insurer.
The insurer shall deposit such amount in a separate interest-bearing account in which
all such amounts shall be deposited. At the end of each calendar year each such insurer
shall donate one-half of such amount to The University of Connecticut Health Center
and one-half of such amount to Uncas-on-Thames Hospital;
(6) A guarantee that the insurer, if directed by the Insurance Commissioner, shall
withdraw the policy form and cease the issuance of new policies under the form in this
state if the applicable loss ratio exceeds the durational target loss ratio for the experience
period by more than twenty per cent, provided the calculations are based on at least two
thousand policyholder-years of experience either in the state or nation-wide.
(f) For the purposes of this section:
(1) "Loss ratio" means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations; and
(2) "Experience period" means the calendar year for which a loss ratio guarantee
is calculated.
(g) Nothing in this chapter shall preclude the issuance of an individual health insurance policy which includes an optional life insurance rider, provided, the optional life
insurance rider must be filed with and approved by the Insurance Commissioner pursuant
to section 38a-430. Any company offering such policies for sale in this state shall be
licensed to sell life insurance in this state pursuant to the provisions of section 38a-41.
(1949 Rev., S. 6177; 1951, S. 2835d; 1967, P.A. 437, S. 1; P.A. 78-280, S. 6, 127; P.A. 88-230, S. 1, 12; 88-326, S. 4;
P.A. 90-243, S. 72; P.A. 91-311; P.A. 93-390, S. 5, 8; P.A. 96-51, S. 2.)
History: 1967 act added Subsec. (b) re effective date of rates and rate standards; P.A. 78-280 replaced "Hartford county"
with "judicial district of Hartford-New Britain" in Subsec. (a); P.A. 88-230 proposed to replace reference to "judicial
district of Hartford-New Britain" with "judicial district of Hartford", effective September 1, 1991, but said reference was
deleted by P.A. 88-326; P.A. 88-326 required the commissioner to adopt regulations establishing a procedure for policy
review and rephrased existing provisions; P.A. 90-243 substituted reference to "individual health insurance policy" for
references to insurance against loss from sickness, bodily injury or accidental death; Sec. 38-165 transferred to Sec. 38a-
481 in 1991; P.A. 91-311 amended Subsec. (b) to exclude Medicare supplement policy rates unless filed in accordance
with Sec. 38a-474, added a new Subsec. (c) re filing of the required loss ratio guarantee form to preclude the claim that a
particular policy has excessive rates and added the discretionary authority for the commissioner to adopt regulations re
the terms of the loss ratio guarantee, added a new Subsec. (d) re premium rates if filed with a loss ratio guarantee and
outlining the minimum requirements of a loss ratio guarantee in order to meet the commissioner's approval, the refund
procedure for Connecticut policyholders and the procedures by which a policy form can be withdrawn and added Subsec.
(e) defining "loss ratio" and "experience period"; P.A. 93-390 inserted new Subsec. (c) prohibiting the incorporation of
factors for age, gender, previous claim or medical condition history into the insurer's rate schedule and relettered the
remaining Subsecs. and internal references accordingly, effective January 1, 1994; P.A. 96-51 added Subsec. (g) to permit
optional life insurance riders.
See Sec. 38a-504 re insurance policy or contract requirements covering surgical removal of tumors and treatment of
leukemia.
Annotation to former section 38-165:
Cited. 186 C. 507, 509.
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(1949 Rev., S. 6178; 1951, S. 2836d; 1972, P.A. 127, S. 63; P.A. 90-243, S. 73.)
History: 1972 act changed maximum insurable age of children in Subsec. (a) (3) from nineteen to eighteen, reflecting
changed age of majority; P.A. 90-243 added reference to "individual health insurance" and deleted former Subsec. (b);
Sec. 38-166 transferred to Sec. 38a-482 in 1991.
Annotations to former section 38-166:
Cited. 214 C. 303, 309, 310.
Subsec. (a):
Subdiv. (5) cited. 214 C. 303, 309.
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(1) A provision as follows: "ENTIRE CONTRACT: CHANGES: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract
of insurance. No change in this policy shall be valid until approved by an executive
officer of the insurer and unless such approval be endorsed hereon or attached hereto.
No agent has authority to change this policy or to waive any of its provisions."
(2) A provision as follows: "TIME LIMIT ON CERTAIN DEFENSES: This policy
shall be incontestable, except for nonpayment of premium, after it has been in force for
two years from its date of issue."
(3) A provision as follows: "GRACE PERIOD: A grace period of .... (insert a number not less than seven for weekly premium policies, ten for monthly premium policies
and thirty-one for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall
continue in force." A policy which contains a cancellation provision may add, at the
end of the above provision, "subject to the right of the insurer to cancel in accordance
with the cancellation provision hereof." A policy in which the insurer reserves the right
to refuse any renewal may have, at the beginning of the above provision, "Unless not
less than five days prior to the premium due date the insurer has delivered to the insured
or has mailed to his last address as shown by the records of the insurer written notice
of its intention not to renew this policy beyond the period for which the premium has
been accepted."
(4) A provision as follows: "REINSTATEMENT: If any renewal premium is not
paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such
premium, without requiring in connection therewith an application for reinstatement,
shall reinstate the policy; provided, if the insurer or such agent requires an application
for reinstatement and issues a conditional receipt for the premium tendered, the policy
shall be reinstated upon approval of such application by the insurer or, lacking such
approval, upon the forty-fifth day following the date of such conditional receipt unless
the insurer has previously notified the insured, in writing, of its disapproval of such
application. The reinstated policy shall cover only loss resulting from such accidental
injury as may be sustained after the date of reinstatement and loss due to such sickness
as may begin more than ten days after such date. In all other respects the insured and
insurer shall have the same rights thereunder as they had under the policy immediately
before the due date of the defaulted premium, subject to any provisions endorsed hereon
or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not
been previously paid, but not to any period more than sixty days prior to the date of
reinstatement." The last sentence of the above provision may be omitted from any policy
which the insured has the right to continue in force subject to its terms by the timely
payment of premiums (1) until at least age fifty or (2), in the case of a policy issued
after age forty-four, for at least five years from its date of issue.
(5) A provision as follows: "NOTICE OF CLAIM: Written notice of claim must
be given to the insurer within twenty days after the occurrence or commencement of
any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice
given by or on behalf of the insured or the beneficiary to the insurer at .... (insert the
location of such office as the insurer may designate for the purpose), or to any authorized
agent of the insurer, with information sufficient to identify the insured, shall be deemed
notice to the insurer." In a policy providing a loss-of-time benefit which may be payable
for at least two years, an insurer may, at its option, insert the following between the first
and second sentences of the above provision: "Subject to the qualifications set forth
below, if the insured suffers loss of time on account of disability for which indemnity
may be payable for at least two years, he shall, at least once in every six months after
having given notice of claim, give to the insurer notice of continuance of said disability,
except in the event of legal incapacity. The period of six months following any filing
of proof by the insured or any payment by the insurer on account of such claim or any
denial of liability in whole or in part by the insurer shall be excluded in applying this
provision. Delay in the giving of such notice shall not impair the insured's right to
any indemnity which would otherwise have accrued during the period of six months
preceding the date on which such notice is actually given."
(6) A provision as follows: "CLAIM FORMS: The insurer, upon receipt of a notice
of claim, shall furnish to the claimant such forms as are usually furnished by it for filing
proofs of loss. If such forms are not furnished within fifteen days after the giving of
such notice, the claimant shall be deemed to have complied with the requirements of
this policy as to proof of loss, upon submitting, within the time fixed in the policy for
filing proofs of loss, written proof covering the occurrence, the character and the extent
of the loss for which claim is made."
(7) A provision as follows: "PROOFS OF LOSS: Written proof of loss shall be
furnished to the insurer at its said office in case of claim for loss for which this policy
provides any periodic payment contingent upon continuing loss within ninety days after
the termination of the period for which the insurer is liable and in case of claim for any
other loss within ninety days after the date of such loss. Failure to furnish such proof
within the time required shall not invalidate nor reduce any claim if it was not reasonably
possible to give proof within such time, provided such proof is furnished as soon as
reasonably possible and in no event, except in the absence of legal capacity, later than
one year from the time proof is otherwise required."
(8) A provision as follows: "TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for any loss other than loss for which this policy provides any
periodic payment will be paid immediately upon receipt of due written proof of such
loss. Subject to due written proof of loss, all accrued indemnities for loss for which this
policy provides periodic payment shall be paid .... (insert period for payment which
must not be less frequently than monthly) and any balance remaining unpaid upon the
termination of liability will be paid immediately upon receipt of due written proof."
(9) A provision as follows: "PAYMENT OF CLAIMS: Indemnity for loss of life
will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of
payment. If no such designation or provision is then effective, such indemnity shall be
payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's
death may, at the option of the insurer, be paid either to such beneficiary or to such
estate. All other indemnities will be payable to the insured." The following provisions,
or either of them, may be included with the foregoing provision at the option of the
insurer: "If any indemnity of this policy shall be payable to the estate of the insured, or
to an insured or beneficiary who is a minor or otherwise not competent to give a valid
release, the insurer may pay such indemnity, up to an amount not exceeding $.... (insert
an amount which shall not exceed one thousand dollars), to any relative by blood or
connection by marriage of the insured or beneficiary who is deemed by the insurer to
be equitably entitled thereto. Any payment made by the insurer in good faith pursuant
to this provision shall fully discharge the insurer to the extent of such payment. Subject
to any written direction of the insured in the application or otherwise, all or a portion
of any indemnities provided by this policy on account of hospital, nursing, medical or
surgical services may, at the insurer's option and unless the insured requests otherwise
in writing not later than the time of filing proofs of such loss, be paid directly to the
hospital or person rendering such services; but it is not required that the service be
rendered by a particular hospital or person."
(10) A provision as follows: "PHYSICAL EXAMINATIONS AND AUTOPSY:
The insurer at its own expense shall have the right and opportunity to examine the person
of the insured when and as often as it may reasonably require during the pendency of
a claim hereunder and to make an autopsy in case of death where it is not forbidden
by law."
(11) A provision as follows: "LEGAL ACTIONS: No action at law or in equity
shall be brought to recover on this policy prior to the expiration of sixty days after written
proof of loss has been furnished in accordance with the requirements of this policy. No
such action shall be brought after the expiration of three years after the time written
proof of loss is required to be furnished."
(12) A provision as follows: "CHANGE OF BENEFICIARY: Unless the insured
makes an irrevocable designation of beneficiary, the right to change of beneficiary is
reserved to the insured and the consent of the beneficiary or beneficiaries shall not be
requisite to surrender or assignment of this policy or to any change of beneficiary or
beneficiaries, or to any other changes in this policy." The first clause of this provision,
relating to the irrevocable designation of beneficiary, may be omitted at the insurer's
option.
(b) Except as provided in subsection (c) of this section, no such policy delivered or
issued for delivery to any person in this state shall contain provisions respecting the
matters set forth below unless such provisions are in the words in which the same appear
in this section; provided the insurer may, at its option, use in lieu of any such provision
a corresponding provision of different wording approved by the commissioner which
is not less favorable in any respect to the insured or the beneficiary. Any such provision
contained in the policy shall be preceded individually by the appropriate caption appearing in this subsection or, at the option of the insurer, by such appropriate individual
or group captions or subcaptions as the commissioner may approve.
(1) A provision as follows: "CHANGE OF OCCUPATION: If the insured be injured or contract sickness after having changed his occupation to one classified by the
insurer as more hazardous than that stated in his policy or while doing for compensation
anything pertaining to an occupation so classified, the insurer will pay only such portion
of the indemnities provided in this policy as the premium paid would have purchased
at the rates and within the limits fixed by the insurer for such more hazardous occupation.
If the insured changes his occupation to one classified by the insurer as less hazardous
than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro-rata unearned premium from the date of change of occupation or from the policy anniversary
date immediately preceding receipt of such proof, whichever is the more recent. In
applying this provision, the classification of occupational risk and the premium rates
shall be such as have been last filed by the insurer prior to the occurrence of the loss
for which the insurer is liable or prior to date of proof of change in occupation with the
state official having supervision of insurance in the state where the insured resided at
the time this policy was issued; but if such filing was not required, then the classification
of occupational risk and the premium rates shall be those last made effective by the
insurer in such state prior to the occurrence of the loss or prior to the date of proof of
change in occupation."
(2) A provision as follows: "MISSTATEMENT OF AGE: If the age of the insured
has been misstated, all amounts payable under this policy shall be such as the premium
paid would have purchased at the correct age."
(3) A provision in accordance with subparagraph (i) or (ii) of this subdivision as
follows: (i) "OTHER INSURANCE IN THIS INSURER: If an accident or sickness or
accident and sickness policy or policies previously issued by the insurer to the insured
be in force concurrently herewith, making the aggregate indemnity for .... (insert type
of coverage or coverages) in excess of $.... (insert maximum limit of indemnity or for
such excess shall be returned to the insured or his estate"; or, (ii) "OTHER INSURANCE
IN THIS INSURER: Insurance effective at any one time on the insured under a like
policy or policies in this insurer is limited to the one such policy elected by the insured,
his beneficiary or his estate, as the case may be, and the insurer will return all premiums
paid for all other such policies."
(4) A provision as follows: "INSURANCE WITH OTHER INSURERS: If there
be other valid coverage, not with this insurer, providing benefits for the same loss on a
provision of service basis or on an expense incurred basis and of which this insurer has
not been given written notice prior to the occurrence or commencement of loss, the only
liability under any expense incurred coverage of this policy shall be for such proportion
of the loss as the amount which would otherwise have been payable hereunder plus the
total of the like amounts under all such other valid coverages for the same loss of which
this insurer had notice bears to the total like amounts under all valid coverages for such
loss, and for the return of such portion of the premiums paid as shall exceed the pro-
rata portion for the amount so determined. For the purpose of applying this provision
when other coverage is on a provision of service basis, the "like amount" of such other
coverage shall be taken as the amount which the services rendered would have cost in
the absence of such coverage." If the foregoing policy provision is included in a policy
which also contains the policy provisions specified in subdivision (5) of this subsection,
there shall be added to the caption of the foregoing provision the phrase "− EXPENSE
INCURRED BENEFITS". The insurer may, at its option, include in this provision a
definition of "other valid coverage", approved as to form by the commissioner, which
definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state
of the United States or any province of Canada, and by hospital or medical service
organizations, and to any other coverage the inclusion of which may be approved by
the commissioner. In the absence of such definition, such terms shall not include group
insurance, automobile medical payments insurance, or coverage provided by hospital
or medical service organizations or by union welfare plans or employer or employee
benefit organizations. For the purpose of applying the foregoing policy provision with
respect to any insured, any amount of benefit provided for such insured pursuant to any
compulsory benefit statute, including any workers' compensation or employer's liability
statute, whether provided by a governmental agency or otherwise, shall in all cases be
deemed to be "other valid coverage" of which the insurer has had notice. In applying
the foregoing policy provision no third party liability coverage shall be included as
"other valid coverage".
(5) A provision as follows: "INSURANCE WITH OTHER INSURERS: If there
be other valid coverage, not with this insurer, providing benefits for the same loss on
other than an expense incurred basis and of which this insurer has not been given written
notice prior to the occurrence or commencement of loss, the only liability for such
benefits under this policy shall be for such proportion of the indemnities otherwise
provided hereunder for such loss as the like indemnities of which the insurer had notice
(including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the
pro-rata portion for the indemnities thus determined." If the foregoing policy provision is
included in a policy which also contains the policy provision specified in subdivision
(4) of this subsection, there shall be added to the caption of the foregoing provision the
phrase "− OTHER BENEFITS". The insurer may, at its option, include in this provision
a definition of "other valid coverage", approved as to form by the commissioner, which
definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state
of the United States or any province of Canada, and to any other coverage the inclusion
of which may be approved by the commissioner. In the absence of such definition, such
term shall not include group insurance, or benefits provided by union welfare plans or by
employer or employee benefit organizations. For the purpose of applying the foregoing
policy provision with respect to any insured, any amount of benefit provided for such
insured pursuant to any compulsory benefit statute including any workers' compensation
or employer's liability statute, whether provided by a governmental agency or otherwise
shall in all cases be deemed to be "other valid coverage" of which the insurer has had
notice. In applying the foregoing policy provision no third party liability coverage shall
be included as "other valid coverage".
(6) A provision as follows: "RELATION OF EARNINGS TO INSURANCE: If
the total monthly amount of loss of time benefits promised for the same loss under all
valid loss of time coverage upon the insured, whether payable on a weekly or monthly
basis, shall exceed the monthly earnings of the insured at the time disability commenced
or his average monthly earnings for the period of two years immediately preceding a
disability for which claim is made, whichever is the greater, the insurer will be liable
only for such proportionate amount of such benefits under this policy as the amount of
such monthly earnings or such average monthly earnings of the insured bears to the
total amount of monthly benefits for the same loss under all such coverage upon the
insured at the time such disability commences and for the return of such part of the
premiums paid during such two years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total
monthly amount of benefits payable under all such coverage upon the insured below
the sum of two hundred dollars or the sum of the monthly benefits specified in such
coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those
payable for loss of time." The foregoing policy provision may be inserted only in a
policy which the insured has the right to continue in force subject to its terms by the
timely payment of premiums (1) until at least age fifty or (2), in the case of a policy
issued after age forty-four, for at least five years from its date of issue. The insurer may,
at its option, include in this provision a definition of "valid loss of time coverage",
approved as to form by the commissioner, which definition shall be limited in subject
matter to coverage provided by governmental agencies or by organizations subject to
regulation by insurance law or by insurance authorities of this or any other state of the
United States or any province of Canada, or to any other coverage the inclusion of which
may be approved by the commissioner or any combination of such coverages. In the
absence of such definition such term shall not include any coverage provided for such
insured pursuant to any compulsory benefit statute, including any workers' compensation or employer's liability statute, or benefits provided by union welfare plans or by
employer or employee benefit organizations.
(7) A provision as follows: "UNPAID PREMIUM: Upon the payment of a claim
under this policy, any premium then due and unpaid or covered by any note or written
order may be deducted therefrom."
(8) A provision as follows: "CANCELLATION: The insurer may cancel this policy
at any time by written notice delivered to the insured and to any dependents who were
listed on the application and any subsequent revisions thereto, or mailed to their last
address as shown by the records of the insurer, stating when, not less than five days
thereafter, such cancellation shall be effective; and after the policy has been continued
beyond its original term the insured may cancel this policy at any time by written notice
delivered or mailed to the insurer, effective upon receipt or on such later date as may
be specified in such notice. In the event of cancellation, the insurer will return promptly
the unearned portion of any premium paid. If the insured cancels, the earned premium
shall be computed by the use of the short-rate table last filed with the state official having
supervision of insurance in the state where the insured resided when the policy was
issued. If the insurer cancels, the earned premium shall be computed pro-rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of
cancellation."
(9) A provision as follows: "CONFORMITY WITH STATE STATUTES: Any
provision of this policy which, on its effective date, is in conflict with the statutes of
the state in which the insured resides on such date is hereby amended to conform to the
minimum requirements of such statutes."
(c) If any provision of this section is in whole or in part inapplicable to or inconsistent
with the coverage provided by a particular form of policy, the insurer, with the approval
of the commissioner, shall omit from such policy any inapplicable provision or part of
a provision, and shall modify any inconsistent provision or part of the provision in such
manner as to make the provision as contained in the policy consistent with the coverage
provided by the policy.
(d) The provisions specified in subsections (a) and (b) of this section, or any corresponding provisions which are used in lieu thereof in accordance with said subsections,
shall be printed in the consecutive order of the provisions in such subsections or, at the
option of the insurer, any such provision may appear as a unit in any part of the policy,
with other provisions to which it may be logically related, provided the resulting policy
shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse or likely
to mislead a person to whom the policy is offered, delivered or issued.
(e) The word "insured", as used in sections 38a-481 to 38a-488, inclusive, shall not
be construed as preventing a person other than the insured with a proper insurable interest
from making application for and owning a policy covering the insured or from being
entitled under such a policy to any indemnities, benefits and rights provided therein.
(f) (1) Any policy of a foreign or alien insurer, when delivered or issued for delivery
to any person in this state, may contain any provision which is not less favorable to the
insured or the beneficiary than the provisions of sections 38a-481 to 38a-488, inclusive,
and which is prescribed or required by the law of the state under which the insurer is
organized.
(2) Any policy of a domestic insurer may, when issued for delivery in any other
state or country, contain any provision permitted or required by the laws of such other
state or country.
(g) The commissioner may make such reasonable rules and regulations concerning
the procedure for the filing or submission of policies subject to sections 38a-481 to
38a-488, inclusive, as are necessary, proper or advisable to the administration of said
sections. This provision shall not abridge any other authority granted the commissioner
by law.
(1949 Rev., S. 6179, 6180, 6186; Apps. B, C; 1951, S. 2837d; 1971, P.A. 267; P.A. 79-376, S. 58; P.A. 90-243, S. 74;
P.A. 95-40.)
History: 1971 act replaced previous provisions re "time limit on defenses" which had detailed voidance of policy
because of misstatements on application with provision stating that policy is uncontestable except for premium nonpayment
after it is in force for two years; P.A. 79-376 substituted "workers' compensation" for "workmen's compensation" where
appearing; P.A. 90-243 added reference to "an individual health insurance" policy; Sec. 38-167 transferred to Sec. 38a-
483 in 1991; P.A. 95-40 added requirement to Subsec. (b)(8) that written notice be delivered not only to the insured but
also to any dependents listed on the application and any subsequent revisions thereto; (Revisor's note: When P.A. 95-40,
which amended Subsec. (b)(8) concerning "CANCELLATION", was incorporated into the section by the Revisors, the
unamended text of Subsec. (b)(8) was inadvertently moved to and replaced the then existing Subsec. (a)(8) concerning
"TIME OF PAYMENT OF CLAIMS". Since there was no legislation in 1995, or subsequently, making any changes to
Subsec. (a)(8), the Revisors editorially corrected their 1995 codification error by reinstating the correct wording of Subsec.
(a)(8) for the 2001 revision).
Annotation to former section 38-167:
Gardener setting off a single bomb on fourth of July held not to have changed occupation to a more hazardous one. 91
C. 729.
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(June 18 Sp. Sess. P.A. 97-8, S. 71, 88.)
History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997.
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(P.A. 99-284, S. 12.)
See Sec. 38a-513a for similar provisions re group policies.
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(b) No such health insurance policy may deny a procedure, treatment or the use of
any drug as experimental if such procedure, treatment or drug, for the illness or condition
being treated, or for the diagnosis for which it is being prescribed, has successfully
completed a phase III clinical trial of the federal Food and Drug Administration.
(c) Any person who has been diagnosed with a condition that creates a life expectancy in that person of less than two years and who has been denied an otherwise covered
procedure, treatment or drug on the grounds that it is experimental may request an
expedited appeal as provided in section 38a-226c and may appeal a denial thereof to
the Insurance Commissioner in accordance with the procedures established in section
38a-478n.
(d) For the purposes of conducting an appeal pursuant to section 38a-478n on the
grounds that an otherwise covered procedure, treatment or drug is experimental, the
basis of such an appeal shall be the medical efficacy of such procedure, treatment or
drug. The entity conducting the review may consider whether the procedure, treatment
or drug (1) has been approved by the National Institute of Health or the American Medical Association, (2) is listed in the United States Pharmacopoeia Drug Information Guide
for Health Care Professionals (USP-DI), the American Medical Association Drug Evaluations (AMA-DE), or the American Society of Hospital Pharmacists' American Hospital Formulary Service Drug Information (AHFS-DI), or (3) is currently in a phase III
clinical trial of the federal Food and Drug Administration.
(P.A. 99-284, S. 15, 60.)
History: P.A. 99-284 effective January 1, 2000.
See Sec. 38a-513b for similar provisions re group policies.
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(b) A policy delivered or issued for delivery to any person in this state in violation
of said sections shall be held valid but shall be construed as provided in said sections.
When any provision in a policy subject to said sections is in conflict with any provision
of said sections, the rights, duties and obligations of the insurer, the insured and the
beneficiary shall be governed by the provisions of said sections.
(1949 Rev., S. 6185; 1951, S. 2838d.)
History: Sec. 38-168 transferred to Sec. 38a-484 in 1991.
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(b) No alteration of any written application for any such policy shall be made by
any person other than the applicant without his written consent, except that insertions
may be made by the insurer, for administrative purposes only, in such manner as to
indicate clearly that such insertions are not to be ascribed to the applicant.
(c) The falsity of any statement in the application for any policy covered by sections
38a-481 to 38a-488, inclusive, may not bar the right to recovery thereunder unless such
false statement materially affected either the acceptance of the risk or the hazard assumed
by the insurer.
(1949 Rev., S. 6184; 1951, S. 2839d; P.A. 90-243, S. 75.)
History: P.A. 90-243 added reference to "an individual health insurance" policy; Sec. 38-169 transferred to Sec. 38a-
485 in 1991.
Annotation to former section 38-169:
Cited. 214 C. 303, 307, 308.
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(1949 Rev., S. 6183; 1951, S. 2840d; P.A. 90-243, S. 76.)
History: P.A. 90-243 added reference to "an individual health insurance" policy; Sec. 38-170 transferred to Sec. 38a-
486 in 1991.
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(1951, S. 2841d; P.A. 90-243, S. 77.)
History: P.A. 90-243 added reference to "an individual health insurance" policy; Sec. 38-171 transferred to Sec. 38a-
487 in 1991.
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(1949 Rev., S. 6188; 1951, S. 2844d; P.A. 90-243, S. 78.)
History: P.A. 90-243 substituted reference to "individual health insurance" policy for reference to policies under Secs.
38-165 to 38-172; Sec. 38-172 transferred to Sec. 38a-488 in 1991.
See Sec. 38a-446 re prohibition against discrimination in favor of individuals by life insurance companies.
See Sec. 38a-447 re prohibition of discrimination against persons on basis of race.
See Sec. 38a-816 re unfair practices.
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(b) No such policy shall establish any terms, conditions or benefits that place a
greater financial burden on an insured for access to diagnosis or treatment of mental or
nervous conditions than for diagnosis or treatment of medical, surgical or other physical
health conditions.
(c) In the case of benefits payable for the services of a licensed physician, such
benefits shall be payable for the same services when such services are lawfully rendered
by a psychologist licensed under the provisions of chapter 383 or by such a licensed
psychologist in a licensed hospital or clinic.
(d) In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by:
(1) A clinical social worker who is licensed under the provisions of chapter 383b
and who has passed the clinical examination of the American Association of State Social
Work Boards and has completed at least two thousand hours of the post-master's social
work experience in a nonprofit agency qualifying as a tax-exempt organization under
Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding
internal revenue code of the United States, as from time to time amended, in a municipal,
state or federal agency or in an institution licensed by the Department of Public Health
under section 19a-490;
(2) A social worker who was certified as an independent social worker under the
provisions of chapter 383b prior to October 1, 1990;
(3) A licensed marital and family therapist who has completed at least two thousand
hours of the post-master's marriage and family therapy work experience in a nonprofit
agency qualifying as a tax-exempt organization under Section 501(c) of the Internal
Revenue Code of 1986 or any subsequent corresponding internal revenue code of the
United States, as from time to time amended, in a municipal, state or federal agency or
in an institution licensed by the Department of Public Health under section 19a-490;
(4) A marital and family therapist who was certified under the provisions of chapter
383a prior to October 1, 1992;
(5) A licensed alcohol and drug counselor, as defined in section 20-74s, or a certified
alcohol and drug counselor, as defined in section 20-74s; or
(6) A licensed professional counselor.
(e) For purposes of this section, the term "covered expenses" means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted
medical standards, except that in the case of a managed care plan, as defined in section
38a-478, "covered expenses" means the payments agreed upon in the contract between
a managed care organization, as defined in section 38a-478, and a provider, as defined
in section 38a-478.
(f) (1) In the case of benefits payable for the services of a licensed physician, such
benefits shall be payable for (A) services rendered in a child guidance clinic or residential
treatment facility by a person with a master's degree in social work or by a person with
a master's degree in marriage and family therapy under the supervision of a psychiatrist,
physician, licensed marital and family therapist, or licensed clinical social worker who
is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d)
of this section; (B) services rendered in a residential treatment facility by a licensed or
certified alcohol and drug counselor who is eligible for reimbursement under subdivision
(5) of subsection (d) of this section; or (C) services rendered in a residential treatment
facility by a licensed professional counselor who is eligible for reimbursement under
subdivision (6) of subsection (d) of this section.
(2) In the case of benefits payable for the services of a licensed psychologist under
subsection (d) of this section, such benefits shall be payable for (A) services rendered
in a child guidance clinic or residential treatment facility by a person with a master's
degree in social work or by a person with a master's degree in marriage and family
therapy under the supervision of such licensed psychologist, licensed marital and family
therapist, or licensed clinical social worker who is eligible for reimbursement under
subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered
in a residential treatment facility by a licensed or certified alcohol and drug counselor
who is eligible for reimbursement under subdivision (5) of subsection (d) of this section;
or (C) services rendered in a residential treatment facility by a licensed professional
counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of
this section.
(g) In the case of benefits payable for the service of a licensed physician practicing
as a psychiatrist or a licensed psychologist, under subsection (d) of this section, such
benefits shall be payable for outpatient services rendered (1) in a nonprofit community
mental health center, as defined by the Department of Mental Health and Addiction
Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician
practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor
or a licensed professional counselor who is eligible for reimbursement under subdivisions (1) to (6), inclusive, of subsection (d) of this section; and (3) within the scope of
the license issued to the center or clinic by the Department of Public Health or to the
residential treatment facility by the Department of Children and Families.
(h) Except in the case of emergency services or in the case of services for which
an individual has been referred by a physician affiliated with a health care center, nothing
in this section shall be construed to require a health care center to provide benefits under
this section through facilities that are not affiliated with the health care center.
(i) In the case of any person admitted to a state institution or facility administered
by the Department of Mental Health and Addiction Services, Department of Public
Health, Department of Children and Families or the Department of Mental Retardation,
the state shall have a lien upon the proceeds of any coverage available to such person
or a legally liable relative of such person under the terms of this section, to the extent
of the per capita cost of such person's care. Except in the case of emergency services,
the provisions of this subsection shall not apply to coverage provided under a managed
care plan, as defined in section 38a-478.
(June 18 Sp. Sess. P.A. 97-8, S. 63, 88; P.A. 99-284, S. 27, 60; P.A. 00-135, S. 10, 21.)
History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997; P.A. 99-284 rewrote Subsec. (a) and referenced Subdivs.
(1),(2), (4), (11) and (12) of section 38a-469, deleted reference to biologically-based mental or nervous conditions and
definition thereof and replaced with provision for coverage of the diagnosis and treatment of mental or nervous conditions,
and defined "mental or nervous conditions", added new Subsec. (b) re prohibition on terms, conditions or benefits that
place a greater financial burden on insured re mental or nervous conditions than for other conditions, added new Subsec.
(c) re benefits payable when rendered by a psychologist, added new Subsec. (d) re benefits payable for enumerated providers,
added new Subsec. (e) to define "covered expenses", added new Subsec. (f) re benefits payable for services rendered in
certain facilities, added new Subsec. (g) re certain outpatient benefits, added new Subsec. (h) re benefits provided by a
health care center, and added new Subsec. (i) re state liens against certain coverage proceeds, effective January 1, 2000;
P.A. 00-135 reorganized section and added provisions re licensed professional counselors, effective May 26, 2000.
See Sec. 38a-514 for similar provisions re group policies.
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(b) Proof of the incapacity and dependency shall be furnished to the insurer, hospital
or medical service plan corporation or health care center by the policyholder or subscriber within thirty-one days of the child's attainment of the limiting age. The insurer,
corporation or health care center may at any time require proof of the child's continuing
incapacity and dependency. After a period of two years has elapsed following the child's
attainment of the limiting age the insurer, corporation or health care center may require
periodic proof of the child's continuing incapacity and dependency but in no case more
frequently than once every year.
(1971, P.A. 408, S. 1, 2; P.A. 87-207, S. 1; P.A. 90-243, S. 79.)
History: P.A. 87-207 amended Subsecs. (a) and (b) to provide that for individual and group policies the continuation
rights for children are applicable if the child is incapable of employment by reason of mental or physical handicap which
has been certified by the child's physician; P.A. 90-243 substituted reference to "health insurance policy" for reference to
hospital or medical expense policies and contracts, divided former Subsec. (a) into Subsecs. (a) and (b), added a reference
to "health care center" and deleted former Subsec. (b) re group policies; Sec. 38-174e transferred to Sec. 38a-489 in 1991.
See Sec. 38a-515 for similar provisions re group policies.
See Sec. 38a-538 re conversion and extension rights of group members and re liability of group employers.
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(b) Coverage for such newly born child shall consist of coverage for injury and
sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.
(c) If payment of a specific premium or subscription fee is required to provide
coverage for a child, the policy or contract may require that notification of birth of such
newly born child and payment of the required premium or fees shall be furnished to the
insurer, hospital or medical service corporation or health care center within thirty-one
days after the date of birth in order to continue coverage beyond such thirty-one-day
period, provided failure to furnish such notice or pay such premium or fees shall not
prejudice any claim originating within such thirty-one-day period.
(d) The provisions of this section shall apply with respect to health insurance policies delivered or issued for delivery in this state on or after October 1, 1974, and to any
health insurance policies which are thereafter amended to substantially alter or change
benefits or coverages, and to any individual health insurance policies renewable at the
option of such insurance company, hospital or medical service corporation or health
care center which are thereafter renewed.
(P.A. 74-6, S. 1−4; P.A. 90-243, S. 80.)
History: P.A. 90-243 substituted references to "health insurance policies" for references to hospital and medical expense
policies and contracts, specified applicability to individual policies only, and applied provisions to "health care centers";
Sec. 38-174g transferred to Sec. 38a-490 in 1991.
See Sec. 38a-516 for similar provisions re group policies.
See Sec. 38a-538 re conversion and extension rights of group members and re liability of group employers.
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