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304.32-310 Benefits.
(1)
(2)
(3)
(4)
A converted policy issued pursuant to the conversion privilege provided in KRS
304.32-300 providing hospital or surgical expense insurance shall provide on
an expense incurred basis, the following minimum benefits:
(a) Hospital room and board benefits of twenty-five dollars ($25) per day, for
a minimum duration of seventy (70) days for any one period of hospital
confinement as defined in the converted policy.
(b) Miscellaneous hospital expense benefits for any one (1) period of hospital
confinement in a minimum amount up to twenty (20) times the hospital
room and board daily benefit provided under the converted policy.
(c) Surgical operation expense benefits according to a relative value
schedule, or a minimum of two hundred fifty dollars ($250).
(d) The option to continue any existing benefits on account of pregnancy,
childbirth, or miscarriage.
The relative values in the surgical schedule shall be consistent with the
schedule of operations generally offered by the insurer under group or
individual health insurance policies. In the event that the insurer and the
employer agree upon one (1) or more additional plans of benefits to be
available for converted policies, the applicant for the converted policy may, at
his option, elect such a plan in lieu of a converted policy providing the benefits
of paragraphs (a), (b), and (c) of subsection (1) of this section. In no event shall
the benefits be less than the minimums set forth in subsection (1) of this
section.
In no event need the insurer provide under the converted policy:
(a) Benefits on account of abortion or complications thereof,
(b) The benefits of paragraphs (a) and (b) of subsection (1) of this section,
unless the group policy from which conversion is made provided hospital
expense insurance benefits, or
(c) The benefits of paragraph (c) of subsection (1) of this section, unless the
group policy provided surgical expense insurance benefits. Furthermore,
the converted policy may contain any exclusion, reduction, or limitation
contained in the group policy and any exclusion, reduction, or limitation
customarily used in individual policies issued by the insurer. With respect
to any person who was covered by the group policy, the period specified
in the time limit on certain defenses of the incontestable provision of the
converted policy shall commence with the date the insurance on such
person or member became effective under the group policy.
The converted policy may provide that any hospital, surgical, or medical
expense benefits otherwise payable thereunder with respect to any person
covered thereunder may be reduced by the amount of any such benefits
payable under the group policy for the same loss with respect to such person
after termination of such person's coverage thereunder. The insurer shall not
be entitled to use deterioration of health as the basis for refusing to renew a
converted policy. The converted policy may provide for termination of coverage
thereunder on any person when he is or could be covered by Medicare (Title
XVIII of the United States Social Security Act as added by the Social Security
(5)
Amendments of 1965 or as later amended or superseded).
A converted policy may include a provision whereby the insurer may request
information in advance of any premium due date of such policy of any person
covered thereunder as to whether:
(a) He is covered for similar benefits by another hospital, surgical, or medical
expense insurance policy or hospital or medical service subscriber
contract or medical practice or other prepayment plan or by any other
plan or program; or
(b) Similar benefits are provided for, or available to, such person pursuant to,
or in accordance with the requirements of, any statute.
If any such person is so covered or such statutory benefits are provided or
available, and such person fails to furnish the insurer the details of such
coverage within thirty-one (31) days after the date of such request, the benefits
payable under the converted policy may be based on the hospital or surgical or
medical expenses actually incurred after excluding expenses to the extent of
the amount of benefits provided or available therefor from any of the sources
referred to in paragraphs (a) and (b) of this subsection. A converted policy may
contain any provisions permitted herein and may also include any other
provisions not expressly prohibited by law; and any provision required to be
permitted herein may be made a part of any such policy by means of an
endorsement or rider.
Effective:July 13, 1984
History: Amended 1984 Ky. Acts ch. 322, sec. 13, effective July 13, 1984. -Created 1978 Ky. Acts ch. 158, sec. 2, effective June 17, 1978.
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