2006 Louisiana Laws - RS 22:215 — Group, family group, blanket, and association health and accident insurance

§215.  Group, family group, blanket, and association health and accident insurance

A.  Any insurer authorized to write health and accident insurance in this state shall have power to issue policies described in this Section.

(1)  Group health and accident insurance is any policy of health and accident insurance, or similar coverage issued by a health maintenance organization, covering more than one person, except family group, and blanket policies hereinafter specifically provided for, which shall conform to the following requirements:

(a)(i)  The policy shall be issued to an employer or association, or trustees of a fund established by an employer or association, who shall be deemed the policyholder, covering one or more employees of such employer or one or more employees of members of such association, for the benefit of persons other than the employer, or the association, its officers or trustees, upon some plan which will preclude individual selection.

(ii)  The premium may be paid by the employer or association, by the employees or members, or by the two parties jointly.  An insurer may but shall not be required to establish a percentage of eligible employees who are required to enroll and participate in a group health and accident policy if the entire premium is not paid by the employer or association.

(iii)  If the policy is issued to any employer, any class or classes of employees eligible for coverage must be determined by conditions pertaining to their employment or age.

(iv)  No such policy issued under individual certificates and considered as individual insurance coverage for purposes of this Part and Part VI-C of this Chapter may be issued to an association unless such association, having had an active existence for at least five years, has a constitution and bylaws and has been organized and is maintained in good faith for purposes other than those of obtaining insurance. No such policy, issued and considered as group health insurance, as defined under R.S. 22:250.1(2)(c), may be issued to an association unless it is a bona fide association as defined under R.S. 22:250.1(5)(b).

(v)  The insurer shall issue to the employer or association for delivery to each employee or member insured under such group policy, an individual certificate containing a statement as to the insurance protection to which he is entitled and to whom payable.

(vi)  The policy may be issued to an employer, association, or to the trustees of a fund established by two or more employers in the same industry or by one or more labor unions, or by one or more employers and one or more labor unions, or to a multiple employer trust established by an insurer on behalf of participating employers, provided all participating employers and employees have the same statutory protections that would apply if such policy was purchased by the employer directly from the insurer, which trustees shall be deemed the policyholder, to insure with or without any eligible family members including spouse, unmarried children under twenty-one years of age, and unmarried grandchildren who are in the legal custody of and residing with the grandparent under twenty-one years of age, employees of the employers or members of the association or of the unions for the benefit of persons other than the employers or the unions.

(b)  The benefits payable under any policy or contract of group health and accident insurance shall be payable to the employee or members or to some beneficiary or beneficiaries designated by him, other than the employer, but if there is no designated beneficiary as to all or any part of the insurance at the death of the employee or member, then the amount of insurance payable for which there is no designated beneficiary shall be payable to the estate of the employee or member, except that the insurer may in such case, at its option, pay such insurance to any one or more of the following surviving relatives of the employee or member:  wife, husband, mother, father, child, or children, brothers or sisters; and except that payment of benefits for expenses incurred on account of hospitalization or medical or surgical aid, may be made by the insurer to the hospital or other person or persons furnishing such aid.  Payment so made shall discharge the insurer's obligations with respect to the amount of insurance so paid.

(c)  Repealed by Acts 2003, No. 129, §2, eff. May 28, 2003.

(d)  Except as may otherwise be provided in the policy or contract of group health and accident insurance or by R.S. 22:228, the policyholder and the insurer may agree to modify, amend, or cancel the group policy, and such agreement shall be binding upon the employee or member insured under the group policy, provided that the modification, amendment, or cancellation shall be without prejudice to any claim for benefits accrued, or for expenses incurred for services rendered, prior to such modification, amendment, or cancellation.  Benefits and expenses incurred shall be as defined and limited by the terms of the policy; however, upon cancellation by the insurer, the insurer shall only be liable for any claim for benefits accrued, or for expenses incurred for services rendered, subsequent to the cancellation date if the subsequent claim is for an illness or condition which was the basis of any claim prior to cancellation and for which the insurer had notice.  Any cancellation pursuant to this Paragraph shall also comply with the provisions of R.S. 22:636(F).

(e)  Except as may otherwise be provided in the policy or contract of group health and accident insurance, the insurer shall not be liable for benefits accrued, or for expenses incurred for services rendered, subsequent to the termination date where the policy of insurance terminates for failure of the group policyholder to pay premiums or where the employee's or member's coverage terminated for failure of the employee or member to maintain eligibility as provided in the policy or contract of group health and accident insurance.

(2)(a)  Except as provided in Subparagraph (b) of this Paragraph, family group health and accident insurance or similar coverage issued by a health maintenance organization is an individual policy covering any one person, with or without any eligible members, including spouse and unmarried children under twenty-one years of age or, in the case of full-time students, unmarried children under the age of twenty-four, and unmarried grandchildren under twenty-one years of age in the legal custody of and residing with the grandparent or, in the case of full-time students, unmarried grandchildren under the age of twenty-four who are in the legal custody of and residing with the grandparent, except that the policy may provide for continuing coverage for any unmarried child or grandchild in the legal custody of and residing with the grandparent who is incapable of self-sustaining employment by reason of mental retardation or physical handicap, who became so incapable prior to attainment of age twenty-one, and any other person dependent upon the policyholder, written under a master policy issued to the head of such family. The policy shall contain a provision that the policy, and the application of the head of the family if attached thereto, shall constitute the entire contract between the parties.

(b)  Every family group health and accident insurance policy or health maintenance organization subscriber agreement which provides coverage, pursuant to Subparagraph (a) of this Paragraph, to a policyholder's unmarried children under the age of twenty-four who are full-time students or the policyholder's unmarried grandchildren in the legal custody of and residing with the policyholder who are full-time students under the age of twenty-four shall continue coverage under such policy if such child or grandchild develops a mental or nervous condition, problem, or disorder which, in the opinion of a qualified psychiatrist, subject, if deemed necessary by the insurer or health maintenance organization, to a second opinion, prevents the unmarried child or grandchild from attending school as a full-time student and from holding self-sustaining employment provided the child or grandchild is under the age of twenty-four.

(3)  Blanket health and accident insurance is any policy covering special groups of persons as enumerated in one of the following Subparagraphs (a) through (g):

(a)  Under a policy or contract issued to any common carrier, which shall be deemed the policyholder, covering a group defined as all persons who may become passengers on such common carrier.

(b)  Under a policy issued to an employer, who shall be deemed the policyholder, covering any group of employees defined by reference to exceptional hazards incident to such employment.

(c)  Under a policy issued to a college, school, or other institution of learning or to the head or principal thereof, who or which shall be deemed the policyholder, covering students or teachers.

(d)  Under a policy issued in the name of any volunteer fire department, first aid, or other such volunteer group, which shall be deemed the policyholder, covering all of the members of such department or group.

(e)  Under a policy or contract issued to a creditor who shall be deemed the policyholder to insure debtors of the creditor.

(f)  Under a policy issued to any other substantially similar group which, in the discretion of the commissioner of insurance, may be subject to the issuance of a blanket health and accident policy.

(g)  Under a policy or contract issued to the Department of Health and Hospitals, which shall be deemed the policyholder, covering a group defined as all persons who are eligible for medical assistance pursuant to a coverage program implemented pursuant to approval of the secretary of the United States Department of Health and Human Services using authority granted under Section 1115 of the Social Security Act.

(h)  An individual application shall not be required from a person covered under such a blanket policy.  The insurer shall furnish to the policyholder for delivery to the insured a certificate of insurance which shall disclose the benefits, limitations, exclusions, and reductions contained in the policy and the provisions relating to notice of claim, proof of loss, time of payment of claim, and any other relevant information, including the name and address of the insurer.  All benefits under any such blanket policy shall be payable to the person insured, or to his designated beneficiary or beneficiaries, if the policy permits the designation of named beneficiaries, or to his estate, except that if the person insured be a minor such benefits may be made payable to his parent, guardian, or other person actually supporting him.

(4)  Repealed by Acts 2003, No. 129, §2, eff. May 28, 2003.

B.  The term "employees" as used in this Section shall be deemed to include, for the purposes of insurance hereunder, as employees of a single employer, the officers, managers, and employees of the employer and of subsidiary or affiliated corporations of a corporation employer, and the individual proprietors, partners, and employees of individuals and firms of which the business is controlled by the insured employer through stock ownership, contract or otherwise.  The term "employer" as used herein may be deemed to include any governmental corporation, unit, agency or department thereof, or the proper officers, as such, of any unincorporated governmental organization.

C.  Insurers issuing policies under this Section shall be subject to all the other applicable provisions of this Part and Part VI-C.  In addition, policies issued under this Section shall also contain a provision that to the group or class thereof originally insured shall be added:

(1)  All new persons becoming eligible for and applying for insurance in such group or class, including new members of a family group; and

(2)  Any persons required to be provided coverage under federal law who apply for insurance in such group or class.

D.  Any policy issued under this Section may provide for the readjustment of the rate of premium based on the experience thereunder at the end of the first year or of any subsequent year of insurance thereunder, and such readjustment may be made retroactive only for such policy year.  Any refund under any plan for readjustment of the rate of premium based on the experience under group policies heretofore or hereafter issued, and any dividend paid under such policies may be issued to reduce the employer's share of the cost of the coverage, except that if the aggregate refunds or dividends under such group policy and any other group policy or contract issued to the policyholder exceed the aggregate contributions of the employer toward the cost of the coverages, such excess shall be applied by the policyholder for the sole benefit of insured employees.

E.  Any group, family group, blanket, or association health and accident insurer, including a group health plan as defined by Section 607(1) of the Employee Retirement Income Security Act of 1974, self-insurance plan, health maintenance organization, nonprofit hospital or medical service organization, or the Office of Group Benefits, shall be prohibited from any consideration of the availability or eligibility for medical assistance in this or any other state, as mandated under federal law, as a requirement of eligibility for coverage or payment under its policy, plan, certificate, or agreement for its policyholders, enrollees, members, certificate holders, or their dependents.

Acts 1958, No. 125.  Amended by Acts 1966, No. 172, §1; Acts 1972, No. 138, §1; Acts 1972, No. 415, §1; Acts 1980, No. 701, §1; Acts 1985, No. 249, §1; Acts 1989, No. 269, §1; Acts 1991, No. 777, §1, eff. Sept. 30, 1991; Acts 1992, No. 637, §1, eff. July 2, 1992; Acts 1993, No. 57, §1; Acts 1993, No. 296, §1; Acts 1993, No. 652, §1, eff. Jan. 1, 1994; Acts 1993, No. 663, §1, eff. June 16, 1993; Acts 1995, No. 593, §2; Acts 1995, No. 717, §1; Acts 1997, No. 1138, §1, eff. July 14, 1997; Acts 1997, No. 1175, §1; Acts 1999, No. 30, §1; Acts 1999, No. 474, §1; Acts 2001, No. 1178, §2, eff. June 29, 2001; Acts 2003, No. 129, §§1 and 2, eff. May 28, 2003; Acts 2004, No. 325, §1, eff. June 18, 2004; Acts 2004, No. 751, §1.