There is a newer version of the New York Consolidated Laws
2006 New York Code - Individual Accident And Health Insurance Policy Provisions.
§ 3216. Individual accident and health insurance policy provisions.
(a) In this section the term:
(1) "Policy of accident and health insurance" includes any individual
policy or contract covering the kind or kinds of insurance described in
paragraph three of subsection (a) of section one thousand one hundred
thirteen of this chapter.
(2) "Indemnity" means benefits promised.
(3) "Family" may include husband, wife, or dependent children, or any
other person dependent upon the policyholder.
(4) "Dependent children" includes any children under a specified age
which shall not exceed age nineteen except:
(A) Any unmarried dependent child, regardless of age, who is incapable
of self-sustaining employment by reason of mental illness, developmental
disability, or mental retardation as defined in the mental hygiene law,
or physical handicap and who became so incapable prior to the age at
which dependent coverage would otherwise terminate, shall be included in
coverage subject to any pre-existing conditions limitation applicable to
other dependents.
(B) Any unmarried student at an accredited institution of learning may
be considered a dependent child until attaining age twenty-three.
(b) No policy of accident and health insurance, including
non-cancellable disability insurance, except as provided in subsection
(h) hereof, shall be delivered or issued for delivery in this state
until the rate manual showing rates, rules and classifications of risks
for use in connection with such accident and health insurance policies
or with riders or endorsements thereon, has been filed with the
superintendent.
(c) No policy of accident and health insurance 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) It purports to insure only one person, except that a policy may
insure, originally or by subsequent amendment, members of a family, as
defined herein, upon the application of an adult member of the family
who shall be deemed the policyholder.
(4) (A) Coverage of an unmarried dependent child who is incapable of
self-sustaining employment by reason of mental illness, developmental
disability, or mental retardation, as defined in the mental hygiene law,
or physical handicap and who became so incapable prior to attainment of
the age at which dependent coverage would otherwise terminate and who is
chiefly dependent upon such policyholder for support and maintenance,
shall not terminate while the policy remains in force and the dependent
remains in such condition, if the policyholder has within thirty-one
days of such dependent's attainment of the limiting age submitted proof
of such dependent's incapacity as described herein.
(B) Coverage of a dependent spouse or named insured which would
terminate upon such spouse or named insured attaining the age prescribed
in subchapter XVIII of the federal Social Security Act, 42 U.S.C. §§
1395 et seq. ("medicare"), as the age of first eligibility for the
benefits provided by such law shall not so terminate, if such dependent
spouse is not then eligible for all of such benefits, for as long as the
policy remains in force and such dependent spouse remains ineligible to
receive any of such "medicare" benefits, provided proof of such
ineligibility is submitted to the insurer within thirty-one days of the
date notice of termination of coverage be sent by first class mail by
the insurer to the last known address of the policyholder.
(C) Any family coverage shall provide that coverage of newborn
infants, including newly born infants adopted by the insured or
subscriber if such insured or subscriber takes physical custody of the
infant upon such infant's release from the hospital and files a petition
pursuant to section one hundred fifteen-c of the domestic relations law
within thirty days of birth; and provided further that no notice of
revocation to the adoption has been filed pursuant to section one
hundred fifteen-b of the domestic relations law and consent to the
adoption has not been revoked, shall be effective from the moment of
birth for injury or sickness including the necessary care and treatment
of medically diagnosed congenital defects and birth abnormalities
including premature birth, except that in cases of adoption, coverage of
the initial hospital stay shall not be required where a birth parent has
insurance coverage available for the infant's care. In the case of
individual coverage the insurer must also permit the person to whom the
policy is issued to elect such coverage of newborn infants from the
moment of birth. If notification and/or payment of an additional premium
or contribution is required to make coverage effective for a newborn
infant, the coverage may provide that such notice and/or payment be made
within no less than thirty days of the day of birth to make coverage
effective from the moment of birth. This election shall not be required
in the case of student insurance.
(5) (A) Any family policy providing hospital or surgical expense
insurance (but not including such insurance against accidental injury
only) shall provide that, in the event such insurance on any person,
other than the policyholder, is terminated because the person is no
longer within the definition of the family as set forth in the policy
but before such person has attained the limiting age, if any, for
coverage of adults specified in the policy, such person shall be
entitled to have issued to him by the insurer, without evidence of
insurability, upon application therefor and payment of the first
premium, within thirty-one days after such insurance shall have
terminated, an individual conversion policy. The conversion privilege
afforded herein shall also be available upon the divorce or annulment of
the marriage of the policyholder to the former spouse of such
policyholder.
(B) Written notice of entitlement to a conversion policy shall be
given by the insurer to the policyholder at least fifteen and not more
than sixty days prior to the termination of coverage due to the initial
limiting age of the covered dependent. Such notice shall include an
explanation of the rights of the dependent with respect to his being
enrolled in an accredited institution of learning or his incapacity for
self-sustaining employment by reason of mental illness, developmental
disability or mental retardation as defined in the mental hygiene law or
physical handicap.
(C) Such individual conversion policy shall be subject to the
following terms and conditions:
(i) The premium shall be that applicable to the class of risk to which
such person belongs, to the age of such person and to the form and
amount of insurance therefor.
(ii) Such policy shall provide, on a basis specified in the family
policy, the same or substantially the same benefits as those provided in
the family policy or such benefits as are provided in a policy
specifically approved as an individual conversion policy by the
superintendent.
(iii) The benefits provided under such policy shall become effective
upon the date that such person was no longer eligible under the family
policy.
(iv) The policy may exclude any condition excluded by the family
policy for such person at the time of the termination of his insurance
thereunder. The policy shall not exclude any other pre-existing
conditions, but the benefits paid under such policy may be reduced by
the amount of any such benefits payable under the family policy after
the termination of such person's insurance thereunder and, during the
first policy year of the conversion policy, the benefits payable under
the policy may be reduced so that they are not in excess of those that
would have been payable had such person's insurance under the family
policy remained in force and effect.
(v) No insurer shall be required to issue a conversion policy if it
appears that the person applying for such policy shall have at that time
in force another insurance policy or hospital service or medical expense
indemnity contract providing similar benefits or is covered by or is
eligible for coverage by a group insurance policy or contract providing
similar benefits or shall be covered by similar benefits required by any
statute or provided by any welfare plan or program, which together with
the conversion policy would result in overinsurance or duplication of
benefits according to standards on file with the superintendent relating
to individual policies.
(vi) The policy may include a provision whereby the insurer may
request information at any premium due date of the policy of the person
covered thereunder as to whether he is then covered by another policy or
hospital service or medical expense indemnity corporation subscriber
contract providing similar benefits or is then covered by a group
contract or policy providing similar benefits or is then provided with
similar benefits required by any statute or provided by any welfare plan
or program. If any such person is so covered or so provided and fails
to furnish the details of such coverage when requested, the benefits
payable under the conversion policy may be based on the hospital
surgical or medical expenses actually incurred after excluding expenses
to the extent they are payable under such other coverage or provided
under such statute, plan, or program.
(6) The style, arrangement and overall appearance of the policy give
no undue prominence to any portion of the text, and unless 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
lower-case unspaced alphabet length not less than one hundred
twenty-point (the "text" shall include 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).
(7) The exceptions and reductions of indemnity are set forth in the
policy and, except those which are set forth in subsection (d) of this
section, 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 that 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.
(8) 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.
(9) It contains no provision purporting to make any portion of the
charter, rules, constitution, or by-laws 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
superintendent.
(10) There is prominently printed on the first page thereof or there
is attached thereto a notice to the effect that during a specified
period of time, which shall not be less than ten days nor more than
twenty days from the date the policy is delivered to the policyholder,
it may be surrendered to the insurer together with a written request for
cancellation of the policy and in such event the insurer will refund any
premium paid therefor including any policy fees or other charges,
provided, however, that this paragraph shall not apply to single premium
nonrenewable policies insuring against accidents only or accidental
bodily injuries only; provided, however, that a contract or certificate
sold by mail order and a contract or certificate providing medicare
supplemental insurance or long-term care insurance must contain a
provision permitting the contract or certificate holder a thirty day
period for such surrender.
(11) The age limit or date or period, if any, after which the coverage
provided by the policy will not be effective or the age limit, date or
period after which the policy may not be renewed is stated in a renewal
provision set forth on the first page of the policy or as a separate
provision bearing an appropriate caption on the first page of the policy
or in a brief description in not less than fourteen-point bold face type
set forth on the first page of the policy. Nothing herein contained
shall limit or restrict the right of the insurer to continue the policy
after the age or period so stated.
(12) Any policy, other than one issued in fulfillment of the
continuing care responsibilities of an operator of a continuing care
retirement community in accordance with article forty-six of the public
health law, made available because of residence in a particular
facility, housing development, or community shall contain the following
notice in twelve point type in bold face on the first page:
"NOTICE - THIS POLICY DOES NOT MEET THE REQUIREMENTS OF A CONTINUING
CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE WILL NOT QUALIFY
A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY."
(13) Any persons covered by the policy who are also members of a
reserve component of the armed forces of the United States, including
the National Guard, shall be entitled, upon written request, to have
their coverage suspended during a period of active duty as described
herein.
The policy shall provide that the insurer will refund any unearned
premiums for the period of such suspension. Persons covered by the
policy shall be entitled to resumption of coverage, upon written
application and payment of the required premium within sixty days after
the date of termination of the period of active duty, with no
limitations or conditions imposed as a result of such period of active
duty except as set forth in subparagraphs (A) and (B) herein. Coverage
shall be retroactive to the date of termination of the period of active
duty. Such right of resumption provided for herein shall be in addition
to other existing rights granted pursuant to state and federal laws and
regulations and shall not be deemed to qualify or limit such rights in
any way. No exclusion or waiting period may be imposed in connection
with coverage of a health or physical condition of a person entitled to
such right of resumption, or a health or physical condition of any other
person who is covered by the policy unless:
(A) the condition arose during the period of active duty and the
condition has been determined by the secretary of veterans affairs to be
a condition incurred in the line of duty; or
(B) a waiting period was imposed and had not been completed prior to
the period of suspension; in no event, however, shall the sum of the
waiting periods imposed prior to and subsequent to the period of
suspension exceed the length of the waiting period originally imposed.
(14) To be entitled to the right defined in paragraph thirteen of this
subsection a person must be a member of a component of the armed forces
of the United States, including the National Guard, who either:
(A) voluntarily or involuntarily enters upon active duty (other than
for the purpose of determining his or her physical fitness and other
than for training), or
(B) has his or her active duty voluntarily or involuntarily extended
during a period when the president is authorized to order units of the
ready reserve or members of a reserve component to active duty, provided
that such additional active duty is at the request and for the
convenience of the federal government, and
(C) serves no more than four years of active duty.
(d) Each policy of accident and health insurance delivered or issued
for delivery to any person in this state shall contain the provisions
specified herein in the words in which the same appear in this
subsection, except that the insurer may, at its option, substitute for
one or more of such provisions corresponding provisions of different
wording approved by the superintendent which are not less favorable in
any respect to the insured or the beneficiary. Each provision contained
in the policy shall be preceded by the applicable caption herein or, at
the insurer's option, by such appropriate captions or subcaptions as the
superintendent may approve.
(1) Each policy shall, except with respect to designation by numbers
or letters as used below, contain the following provisions:
(A) 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 or broker has authority to change
this policy or to waive any of its provisions.
(B) TIME LIMIT ON CERTAIN DEFENSES: (i) After two years from the date
of issue of this policy no misstatements, except fraudulent
misstatements, made by the applicant in the application for such policy
shall be used to void the policy or to deny a claim for loss incurred or
disability (as defined in the policy) commencing after the expiration of
such two year period.
(The foregoing policy provision shall not be so construed as to affect
any legal requirement for avoidance of a policy or denial of a claim
during such initial two year period, nor to limit the application of
subparagraphs (A) through (E), inclusive, of this paragraph in the event
of misstatement with respect to age or occupation or other insurance.)
(A policy which the insured has the right to continue in force subject
to its terms by the timely payment of premium until at least age fifty
or, in the case of a policy issued after age forty-four, for at least
five years from its date of issue, may contain in lieu of the foregoing
the following provision (from which the clause in parentheses may be
omitted at the insurer's option) under the caption "INCONTESTABLE":
After this policy has been in force for a period of two years during
the lifetime of the insured (excluding any period during which the
insured is disabled), it shall become incontestable as to the statements
contained in the application.)
(ii) No claim for loss incurred or disability (as defined in the
policy) commencing after two years from the date of issue of this policy
shall be reduced or denied on the ground that a disease or physical
condition not excluded from coverage by name or specific description
effective on the date of loss had existed prior to the effective date of
coverage of this policy.
(C) GRACE PERIOD: A grace period of ........................ (insert a
number not less than "7" for weekly premium policies, "10" for monthly
premium policies and "31" 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 in which the insurer reserves the right to refuse renewal
shall have, at the beginning of the above provision, the following
clause:
"Unless not less than thirty days prior to the renewal date the
insurer has delivered to the insured or has sent by first class mail 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,"
Furthermore, such a policy, except an accident only policy, shall also
provide in substance, in a provision thereof, or in an endorsement
thereon or in a rider attached thereto, that the insurer may refuse
renewal of the policy only as of the renewal date occurring on, or
nearest its first anniversary, or as of an anniversary of such renewal
date, or at the option of the insurer as of the renewal date occurring
on or nearest the anniversary of its date of last reinstatement.)
(D) REINSTATEMENT: If any renewal premium be not paid within the time
granted the insured for payment, a subsequent acceptance of the premium
by the insurer or by any agent or broker duly authorized by the insurer
to accept such premium, without requiring in connection therewith an
application for reinstatement, shall reinstate the policy; provided,
however, that if the insurer or such agent or broker requires an
application for reinstatement and issues a conditional receipt for the
premium tendered, the policy will 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 until at least age fifty or,
in the case of a policy issued after age forty-four, for at least five
years from its date of issue.)
(E) 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 or to any authorized broker, 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.)
(F) CLAIM FORMS: The insurer, upon receipt of a notice of claim, will
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 extent
of the loss for which claim is made.
(G) PROOFS OF LOSS: Written proof of loss must 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.
(H) 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 will 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.
(I) PAYMENT OF CLAIMS: Any 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.)
(J) 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.
(K) 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.
(L) 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.)
(M) "CONVERSION PRIVILEGE" (under this caption) a provision which
shall set forth in substance the conversion privileges and related
provisions required of certain policies by paragraph five of subsection
(c) of this section.
(2) Other provisions. 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 (not
including the designation by number or letter) in which the same appear
in this paragraph except that the insurer may, at its option, use in
lieu of any such provision a corresponding provision of different
wording approved by the superintendent 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 herein or, at the option of the insurer,
by such appropriate individual or group captions or subcaptions as the
superintendent may approve.
(A) 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 this 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.
(B) MISSTATEMENT OF AGE: If the insured's age has been misstated, all
amounts payable under this policy shall be such as the premium paid
would have purchased at the correct age.
(C) OTHER INSURANCE IN THIS INSURER: If an accident or sickness or
accident and health 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 indemnities) the excess insurance shall be void and all
premiums paid for such excess shall be returned to the insured or to his
estate,
or, in lieu thereof:
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.
(D) 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 next following policy provision 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
superintendent, 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 superintendent. In the absence of such definition such
term 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 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".)
(E) 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 next preceding policy provision 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 superintendent, 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 superintendent. 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".)
(F) 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 for only 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 until at least age fifty or, 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 superintendent, which definition shall be limited in subject
matter to coverage provided by governmental agencies or by organizations
subject to regulation by the 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 superintendent 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.)
(G) 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.
(H) CANCELLATION: Within the first ninety days after the date of
issue, the insurer may cancel this policy by written notice delivered to
the insured, or sent by first class mail to his last address as shown by
the records of the insurer, stating when, not less than ten days
thereafter, such cancellation shall be effective. In the event of
cancellation, the insurer will return promptly the pro-rata unearned
portion of any premium paid. Cancellation shall be without prejudice to
any claim originating prior to the effective date of cancellation.
(Nothing in this subsection shall be construed to prohibit an insurer
from granting to the insured the right to cancel a policy at any time
and to receive in such event a refund of the unearned portion of any
premium paid, 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).
(I) 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.
(J) ILLEGAL OCCUPATION: The insurer shall not be liable for any loss
to which a contributing cause was the insured's commission of or attempt
to commit a felony or to which a contributing cause was the insured's
being engaged in an illegal occupation.
(K) INTOXICANTS AND NARCOTICS: The insurer shall not be liable for any
loss sustained or contracted in consequence of the insured's being
intoxicated or under the influence of any narcotic unless administered
on the advice of a physician.
(3) If any provision of this subsection 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
superintendent, 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.
(4) The provisions which are the subject of paragraphs one and two of
this subsection, or any corresponding provisions which are used in lieu
thereof in accordance with such paragraphs, shall be printed in the
consecutive order of the provisions in such paragraphs 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.
(5) The word "insured", as used in this section, 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.
(6) The superintendent may make such reasonable rules and regulations
concerning the procedure for the filing or submission of policies
subject to this section as are necessary, proper or advisable to the
administration of this section. This provision shall not abridge any
other authority granted the superintendent by law.
(e) The acknowledgment by any insurer of the receipt of notice given
under any policy covered by this section, 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.
(f) If any such 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 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 premium has been accepted. In the event 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, then 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.
(g)(1) No insurer shall refuse to renew a policy of hospital, surgical
or medical expense insurance, an individual converted policy, or any
other policy in which one-third or more of the total premium is
allocable to hospital, surgical or medical expense benefits, or any
combination thereof (but not including insurance against accidental
injury only), except for one or more of the following reasons:
(A) nonpayment of premiums,
(B) fraud in applying for the policy or in applying for any benefits
under the policy or intentional misrepresentation of material fact under
the terms of the coverage,
(C) discontinuance of a class of policies in accordance with paragraph
two of this subsection, except that no insurer or organization certified
pursuant to article forty-four of the public health law shall refuse to
renew the policies of insureds holding contracts which provide major
medical or similar comprehensive type coverage in effect prior to June
first, two thousand one who are ineligible to purchase policies offered
pursuant to section four thousand three hundred twenty-one or four
thousand three hundred twenty-two of this chapter due to the provisions
of section 42 USC 1395ss in effect on January first, two thousand one,
and who are eligible for Medicare benefits by reason of disability.
(i) Coverage shall be reinstated only for such insureds terminated on
or after January first, two thousand one and such coverage shall be
reinstated on a prospective basis only, irrespective of any pre-existing
conditions.
(ii) In the event any such insured becomes eligible to purchase
policies offered pursuant to section four thousand three hundred
twenty-one or four thousand three hundred twenty-two of this chapter,
then such insured may be discontinued upon not less than five months
prior written notice. In the event any such insured becomes eligible for
Medicare by reason of age, then such insured may be terminated by not
less than thirty days notice with prior written notice.
(iii) Within sixty days of this item taking effect, the insurer or
organization shall notify the insured of the prospective reinstatement
of coverage under this section. Within thirty days of receipt of such
notice, an insured shall notify the insurer or organization of his or
her election for prospective coverage,
(D) discontinuance of all hospital, surgical and medical expense
coverage in the individual market in this state in accordance with
paragraph three of this subsection,
(E) in the case of an insurer that offers coverage in the individual
market through a network plan, termination of an individual who no
longer resides, lives or works in the service area (or in an area for
which the insurer is authorized to do business) but only if such
coverage is terminated under this subparagraph uniformly without regard
to any health status-related factor of covered individuals, and
(F) for such other reasons as are acceptable to the superintendent and
authorized by the Health Insurance Portability and Accountability Act of
1996, Public Law 104-191, and any later amendments or successor
provisions, or by any federal regulations or rules that implement the
provisions of the Act.
In no event shall any insurer refuse to renew any such policy because
of the physical or mental condition or the health of any person covered
thereunder. Furthermore, no insurer shall require as a condition for the
renewal of any such policy any rider, endorsement or other attachment
which shall limit the nature or extent of the benefits provided
thereunder. The superintendent may require every insurer to file with
him such documents, statistics or other information regarding the
refusal to renew permitted by this subsection as he may deem necessary
for the proper administration of this subsection.
(2) In any case in which an insurer decides to discontinue offering a
class of hospital, surgical or medical expense policies in the
individual health insurance market, coverage of the class of policies
may be discontinued by the insurer only if:
(A) the insurer gives at least ninety days prior written notice of
such discontinuance to the superintendent;
(B) the insurer provides written notice of such discontinuance to each
covered individual at least ninety days prior to the date of
discontinuance of such coverage;
(C) the insurer offers to each covered individual the option to
purchase all other individual hospital, surgical and medical expense
coverage currently being offered by the insurer in the individual health
insurance market; and
(D) in exercising the option to discontinue coverage of a class of
policies and in offering the option of coverage under subparagraph (C)
of this paragraph, the insurer acts uniformly without regard to claims
experience or to any health status-related factor of insured individuals
or individuals who may become eligible for such coverage.
(3) In any case in which an insurer elects to discontinue offering all
hospital, surgical and medical expense coverage in the individual market
in this state, health insurance coverage may be discontinued by the
insurer only if:
(A) the insurer gives at least one hundred eighty days prior written
notice of such discontinuance to the superintendent;
(B) the insurer provides written notice of such discontinuance to each
covered individual at least one hundred eighty days prior to the date of
termination of such coverage;
(C) all hospital, surgical and medical expense coverage issued or
delivered for issuance in this state in the individual market is
discontinued and coverage under such health insurance coverage in such
market is not renewed; and
(D) in addition to the notice referred to in subparagraph (A) of this
paragraph, the insurer must provide the superintendent with a written
plan to minimize potential disruption in the marketplace occasioned by
its withdrawal from the individual market.
(4) In the case of a discontinuance under paragraph three of this
subsection, the insurer may not provide for the issuance of any policy
of hospital, surgical or medical expense insurance in the individual
market in this state during the five year period beginning on the date
of the discontinuance of the last health insurance coverage not so
renewed.
(5) At the time of coverage renewal, an insurer may modify the health
insurance coverage for a policy form offered to individuals in the
individual market so long as such modification is consistent with this
chapter and effective on a uniform basis among all individuals with that
policy form.
(6) For purposes of this subsection the term "network plan" shall mean
a health insurance policy under which the financing and delivery of
health care (including items and services paid for as such care) are
provided, in whole or in part, through a defined set of providers under
contract with the insurer or another entity which has contracted with
the insurer.
(h) This section shall not apply to or affect:
(1) Any contract of non-cancellable disability insurance which is
governed by or excepted from section three thousand two hundred fifteen
of this article.
(2) Any policy or contract of reinsurance.
(3) Any policy of group or blanket insurance which is governed by
section three thousand two hundred twenty-one of this article except
that the provisions of subsection (b) hereof and paragraphs one through
ten of subsection (i) hereof and the provisions of subsection (j) hereof
shall be applicable to a policy of group insurance authorized under
subparagraph (J) of paragraph one of subsection (c) of section four
thousand two hundred thirty-five of this chapter.
(4) Any policy providing disability benefits pursuant to article nine
of the workers' compensation law.
(5) Any policy of a co-operative life and accident insurance company
except as was provided in section two hundred thirty-seven of the former
insurance law.
(6) Life insurance, endowment or annuity contracts, or contracts
supplemental thereto which contain only such provisions relating to
accident and health insurance as provide additional benefits in case of
death or dismemberment or loss of sight by accident, or as 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 shall become totally and permanently disabled, as defined by
the contract or supplemental contract.
(i) Every person insured under a policy of accident and health
insurance delivered or issued for delivery in this state shall be
entitled to the reimbursements and coverages specified below.
(1) If a policy provides for reimbursement for any optometric service
which is within the lawful scope of practice of a licensed optometrist,
the insured shall be entitled to reimbursement for such service whether
it is performed by a physician or licensed optometrist. Unless such
policy shall otherwise provide there shall be no reimbursement for
ophthalmic materials, lenses, spectacles, eyeglasses, or appurtenances
thereto.
(2) If a policy provides for reimbursement for any podiatrical service
within the lawful scope of practice of a licensed podiatrist, the
insured shall be entitled to reimbursement for such service whether it
is performed by a physician or licensed podiatrist.
(3) If a policy provides for reimbursement for any dental service
within the lawful scope of practice of a licensed dentist, the insured
shall be entitled to reimbursement for such service whether it is
performed by a physician or a licensed dentist.
(4) If a policy provides for reimbursement for psychiatric or
psychological services or for diagnosis and treatment of mental,
nervous, or emotional disorders or ailments, however defined in the
policy, the insured shall be entitled to reimbursement for such
services, diagnosis or treatment whether performed by a physician,
psychiatrist or a certified and registered psychologist, when the
services rendered are within the lawful scope of their practice.
(5) Every policy providing for reimbursement for laboratory tests or
reimbursement for diagnostic X-ray services shall provide for
reimbursement at the same percentage of reimbursement whether such tests
or services are provided to the insured as an admitted patient in a
health care facility or as an out-patient.
(6) Every policy which provides coverage for in-patient hospital care
shall provide coverage for home care to residents in this state. Such
home care coverage shall be included at the inception of all new
policies and, with respect to all other policies, at any anniversary
date of the policy subject to evidence of insurability.
(A) Home care means the care and treatment of a covered person who is
under the care of a physician but only if hospitalization or confinement
in a nursing facility as defined in subchapter XVIII of the federal
Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been
required if home care was not provided, and the plan covering the home
health service is established and approved in writing by such physician.
Home care shall be provided by an agency possessing a valid certificate
of approval or license issued pursuant to article thirty-six of the
public health law and shall consist of one or more of the following:
(i) Part-time or intermittent home nursing care by or under the
supervision of a registered professional nurse (R.N.).
(ii) Part-time or intermittent home health aide services which consist
primarily of caring for the patient.
(iii) Physical, occupational or speech therapy if provided by the home
health service or agency.
(iv) Medical supplies, drugs and medications prescribed by a
physician, and laboratory services by or on behalf of a certified home
health agency or licensed home care services agency to the extent such
items would have been covered under the contract if the covered person
had been hospitalized or confined in a skilled nursing facility as
defined in title subchapter XVIII of the federal Social Security Act, 42
U.S.C. §§ 1395 et seq.
(B) Coverage may be subject to an annual deductible of not more than
fifty dollars for each person covered under the policy and may be
subject to a coinsurance provision which provides for coverage of not
less than seventy-five percent of the reasonable charges for such
services. For the purpose of determining the benefits for home care
available to a covered person, each visit by a member of a home care
team shall be considered as one home care visit; the contract may
contain a limitation on the number of home care visits, but not less
than forty such visits in any calendar year or in any continuous period
of twelve months for each person covered under the contract; four hours
of home health aide service shall be considered as one home care visit.
(7) Every policy which provides coverage for in-patient hospital care
shall also provide coverage for pre-admission tests performed in
hospital out-patient facilities prior to scheduled surgery provided:
(A) the tests are ordered by a physician as a planned preliminary to
admission of the patient as an in-patient for surgery in the same
hospital;
(B) tests are necessary for and consistent with the diagnosis and
treatment of the condition for which surgery is to be performed;
(C) reservations for a hospital bed and for an operating room shall
have been made prior to the performance of the tests;
(D) the surgery actually takes place within seven days of such
presurgical tests; and
(E) the patient is physically present at the hospital for the tests.
(8) Every policy which provides coverage for in-patient surgical care
shall include coverage for a second surgical opinion by a qualified
physician on the need for surgery.
(9) Every policy which provides coverage for inpatient hospital care
shall also include coverage for services to treat an emergency condition
in hospital facilities. An "emergency condition" means a medical or
behavioral condition, the onset of which is sudden, that manifests
itself by symptoms of sufficient severity, including severe pain, that a
prudent layperson, possessing an average knowledge of medicine and
health, could reasonably expect the absence of immediate medical
attention to result in (A) placing the health of the person afflicted
with such condition in serious jeopardy, or in the case of a behavioral
condition placing the health of such person or others in serious
jeopardy, or (B) serious impairment to such person's bodily functions;
(C) serious dysfunction of any bodily organ or part of such person; or
(D) serious disfigurement of such person.
(10) (A) (i) Every policy which provides hospital, surgical or medical
coverage shall provide coverage for maternity care, including hospital,
surgical or medical care to the same extent that hospital, surgical or
medical coverage is provided for illness or disease under the policy.
Such maternity care coverage, other than coverage for perinatal
complications, shall include inpatient hospital coverage for mother and
for newborn for at least forty-eight hours after childbirth for any
delivery other than a caesarean section, and for at least ninety-six
hours after a caesarean section. Such coverage for maternity care shall
include the services of a midwife licensed pursuant to article one
hundred forty of the education law, practicing consistent with a written
agreement pursuant to section sixty-nine hundred fifty-one of the
education law and affiliated or practicing in conjunction with a
facility licensed pursuant to article twenty-eight of the public health
law, but no insurer shall be required to pay for duplicative routine
services actually provided by both a licensed midwife and a physician.
(ii) Maternity care coverage shall also include, at minimum, parent
education, assistance and training in breast or bottle feeding, and the
performance of any necessary maternal and newborn clinical assessments.
(iii) The mother shall have the option to be discharged earlier than
the time periods established in item (i) of this subparagraph. In such
case, the inpatient hospital coverage must include at least one home
care visit, which shall be in addition to, rather than in lieu of, any
home health care coverage available under the policy. The policy must
cover the home care visit which may be requested at any time within
forty-eight hours of the time of delivery (ninety-six hours in the case
of caesarean section) and shall be delivered within twenty-four hours,
(I) after discharge, or (II) of the time of the mother's request,
whichever is later. Such home care coverage shall be pursuant to the
policy and subject to the provisions of this subparagraph, and not
subject to deductibles, coinsurance or copayments.
(B) Coverage provided under this paragraph for care and treatment
during pregnancy shall include provision for not less than two payments,
at reasonable intervals and for services rendered, for prenatal care and
a separate payment for the delivery and postnatal care provided.
(11) (A) Every policy which provides coverage for hospital, surgical
or medical care shall provide the following coverage for mammography
screening for occult breast cancer:
(i) upon the recommendation of a physician, a mammogram at any age for
covered persons having a prior history of breast cancer or whose mother
or sister has a prior history of breast cancer;
(ii) a single baseline mammogram for covered persons aged thirty-five
through thirty-nine, inclusive;
(iii) a mammogram every two years, or more frequently upon the
recommendation of a physician, for covered persons aged forty through
forty-nine, inclusive; and
(iv) an annual mammogram for covered persons aged fifty and older.
(B) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and as are consistent
with those established for other benefits within a given policy.
(C) For purposes of this paragraph, mammography screening means an
X-ray examination of the breast using dedicated equipment, including
X-ray tube, filter, compression device, screens, films and cassettes,
with an average glandular radiation dose less than 0.5 rem per view per
breast.
(11-a) (A) Every policy delivered or issued for delivery in this state
which provides medical coverage that includes coverage for physician
services in a physician's office and every policy which provides major
medical or similar comprehensive-type coverage shall provide, upon the
prescription of a health care provider legally authorized to prescribe
under title eight of the education law, the following coverage for
diagnostic screening for prostatic cancer:
(i) standard diagnostic testing including, but not limited to, a
digital rectal examination and a prostate-specific antigen test at any
age for men having a prior history of prostate cancer; and
(ii) an annual standard diagnostic examination including, but not
limited to, a digital rectal examination and a prostate-specific antigen
test for men age fifty and over who are asymptomatic and for men age
forty and over with a family history of prostate cancer or other
prostate cancer risk factors.
(B) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and as are consistent
with those established for other benefits within a given policy.
(12) (A) Every policy which provides coverage for prescribed drugs
approved by the food and drug administration of the United States
government for the treatment of certain types of cancer shall not
exclude coverage of any such drug on the basis that such drug has been
prescribed for the treatment of a type of cancer for which the drug has
not been approved by the food and drug administration. Provided,
however, that such drug must be recognized for treatment of the specific
type of cancer for which the drug has been prescribed in one of the
following established reference compendia:
(i) the American Medical Association Drug Evaluations;
(ii) the American Hospital Formulary Service Drug Information; or
(iii) the United States Pharmacopeia Drug Information; or recommended
by review article or editorial comment in a major peer reviewed
professional journal.
(B) Notwithstanding the provisions of this paragraph, coverage shall
not be required for any experimental or investigational drugs or any
drug which the food and drug administration has determined to be
contraindicated for treatment of the specific type of cancer for which
the drug has been prescribed. The provisions of this paragraph shall
apply to cancer drugs only and nothing herein shall be construed to
create, impair, alter, limit, modify, enlarge, abrogate or prohibit
reimbursement for drugs used in the treatment of any other disease or
condition.
(13) (A) Every policy which provides coverage for hospital care shall
not exclude coverage for hospital care for diagnosis and treatment of
correctable medical conditions otherwise covered by the policy solely
because the medical condition results in infertility.
(B) Every policy which provides coverage for surgical and medical care
shall not exclude coverage for surgical and medical care for diagnosis
and treatment of correctable medical conditions otherwise covered by the
policy solely because the medical condition results in infertility.
(14) If a policy provides for reimbursement for the services of
licensed health professionals who can bill for services, the insured
shall be entitled to reimbursement for such service provided pursuant to
a clinical practice plan established pursuant to subdivision fourteen of
section two hundred six of the public health law.
(15) (A) Every policy which provides hospital, surgical or medical
care coverage or provides reimbursement for laboratory tests or
reimbursement for diagnostic X-ray services shall provide coverage for
an annual cervical cytology screening for cervical cancer and its
precursor states for women aged eighteen and older.
(B) For purposes of this paragraph, cervical cytology screening shall
include an annual pelvic examination, collection and preparation of a
Pap smear, and laboratory and diagnostic services provided in connection
with examining and evaluating the Pap smear.
(C) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and as are consistent
with those established for other benefits within a given policy.
(15-a) (A) Every policy which provides medical coverage that includes
coverage for physician services in a physician's office and every policy
which provides major medical or similar comprehensive-type coverage
shall include coverage for the following equipment and supplies for the
treatment of diabetes, if recommended or prescribed by a physician or
other licensed health care provider legally authorized to prescribe
under title eight of the education law: blood glucose monitors and blood
glucose monitors for the visually impaired, data management systems,
test strips for glucose monitors and visual reading and urine testing
strips, insulin, injection aids, cartridges for the visually impaired,
syringes, insulin pumps and appurtenances thereto, insulin infusion
devices, and oral agents for controlling blood sugar. In addition, the
commissioner of the department of health shall provide and periodically
update by rule or regulation a list of additional diabetes equipment and
related supplies such as are medically necessary for the treatment of
diabetes, for which there shall also be coverage. Such policies shall
also include coverage for diabetes self-management education to ensure
that persons with diabetes are educated as to the proper self-management
and treatment of their diabetic condition, including information on
proper diets. Such coverage for self-management education and education
relating to diet shall be limited to visits medically necessary upon the
diagnosis of diabetes, where a physician diagnoses a significant change
in the patient's symptoms or conditions which necessitate changes in a
patient's self-management, or where reeducation or refresher education
is necessary. Such education may be provided by the physician or other
licensed health care provider legally authorized to prescribe under
title eight of the education law, or their staff, as part of an office
visit for diabetes diagnosis or treatment, or by a certified diabetes
nurse educator, certified nutritionist, certified dietitian or
registered dietitian upon the referral of a physician or other licensed
health care provider legally authorized to prescribe under title eight
of the education law. Education provided by the certified diabetes nurse
educator, certified nutritionist, certified dietitian or registered
dietitian may be limited to group settings wherever practicable.
Coverage for self-management education and education relating to diet
shall also include home visits when medically necessary.
(B) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and as are consistent
with those established for other benefits within a given policy.
(16) If a policy provides for reimbursement for speech-language
pathology or audiology service which is within the lawful scope of
practice of a duly licensed speech-language pathologist or audiologist,
an insured shall be entitled to reimbursement for such service whether
the said service is performed by a physician or duly licensed
speech-language pathologist or audiologist, provided however, that
nothing contained herein shall be construed to impair any terms of such
policy which may require said service to be performed pursuant to a
medical order, or a similar or related service of a physician, in which
case coverage need not be provided for any tests, evaluations or
diagnoses if such tests, evaluations or diagnoses have already been
provided by or through a physician within twelve months of the referral
or order from the physician. However, nothing herein shall be construed
as preventing an insurer from covering more than one test or evaluation
provided by a speech-language pathologist or audiologist within a
twelve-month period where such test or evaluation is ordered by a
physician as medically necessary. Nor shall anything herein be construed
as prohibiting the limitation of such services, where covered, to
specified settings other than offices, such as hospitals or to services
provided by such professionals as part of a home care agency's services.
(17) (A) Every policy which provides medical, major-medical or similar
comprehensive-type coverage shall provide coverage for the provision of
preventive and primary care services.
(B) For the purposes of this paragraph, preventive and primary care
services means the following services rendered to a dependent child of
an insured from the date of birth through the attainment of nineteen
years;
(i) an initial hospital check-up and well-child visits scheduled in
accordance with the prevailing clinical standards of a national
association of pediatric physicians designated by the commissioner of
health (except for any standard that would limit the specialty or forum
of licensure of the practitioner providing the service other than the
limits under state law). Coverage for such services rendered shall be
provided only to the extent that such services are provided by or under
the supervision of a physician, or other professional licensed under
article one hundred thirty-nine of the education law whose scope of
practice pursuant to such law includes the authority to provide the
specified services. Coverage shall be provided for such services
rendered in a hospital, as defined in section twenty-eight hundred one
of the public health law, or in an office of a physician or other
professional licensed under article one hundred thirty-nine of the
education law whose scope of practice pursuant to such law includes the
authority to provide the specified services;
(ii) at each visit, services in accordance with the prevailing
clinical standards of such designated association, including a medical
history, a complete physical examination, developmental assessment,
anticipatory guidance, appropriate immunizations and laboratory tests
which tests are ordered at the time of the visit and performed in the
practitioner's office, as authorized by law, or in a clinical
laboratory; and
(iii) necessary immunizations as determined by the superintendent in
consultation with the commissioner of health consisting of at least
adequate dosages of vaccine against diphtheria, pertussis, tetanus,
polio, measles, rubella, mumps, haemophilus influenzae type b and
hepatitis b which meet the standards approved by the United States
public health service for such biological products.
(C) Such coverage shall not be subject to annual deductibles and/or
coinsurance.
(D) Such coverage shall not restrict or eliminate existing coverage
provided by the policy.
(18) (A) Every policy which provides coverage for inpatient hospital
care shall provide such coverage for such period as is determined by the
attending physician in consultation with the patient to be medically
appropriate for such covered person undergoing a lymph node dissection
or a lumpectomy for the treatment of breast cancer or a mastectomy
covered by the policy. Such coverage may be subject to annual
deductibles and coinsurance as may be deemed appropriate by the
superintendent and as are consistent with those established for other
benefits within a given policy. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to inception
of such policy and annually thereafter.
(B) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph; or
(v) restrict coverage for any portion of a period within a hospital
length of stay required under this paragraph in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay.
(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition to the provisions of sections three thousand two hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing in this subparagraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(19) (A) Every policy which provides medical, major medical, or
similar comprehensive-type coverage must provide coverage for a second
medical opinion by an appropriate specialist, including but not limited
to a specialist affiliated with a specialty care center for the
treatment of cancer, in the event of a positive or negative diagnosis of
cancer or a recurrence of cancer or a recommendation of a course of
treatment for cancer, subject to the following:
(i) In the case of a policy that requires, or provides financial
incentives for, the insured to receive covered services from health care
providers participating in a provider network maintained by or under
contract with the insurer, the policy shall include coverage for a
second medical opinion from a non-participating specialist, including
but not limited to a specialist affiliated with a specialty care center
for the treatment of cancer, when the attending physician provides a
written referral to a non-participating specialist, at no additional
cost to the insured beyond what such insured would have paid for
services from a participating appropriate specialist. Provided however
that nothing herein shall impair an insured's rights (if any) under the
policy to obtain the second medical opinion from a non-participating
specialist without a written referral, subject to the payment of
additional coinsurance (if any) required by the policy for services
provided by non-participating providers. The insurer shall compensate
the non-participating specialist at the usual, customary and reasonable
rate, or at a rate listed on a fee schedule filed and approved by the
superintendent which provides a comparable level of reimbursement.
(ii) In the case of a policy that does not provide financial
incentives for, and does not require, the insured to receive covered
services from health care providers participating in a provider network
maintained by or under contract with the insurer, the policy shall
include coverage for a second medical opinion from a specialist at no
additional cost to the insured beyond what the insured would have paid
for comparable services covered under the policy.
(iii) Such coverage may be subject to annual deductibles and
coinsurance as may be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a given
policy, and, where applicable, consistent with the provisions of clauses
(i) and (ii) of this subparagraph.
Nothing in this paragraph shall eliminate or diminish an insurer's
obligation to comply with the provisions of section four thousand eight
hundred four of this chapter where applicable. Written notice of the
availability of such coverage shall be delivered to the policyholder
prior to the inception of such policy and annually thereafter.
(B) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph; or
(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph.
(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition to the provisions of sections three thousand two hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing in this subparagraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(20) (A) Every policy which provides medical, major medical, or
similar comprehensive-type coverage shall provide the following coverage
for breast reconstruction surgery after a mastectomy:
(i) all stages of reconstruction of the breast on which the mastectomy
has been performed; and
(ii) surgery and reconstruction of the other breast to produce a
symmetrical appearance;
in the manner determined by the attending physician and the patient to
be appropriate. Such coverage may be subject to annual deductibles and
coinsurance provisions as may be deemed appropriate by the
superintendent and as are consistent with those established for other
benefits within a given policy. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to inception
of such policy and annually thereafter.
(B) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph; or
(v) restrict coverage for any portion of a period within a hospital
length of stay required under this paragraph in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay.
(C) The prohibitions in this paragraph shall be in addition to the
provisions of sections three thousand two hundred thirty-one and three
thousand two hundred thirty-two of this article and nothing in this
paragraph shall be construed to suspend, supersede, amend or otherwise
modify such sections.
* (21) Every policy which provides coverage for prescription drugs
shall include coverage for the cost of enteral formulas for home use for
which a physician or other licensed health care provider legally
authorized to prescribe under title eight of the education law has
issued a written order. Such written order shall state that the enteral
formula is clearly medically necessary and has been proven effective as
a disease-specific treatment regimen for those individuals who are or
will become malnourished or suffer from disorders, which if left
untreated, cause chronic physical disability, mental retardation or
death. Specific diseases for which enteral formulas have been proven
effective shall include, but are not limited to, inherited diseases of
amino acid or organic acid metabolism; Crohn's Disease; gastroesophageal
reflux with failure to thrive; disorders of gastrointestinal motility
such as chronic intestinal pseudo-obstruction; and multiple, severe food
allergies which if left untreated will cause malnourishment, chronic
physical disability, mental retardation or death. Enteral formulas which
are medically necessary and taken under written order from a physician
for the treatment of specific diseases shall be distinguished from
nutritional supplements taken electively. Coverage for certain inherited
diseases of amino acid and organic acid metabolism shall include
modified solid food products that are low protein or which contain
modified protein which are medically necessary, and such coverage for
such modified solid food products for any calendar year or for any
continuous period of twelve months for any insured individual shall not
exceed two thousand five hundred dollars.
* NB There are 2 par (21)'s
* (21)(A) Every policy which is a "managed care product" as defined
in subparagraph (D) of this paragraph that provides coverage for
physician services in a physician's office, and every policy which is a
"managed care product" that provides major medical or similar
comprehensive-type coverage, shall include coverage for chiropractic
care, as defined in section six thousand five hundred fifty-one of the
education law, provided by a doctor of chiropractic licensed pursuant to
article one hundred thirty-two of the education law, in connection with
the detection or correction by manual or mechanical means of structural
imbalance, distortion or subluxation in the human body for the purpose
of removing nerve interference, and the effects thereof, where such
interference is the result of or related to distortion, misalignment or
subluxation of or in the vertebral column. However, chiropractic care
and services may be subject to reasonable deductible, co-payment and
co-insurance amounts, reasonable fee or benefit limits, and reasonable
utilization review, provided that any such amounts, limits and review:
(a) shall not function to direct treatment in a manner discriminative
against chiropractic care, and (b) individually and collectively shall
be no more restrictive than those applicable under the same policy to
care or services provided by other health professionals in the
diagnosis, treatment and management of the same or similar conditions,
injuries, complaints, disorders or ailments, even if differing
nomenclature is used to describe the condition, injury, complaint,
disorder or ailment. Nothing herein contained shall be construed as
impeding or preventing either the provision or coverage of chiropractic
care and services by duly licensed doctors of chiropractic, within the
lawful scope of chiropractic practice, in hospital facilities on a staff
or employee basis.
(C) Every policy which includes coverage for physician services in a
physician's office, and every policy which provides major medical or
similar comprehensive-type coverage, other than a "managed care product"
as defined in subparagraph (D) of this paragraph, shall provide coverage
for chiropractic care, as defined in section six thousand five hundred
fifty-one of the education law, provided by a doctor of chiropractic
licensed pursuant to article one hundred thirty-two of the education
law, in connection with the detection or correction by manual or
mechanical means of structural imbalance, distortion or subluxation in
the human body for the purpose of removing nerve interference, and the
effects thereof, where such interference is the result of or related to
distortion, misalignment or subluxation of or in the vertebral column.
However, chiropractic care and services may be subject to reasonable
deductible, co-payment and co-insurance amounts, reasonable fee or
benefit limits, and reasonable utilization review, provided that any
such amounts, limits and review: (a) shall not function to direct
treatment in a manner discriminative against chiropractic care, and (b)
individually and collectively shall be no more restrictive than those
applicable under the same policy to care or services provided by other
health professionals in the diagnosis, treatment and management of the
same or similar conditions, injuries, complaints, disorders or ailments,
even if differing nomenclature is used to describe the condition,
injury, complaint, disorder or ailment. Nothing herein contained shall
be construed as impeding or preventing either the provision or coverage
of chiropractic care and services by duly licensed doctors of
chiropractic, within the lawful scope of chiropractic practice, in
hospital facilities on a staff or employee basis.
(D) For purposes of this paragraph, a "managed care product" shall
mean a policy which requires that medical or other health care services
covered under the policy, other than emergency care services, be
provided by, or pursuant to a referral from, a primary care provider,
and that services provided pursuant to such a referral be rendered by a
health care provider participating in the insurer's managed care
provider network. In addition, a managed care product shall also mean
the in-network portion of a contract which requires that medical or
other health care services covered under the contract, other than
emergency care services, be provided by, or pursuant to a referral from,
a primary care provider, and that services provided pursuant to such a
referral be rendered by a health care provider participating in the
insurer's managed care provider network, in order for the insured to be
entitled to the maximum reimbursement under the contract.
(E) The coverage required by this paragraph shall not be abridged by
any regulation promulgated by the superintendent.
* NB There are 2 par (21)'s
(22) No policy shall exclude coverage of a health care service, as
defined in paragraph two of subsection (e) of section four thousand nine
hundred of this chapter, rendered or proposed to be rendered to an
insured on the basis that such service is experimental or
investigational, is rendered as part of a clinical trial as defined in
subsection (b-2) of section forty-nine hundred of this chapter, or a
prescribed pharmaceutical product referenced in subparagraph (B) of
paragraph two of subsection (e) of section forty-nine hundred of this
chapter provided that coverage of the patient costs of such service has
been recommended for the insured by an external appeal agent upon an
appeal conducted pursuant to subparagraph (B) of paragraph four of
subsection (b) of section four thousand nine hundred fourteen of this
chapter. The determination of the external appeal agent shall be binding
on the parties. For purposes of this paragraph, patient costs shall have
the same meaning as such term has for purposes of subparagraph (B) of
paragraph four of subsection (b) of section four thousand nine hundred
fourteen of this chapter; provided, however, that coverage for the
services required under this paragraph shall be provided subject to the
terms and conditions generally applicable to other benefits provided
under the policy.
(23) If a policy provides for reimbursement for physical and
occupational therapy service which is within the lawful scope of
practice of a duly licensed physical or occupational therapist, an
insured shall be entitled to reimbursement for such service whether the
said service is performed by a physician or through a duly licensed
physical or occupational therapist, provided however, that nothing
contained herein shall be construed to impair any terms of such policy
including appropriate utilization review and the requirement that said
service be performed pursuant to a medical order, or a similar or
related service of a physician.
(24)(A) Every policy which provides major medical or similar
comprehensive-type coverage shall include coverage for prehospital
emergency medical services for the treatment of an emergency condition
when such services are provided by an ambulance service issued a
certificate to operate pursuant to section three thousand five of the
public health law.
(B) Payment by an insurer pursuant to this section shall be payment in
full for the services provided. An ambulance service reimbursed pursuant
to this section shall not charge or seek any reimbursement from, or have
any recourse against an insured for the services provided pursuant to
this paragraph, except for the collection of copayments, coinsurance or
deductibles for which the insured is responsible for under the terms of
the policy.
(C) An insurer shall provide reimbursement for those services
prescribed by this section at rates negotiated between the insurer and
the provider of such services. In the absence of agreed upon rates, an
insurer shall pay for such services at the usual and customary charge,
which shall not be excessive or unreasonable.
(D) The provisions of this paragraph shall have no application to
transfers of patients between hospitals or health care facilities by an
ambulance service as described in subparagraph (A) of this paragraph.
(E) As used in this paragraph:
(i) "Prehospital emergency medical services" means the prompt
evaluation and treatment of an emergency medical condition, and/or
non-air-borne transportation of the patient to a hospital, provided
however, where the patient utilizes non-air-borne emergency
transportation pursuant to this paragraph, reimbursement will be based
on whether a prudent layperson, possessing an average knowledge of
medicine and health, could reasonably expect the absence of such
transportation to result in (1) placing the health of the person
afflicted with such condition in serious jeopardy, or in the case of a
behavioral condition placing the health of such person or others in
serious jeopardy; (2) serious impairment to such person's bodily
functions; (3) serious dysfunction of any bodily organ or part of such
person; or (4) serious disfigurement of such person.
(ii) "Emergency condition" means a medical or behavioral condition,
the onset of which is sudden, that manifests itself by symptoms of
sufficient severity, including severe pain, that a prudent layperson,
possessing an average knowledge of medicine and health, could reasonably
expect the absence of immediate medical attention to result in (1)
placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition placing the
health of such person or others in serious jeopardy; (2) serious
impairment to such person's bodily functions; (3) serious dysfunction of
any bodily organ or part of such person; or (4) serious disfigurement of
such person.
(j) (1) Every insurer issuing a policy of accident and health
insurance for delivery in this state which provides coverage for
in-patient hospital care must make available and, if requested by the
policyholder, provide coverage for care in a nursing home. Such coverage
shall be made available at the inception of all new policies and, with
respect to all other policies at any anniversary date of the policy
subject to evidence of insurability.
(A) In this paragraph nursing home care means the continued care and
treatment of a covered person who is under the care of a physician but
only if (i) the care is provided in a nursing home as defined in section
twenty-eight hundred one of the public health law or a skilled nursing
facility as defined in subchapter XVIII of the federal Social Security
Act, 42 U.S.C. §§ 1395 et seq, (ii) the covered person has been in a
hospital for at least three days immediately preceding admission, and
(iii) further hospitalization would otherwise be necessary. The
aggregate of the number of covered days of care in a hospital and the
number of covered days of care in a nursing home, with two days of care
in a nursing home equivalent to one day of care in a hospital, may not
exceed the number of covered days of hospital care provided under the
contract in a benefit period. The level of benefits to be provided for
nursing home care must be reasonably related to the benefits provided
for hospital care.
(B) Ambulatory care means care in hospital out-patient facilities, as
a hospital is defined in section twenty-eight hundred one of the public
health law or subchapter XVIII of the federal Social Security Act, 42
U.S.C. §§ 1395 et seq, and physicians' offices. Ambulatory care in
hospital out-patient facilities means services for diagnostic X-rays,
laboratory and pathological examinations, physical therapy and radiation
therapy, and services and medications used for nonexperimental cancer
chemotherapy and cancer hormone therapy, provided that such services and
medications are (i) related to and necessary for the treatment or
diagnosis of the patient's illness or injury, (ii) ordered by a
physician and (iii) in the case of physical therapy, services are to be
furnished in connection with the same illness for which the patient had
been hospitalized or in connection with surgical care, but in no event
need benefits be provided for physical therapy which commences more than
six months after discharge from a hospital or the date surgical care was
rendered, and in no event need benefits for physical therapy be provided
after three hundred sixty-five days from the date of discharge from a
hospital or the date surgical care was rendered. Ambulatory care in
physicians' offices means services for diagnostic X-rays, radiation
therapy, laboratory and pathological examinations, and services and
medications used for nonexperimental cancer chemotherapy and cancer
hormone therapy, provided that such services and medications are related
to and necessary for the treatment or diagnosis of the patient's illness
or injury, and ordered by a physician. Such coverage shall be made
available at the inception of all new policies and, with respect to all
other policies, at any anniversary date of the policy subject to
evidence of insurability.
(2) Every insurer issuing a policy of accident and health insurance
for delivery in this state which provides coverage supplementing part A
and part B of subchapter XVIII of the federal Social Security Act, 42
U.S.C. §§ 1395 et seq, must make available and, if requested by the
insured, provide coverage of supplemental home care visits beyond those
provided by part A and part B, sufficient to produce an aggregate
coverage of three hundred sixty-five home case visits per policy year.
Such coverage shall be provided pursuant to regulations prescribed by
the superintendent.
(3) Consistent with federal law, every insurer issuing a policy of
accident and health insurance for delivery in this state which provides
coverage supplementing part A and part B of subchapter XVIII of the
federal Social Security Act, 42 USC §§ 1395 et seq., shall make
available and, if requested by the insured, provide coverage for at
least ninety days of care in a nursing home as defined in section
twenty-eight hundred one of the public health law, except where such
coverage would duplicate coverage that is available under the
aforementioned subchapter XVIII. Such coverage shall be made available
at the inception of all new policies and, with respect to all other
policies, at each anniversary date of the policy.
(A) Coverage shall be subject to a copayment of twenty-five dollars
per day.
(B) Brochures describing such coverage must be provided to all
applicants at the time of application for all new policies and
thereafter on each anniversary date of the policy, and with respect to
all other policies annually at each anniversary date of the policy. Such
brochures must be approved by the superintendent in consultation with
the commissioner of health.
(C) The commensurate rate for the coverage must be approved by the
superintendent.
(D) Such insurers shall report to the superintendent each year the
number of contract holders to whom such insurers have issued such
policies for nursing home coverage and the approximate number of persons
covered by such policies.
(k) Any person, partnership or corporation willfully violating any
provision of this section, regulation or order of the superintendent
made in accordance with this section, shall forfeit to the people of the
state a sum not to exceed one hundred dollars for each such violation.
The superintendent may also suspend or revoke the license of an insurer
or agent or broker for any such willful violation.
(l) On and after January first, nineteen hundred ninety-seven, no
insurer shall offer major medical, comprehensive or other comparable
individual contracts, other than for purposes of conversion, unless the
benefits of such contracts, including deductibles and coinsurance, are
identical to the out-of-plan benefits of the contracts described in
section four thousand three hundred twenty-two of this chapter. Such
contracts must include a prescription drug benefit complying with the
requirements of that section.
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