There is a newer version of the New York Consolidated Laws
2013 New York Consolidated Laws
ISC - Insurance
Article 42 - (4202 - 4241) LIFE INSURANCE COMPANIES AND ACCIDENT AND HEALTH INSURANCE COMPANIES AND LEGAL SERVICES INSURANCE COMPANIES
4235 - Group accident and health insurance.
NY Ins L § 4235 (2012) What's This?
§ 4235. Group accident and health insurance. (a) (1) Any policy of
insurance against death or injury resulting from an accident which
covers more than one person, except blanket accident insurance policies
as defined in section four thousand two hundred thirty-seven of this
article and accident and health insurance policies conforming to
subsections (a), (b) and (c) of section three thousand two hundred
sixteen of this chapter, shall be deemed a group accident insurance
policy.
(2) Any policy which insures against disablement, disease or sickness
(excluding disablement which results from accident), and which covers
more than one person, except blanket health insurance policies as
defined in section four thousand two hundred thirty-seven of this
article and accident and health insurance policies conforming to
subsections (a), (b) and (c) of section three thousand two hundred
sixteen of this chapter, shall be deemed a group health insurance
policy.
(3) Any policy of insurance which combines the coverage of group
accident insurance and of group health insurance shall be deemed a group
accident and health insurance policy.
(b) No policy of group accident, group health or group accident and
health insurance, and no certificate thereunder, shall be delivered or
issued for delivery in this state unless it conforms to the requirements
of section three thousand two hundred twenty-one of this chapter and
with the exception of a group policy or contract of insurance issued
pursuant to article nine of the workers' compensation law, unless it
conforms to the requirements of subsection (c) of this section.
(c) (1) No policy of group accident, group health or group accident
and health insurance shall be delivered or issued for delivery in this
state unless it conforms to one of the following descriptions:
(A) A policy issued to an employer or to a trustee or trustees of a
fund established by an employer, which employer or trustee or trustees
shall be deemed the policyholder, insuring with or without evidence of
insurability satisfactory to the insurer, employees of such employer,
and insuring, except as hereinafter provided, all of such employees or
all of any class or classes thereof determined by conditions pertaining
to the employment or a combination of such conditions and conditions
pertaining to the family status of the employee, for insurance coverage
on each person insured based upon some plan which will preclude
individual selection. However, such a plan may permit a limited number
of selections by employees if the selections offered utilize consistent
plans of coverage for individual group members so that the resulting
plans of coverage are reasonable. The premium for the policy shall be
paid by the policyholder, either from the employer's funds, or from
funds contributed by the insured employees, or from funds contributed
jointly by the employer and employees. If all or part of the premium is
to be derived from funds contributed by the insured employees, then such
policy must insure not less than fifty percent of such eligible
employees or, if less, fifty or more of such employees when such policy
is providing coverage for group hospital, medical, major medical or
similar comprehensive types of expense reimbursed insurance and, for all
other types of group accident and health insurance, must insure a
minimum of fifty percent or five of such eligible employees, whichever
is fewer.
(B) A policy issued to a trustee or trustees of a fund established by,
or participated in, by the employer members of a trade association,
which trustees shall be deemed the policyholder, for the sole benefit of
the employees of such employers, the policy must conform subject to the
following requirements:
(i) The policy may be issued only if:
(I) the association has been in existence for at least two years and
was formed for purposes principally other than obtaining insurance, and
(II) the participating employers, meaning such employer members whose
employees are to be insured, constitute at date of issue at least fifty
percent of the total employers eligible to participate, unless the total
number of persons covered at date of issue exceeds six hundred, in which
event such participating employers must constitute at least twenty-five
percent of such total employers, in either case omitting from
consideration any employer whose employees are already insured under a
similar group accident and health insurance policy.
(ii) The persons eligible for insurance under the policy shall be all
of the employees of the participating employers, or all of any class or
classes thereof determined by conditions pertaining to their employment.
(iii) The premium for the policy shall be paid by the trustee or
trustees either from funds contributed by the employers or by the
employees; or funds contributed jointly by the employers and the
employees. A policy on which no part of the premium so payable is to be
derived from funds contributed by the insured employees must insure all
eligible employees.
(iv) The policy must cover at least fifty employees at date of issue.
(v) The insurance coverage under the policy must be based upon some
plan precluding individual selection either by the employees or by the
policyholder or the employer. However, such a plan may permit a number
of selections by the employer if the selections offered utilize
consistent plans of coverage so the resulting plans of coverage are
reasonable. Furthermore, such a plan may permit a limited number of
selections by employees if the selections offered utilize consistent
plans of coverage for individual group members so that the resulting
plans of coverage are reasonable.
(C) A policy issued to a labor union, which shall be deemed the
policyholder, insuring, with or without evidence of insurability
satisfactory to the insurer, members of such union and insuring, except
as hereinafter provided all of such members or of any class or classes
thereof determined by conditions pertaining to their employment or
membership in the union or both for amounts of insurance on each person
insured based on a plan precluding individual selection, provided
however, such a plan may permit a limited number of selections by
members if the selections offered utilize consistent plans of coverage
for individual group members so that the resulting plans of coverage are
reasonable, and not less than fifty percent of all eligible union or, if
less, fifty or more of such eligible members are insured.
(D) A policy issued to a trustee or trustees of a fund established, or
participated in, by two or more employers or by one or more labor
unions, or by one or more employers and one or more labor unions, which
trustee or trustees shall be deemed the policyholder, to insure
employees of the employers or members of the unions for the benefit of
persons other than the employers or the unions, subject to the following
requirements:
(i) The persons eligible for insurance shall be all of the employees
of the employers or all of the members of the unions, or all of any
class or classes thereof determined by conditions pertaining to their
employment, or to membership in the unions, or to both.
(ii) The premium for the policy shall be paid by the trustee or
trustees either wholly from funds contributed by the employer or
employers of the insured person or by the union or unions, or by both,
or jointly from such funds and funds contributed by the insured persons
specifically for their insurance or from contributions by the insured
persons. A policy on which all or part of the premium is to be derived
from funds contributed by the insured persons specifically for their
insurance may be placed in force only if it insures not less than fifty
percent of the then eligible persons, or, if less, fifty or more of such
eligible persons excluding any as to whom evidence of individual
insurability is not satisfactory to the insurer. A policy on which no
part of the premium is to be derived from funds contributed by the
insured persons specifically for their insurance must insure all
eligible persons, excluding any as to whom evidence of individual
insurability is not satisfactory to the insurer.
(iii) The policy shall insure at least fifty persons at date of issue,
except that if part of the premium is to be derived from funds to be
contributed by the insured persons specifically for their insurance the
policy shall insure at least one hundred employees or members at date of
issue.
(iv) The insurance coverage under the policy shall be based upon some
plan precluding individual selection either by the insured persons or by
the policyholders, employers, or unions. However, with respect to a
policyholder, employer or union, such plan may permit a number of
selections by the policyholder, employer or union, if the selections
offered utilize consistent plans of coverage so that the resulting plans
of coverage are reasonable. Furthermore, such a plan may permit a
limited number of selections by insured persons if the selections
offered utilize consistent plans of coverage for individual group
members so that the resulting plans of coverage are reasonable.
(v) With respect to a policy issued to a trustee or trustees of a fund
established by one or more labor unions, or by one or more employers and
one or more labor unions the proposed insured must submit, and the
insurer must obtain, a written certification that a reasonable number of
comparative bids have been obtained from different insurers and that
such bids have been considered by the trustees before making a decision
concerning which bid to accept. Such decision must be made at a
trustees' meeting held on a date certain, and a copy of the minutes of
such meeting must be attached to such certification.
(E) A policy issued to a creditor, vendor, (including the parent
holding company of such creditor or vendor), trustee, trustees or agent
insuring a group of debtors or vendees, (including coverage on the
spouse of a debtor or vendee), all as defined and set forth in paragraph
three of subsection (b) of section four thousand two hundred sixteen of
this article and under the same conditions and limitations and subject
to the definitions as specified therein; provided, however, that the
amount of indemnity payable with respect to any person insured
thereunder shall not at any time exceed:
(i) in all cases except as hereinafter provided the lesser of thirty
thousand dollars and the amount of unpaid indebtedness due from or the
amount of the purchase price unpaid by such person;
(ii) in the case of a loan commitment pursuant to a program for
defraying the cost of attendance of a student at a college or university
or at an elementary or secondary school providing education required for
minors as described in said paragraph, the lesser of thirty thousand
dollars and the total of the unpaid balance of the scheduled periodic
payments whether due or not due and the amount of any outstanding loan
commitment pursuant to such a program; or
(iii) in the case of a transaction secured by a real estate mortgage,
the lesser of the sum of seventy-five thousand dollars and the amount of
the indebtedness so secured.
(F) A policy issued to a social services district pursuant to section
three hundred sixty-seven-a of the social services law.
(G) A policy issued to the state of New York insuring, with or without
evidence of individual insurability satisfactory to the insurer, persons
who are managerial or confidential employees, or retired managerial or
confidential employees, of governments or public employers for the
purposes of article fourteen of the civil service law. The state shall
be deemed to be the policyholder. With respect to its employees, the
state and each other participating government or public employer shall
be deemed to be the employer. The premiums on such policy may be paid by
the employer, by the employees, or by the employer and employees
jointly. If the premiums are derived from funds contributed wholly by
the employer, the policy must insure all eligible employees. If all or
part of the premium is to be derived from funds contributed by insured
employees, then such policy must insure not less than forty percent of
such employees, the calculation being with respect to each employer
individually. The insurance coverage may be based upon a plan which
permits a limited number of selections by the employees. The provisions
of subsections (d), (h), (i) and (j) hereof shall not apply to a policy
issued pursuant to this subparagraph.
(H) A policy issued to an association, or to a trustee or trustees of
a fund established, created or maintained for the benefit of members of
one or more associations, all of whose eligible members have the same
profession, trade or occupation, which association or associations have
been organized and maintained in good faith for purposes principally
other than that of obtaining insurance and have been in active existence
for at least two years. The policy shall insure members, or employees of
members, of such association or associations for the benefit of persons
other than employers and the association or associations, or any
officials, representatives, trustees or agents thereof and shall provide
for the issuance of a certificate to the persons insured or such
beneficiary as evidence of such insurance. The members or employees
eligible for the insurance under the policy shall be all the members, or
all the members and their employees, or all of any class or classes
thereof determined by conditions pertaining to their employment or to
association membership or both. The premiums for the policy shall be
paid from association or members' funds, or partly from such funds and
partly from funds contributed by the insured individuals, or from funds
wholly contributed by the insured individuals. A policy on which all or
part of the premium is to be derived from funds contributed by the
insured individuals specifically for their insurance must insure at
least fifty percent of the then eligible individuals or a minimum of two
hundred individuals, whichever is less, excluding any as to whom
evidence of individual insurability is not satisfactory to the insurer.
A policy on which no part of the premium is to be derived from funds
contributed by the insured individuals specifically for their insurance
must cover all eligible individuals, excluding any as to whom evidence
of individual insurability is not satisfactory to the insurer. In every
case the policy must cover at least one hundred individuals at date of
issue. The insurance coverage on employees insured under the policy
shall be based upon some plan precluding individual selection. However,
with respect to such fund, or association or associations, such a plan
may permit a number of selections by the fund, association or
associations if the selections offered utilize consistent plans of
coverage so that the resulting plans of coverage are reasonable.
Furthermore, such a plan may permit a limited number of selections
offered by employees or members if the selections offered utilize
consistent plans of coverage for individual group members so that the
resulting plans of coverage are reasonable. If a policy dividend is
declared or a reduction in rate is made under such a policy, the excess,
if any, of the aggregate dividends or rate reductions under the policy
over the aggregate expenditure for insurance under such policy made from
association or employer funds, including expenditures made in connection
with administration of such policy, shall be applied by the policyholder
for the sole benefit of the insured individuals. A policy issued
pursuant to this subparagraph shall provide a conversion privilege no
less favorable than that provided for in subsection (e) of section three
thousand two hundred twenty-one of this chapter.
(I) A policy insuring persons employed under 32 U.S.C. § 709, members
of the national guard on full-time training duty under title 32 of the
United States Code, or on active duty or active duty for training under
title 10 of the United States Code, under the full-time manning program,
issued to the adjutant general, who shall be deemed the policyholder, or
to a trustee or trustees of a fund established, created, or maintained
for the benefit of such individuals insured, which trustee or trustees
shall be deemed the policyholder, the premium of which is to be paid by
the individuals insured either directly or by deduction from wages or
salary. The policy must insure at least fifty percent or four hundred of
the individuals eligible for such insurance, whichever is less. Such
policy shall provide for the payment of benefits, to the individual
insured or to some beneficiary or beneficiaries other than to the
aforesaid trustees or the adjutant general. The policy shall also
provide for the issuance of a certificate of insurance to the individual
insured or to such beneficiary, as evidence of such insurance. The
insurance coverage may be based upon a plan which permits a limited
number of selections by the insured member, if the selections offered
utilize consistent plans of coverage so that the resulting plans of
coverage are reasonable.
(J) Under a policy issued by an insurer to a trustee or to the
trustees of a trust, established or adopted by two or more individuals
who are entitled to a right of conversion, pursuant to subsection (e) of
section three thousand two hundred twenty-one of this chapter or under
the terms of a contract covering residents of New York, which trustee or
trustees shall be deemed to be the policyholder, to insure such
individuals, subject to the following requirements:
(i) The policy must cover at least twenty-five individuals during the
first policy year.
(ii) The benefits provided under the policy shall be those required by
subsection (f), (g) or (h) of section three thousand two hundred
twenty-one of this chapter.
(iii) In lieu of the coverage requirements of subsections (k) and (l)
of section three thousand two hundred twenty-one of this chapter and
subparagraphs (B), (C), (D), (E) and (F) of paragraph four of subsection
(f) of this section, the coverage requirements of paragraphs one through
ten of subsection (i) and the requirements of subsection (j) of section
three thousand two hundred sixteen of this chapter shall be applicable
to such policy.
(iv) If a policy dividend is declared or a reduction in rate is made
under such a policy, it shall be applied by the policyholder for the
sole benefit of the insured individuals.
(K) A policy issued to an association or the trustee or trustees of a
trust established, or participated in, by one or more associations, to
insure association members, subject to the following:
(i) Each association shall have:
(I) A minimum of two hundred insured members at the policy's date of
issue;
(II) Been organized and maintained in good faith for purposes
principally other than that of obtaining insurance;
(III) Been in active existence for at least two years; and
(IV) A constitution and by-laws which provide that:
(aa) The association hold regular meetings not less than annually to
further the purposes of the association;
(bb) The association collect dues or solicit contributions from
members; and
(cc) The members have voting privileges and representation on the
governing board and committees.
(ii) The premium for the policy shall be paid by the association or
the trustees either wholly from funds contributed by the association or
by the insured individuals, or from funds contributed jointly by the
association and insured individuals. A policy on which no part of the
premium is to be derived from funds contributed by the insured
individuals specifically for their insurance must insure all eligible
individuals excluding any as to whom evidence of individual insurability
is not satisfactory to the insurer.
(iii) The amount of insurance under the policy shall be based upon
some plan precluding individual selection either by the insured members
or by the association. However, with respect to an association, such a
plan may permit a number of selections by the association if the
selections offered utilize consistent plans of insurance so that the
resulting plans of coverage are reasonable. Furthermore, such a plan may
permit a limited number of selections by insured members if the
selections offered utilize consistent plans of insurance for individual
group members so that the resulting plans of coverage are reasonable.
(iv) Except as provided in subsection (e) of this section, such policy
shall provide for the payment of benefits to the person insured or to
some beneficiary or beneficiaries other than the association or any
officials, representatives, trustees or agents thereof and shall provide
for the issuance of a certificate to the association for delivery to the
member or such beneficiary, as evidence of such insurance.
(v) The premiums charged must be reasonable in relation to the
benefits provided.
(L) A policy issued to any organization, or the trustee or trustees of
a trust established, or participated in, by one or more of such
organizations, to insure certain persons subject to the following:
(i) The organization must be:
(I) A bank, retailer or other issuer of a credit card, charge card or
payment card which can be used to buy goods or services, and the policy
must insure holders of that card;
(II) A bank, savings and loan association, credit union, mutual fund,
money market fund, stockbroker or other similar financial institution
regulated by state or federal law, and the policy must insure the
depositors, account holders or members of that institution.
(ii) Except for a credit union where the premium shall be paid
entirely from funds contributed by the credit union, the organization or
organizations shall have a minimum of two hundred insured persons at the
policy's date of issue.
(iii) The premium for the policy shall be paid by the organization or
trustees either wholly from funds contributed by the organization or by
the insured individuals, or from funds contributed jointly by the
organization and insured individuals. A policy on which no part of the
premium is to be derived from funds contributed by the insured
individuals specifically for their insurance must cover all eligible
individuals excluding any as to whom evidence of individual insurability
is not satisfactory to the insurer.
(iv) The amounts of insurance under the policy shall be based upon
some plan precluding individual selection either by the insured persons
or by the organization. However, with respect to an organization, such a
plan may permit a number of selections by the organization if the
selections offered utilize consistent plans of insurance so that the
resulting plans of coverage are reasonable. Furthermore, such a plan may
permit a limited number of selections by members if the selections
offered utilize consistent plans of grading the amounts of insurance for
individual group members so that the resulting plans of coverage are
reasonable.
(v) Except as provided in subsection (e) of this section, such policy
shall provide for the payment of benefits to the person insured or to
some beneficiary or beneficiaries other than the organization, or any
officials, representatives, trustees or agents thereof, and shall
provide for the issuance of a certificate to the persons insured or such
beneficiary, as evidence of such insurance.
(vi) The premium charged must be reasonable in relation to the
benefits provided.
(M) A policy issued to insure any other group approved by the
superintendent upon a finding that: (i) there is a common enterprise or
economic or social affinity or relationship; (ii) the premiums charged
are reasonable in relation to the benefits provided; and (iii) the
issuance of the policy would result in economies of acquisition or
administration, would be actuarially sound, and would not be contrary to
the best interest of the public. The superintendent shall promulgate
regulations setting forth any such groups that have been accepted as
qualifying pursuant to this subparagraph.
(N) A policy issued to a continuing care retirement community covering
at least fifty percent of the residents of the community, in conjunction
with a continuing care retirement contract described in section four
thousand six hundred one of the public health law.
(2) For the purpose of complying with the participation requirements
prescribed in subparagraphs (A), (B), (C), (D) and (G) of paragraph one
of this subsection, the provisions of this subsection are to be
construed as permitting the issuance of more than one policy or contract
when offered as alternatives to the eligible employees or members.
(3) (A) Any dividend hereafter apportioned on any participating group
insurance policy, or any rate reduction hereafter made or continued on
any non-participating group policy for the first or any subsequent year
of insurance under any such policy heretofore or hereafter issued under
subparagraph (K), (L) or (M) of paragraph one of this subsection, may be
applied to reduce the policyholder's part of the cost of such policy,
except that the excess, if any, of the insured's aggregate contribution
under the policy over the net cost (gross premium less dividends or rate
reductions) of the insurance shall be applied at the discretion of the
insurer either as a cash payment to the insured or to reduce the
insured's premium, unless the insured assigns the dividend or rate
reduction to the policyholder. If a dividend or rate reduction is
payable upon termination of the policy the insurer shall either make
payment to the insured or to the policyholder upon receipt of a
certification from the policyholder that the dividend or rate reduction
will be distributed by the policyholder to the insureds or applied to
reduce the insured's premium.
(B) The provisions of subparagraph (A) of this paragraph shall apply
to New York residents insured under a policy issued in any other
jurisdiction to a group which is not of the type described in
subparagraphs (A) through (J) of paragraph one of this subsection.
(d) * (1) In this section, for the purpose of insurance hereunder:
"employees" includes the officers, managers, employees and retired
employees of the employer and of subsidiary or affiliated corporations
of a corporate employer, and the individual proprietors, partners,
employees and retired employees of affiliated individuals and firms
controlled by the insured employer through stock ownership, contract or
otherwise; "employees" may be deemed to include the individual
proprietor or partners if the employer is an individual proprietor or a
partnership; and "employees" as used in subparagraph (A) of paragraph
one of subsection (c) hereof may also include the directors of the
employer and of subsidiary or affiliated corporations of a corporate
employer.
* NB Effective until January 1, 2016
* (1) In this section, for the purpose of insurance other than for
group hospital, medical, major medical or similar comprehensive-types of
expense reimbursed insurance hereunder: "employees" includes the
officers, managers, employees and retired employees of the employer and
of subsidiary or affiliated corporations of a corporate employer, and
the individual proprietors, partners, employees and retired employees of
affiliated individuals and firms controlled by the insured employer
through stock ownership, contract or otherwise; "employees" may be
deemed to include the individual proprietor or partners if the employer
is an individual proprietor or a partnership; and "employees" as used in
subparagraph (A) of paragraph one of subsection (c) hereof may also
include the directors of the employer and of subsidiary or affiliated
corporations of a corporate employer.
* NB Effective January 1, 2016
(2) In this section "employer" may include any municipal corporation,
or the proper officers, as such, of any unincorporated municipality, or
any department of such corporation or municipality determined by
conditions pertaining to the employment.
* (3) In this section, for the purpose of group hospital, medical,
major medical or similar comprehensive-types of expense reimbursed
insurance hereunder:
(A) "employee" shall have the meaning set forth in section 2791 of the
public health service act, 42 U.S.C. § 300gg-91(d)(5) or any regulations
promulgated thereunder; and
(B) "full-time employee" means with respect to any month, an employee
who is employed on average for at least thirty hours of service per week
as set forth in section 4980H(c)(4) of the internal revenue code, 26
U.S.C. § 4980H(c)(4), or any regulations promulgated thereunder.
* NB Effective January 1, 2016
(e) The benefits payable under the policy shall be payable to the
employee or other insured member of the group or to some beneficiary or
beneficiaries designated by him, other than the employer or the
association or any officer thereof as such; but if there is no
designated beneficiary as to all or any part of the insurance benefits
at the death of the employee or member, then the benefits payable for
which there is no designated beneficiary shall be payable to the estate
of the employee or member, except that the insurer may in such case, at
its option, pay such insurance to any one or more of the following
surviving relatives of the employee or member: wife, husband, mother,
father, child or children, brothers or sisters; and except that payment
of benefits for expenses incurred on account of hospitalization or
medical or surgical aid, may be made by the insurer to the hospital or
other person or persons furnishing such aid, and the payment of benefits
for expenses incurred on account of hospitalization or medical or
surgical aid after the death of an employee or other member of the
insured group for such person's spouse, child or children, or other
person chiefly dependent upon him for support or maintenance, may be
made by the insurer to the surviving spouse or otherwise as the policy
may provide. Payment so made shall discharge the insurer's obligation
with respect to the amount of insurance so paid.
(f) (1) (A) Any policy of group accident, group health or group
accident and health insurance may include provisions for the payment by
the insurer of benefits for expenses incurred on account of hospital,
medical or surgical care or physical and occupational therapy by
licensed physical and occupational therapists upon the prescription or
referral of a physician for the employee or other member of the insured
group, the employee's or member's spouse, the employee's or member's
child or children, or other persons chiefly dependent upon the employee
or member for support and maintenance; provided that:
(i) a policy of hospital, medical, surgical, or prescription drug
expense insurance that provides coverage for children shall provide such
coverage to a married or unmarried child until attainment of age
twenty-six, without regard to financial dependence, residency with the
employee or member, student status, or employment, except a policy that
is a grandfathered health plan may, for plan years beginning before
January first, two thousand fourteen, exclude coverage of an adult child
under age twenty-six who is eligible to enroll in an employer-sponsored
health plan other than a group health plan of a parent. For purposes of
this item, "grandfathered health plan" means coverage provided by an
insurer in which an individual was enrolled on March twenty-third, two
thousand ten for as long as the coverage maintains grandfathered status
in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
§ 18011(e); and
(ii) a policy under which coverage terminates at a specified age shall
not so terminate with respect to an unmarried child who is incapable of
self-sustaining employment by reason of mental illness, developmental
disability, 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 coverage would otherwise terminate and who is chiefly
dependent upon such employee or member for support and maintenance,
while the insurance of the employee or member remains in force and the
child remains in such condition, if the insured employee or member has
within thirty-one days of such child's attainment of the termination age
submitted proof of such child's incapacity as described herein.
(B) In addition to the requirements of subparagraph (A) of this
paragraph, every insurer issuing a group policy of hospital, medical or
surgical expense insurance pursuant to this section that provides
coverage for children, must make available and if requested by the
policyholder, extend coverage under the policy to an unmarried child
through age twenty-nine, without regard to financial dependence who is
not insured by or eligible for coverage under any employer health
benefit plan as an employee or member, whether insured or self-insured,
and who lives, works or resides in New York state or the service area of
the insurer. Such coverage shall be made available at the inception of
all new policies and with respect to all other policies at any
anniversary date. Written notice of the availability of such coverage
shall be delivered to the policyholder prior to the inception of such
group policy and annually thereafter.
(2) Notwithstanding any rule, regulation or law to the contrary, any
family coverage available under this article 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
certificate 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 or where the group's plan does not
provide coverage for children.
(3) A policy under which coverage of a dependent spouse or named
insured 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. Any such
policy may provide for the continuation of such benefit provisions, or
any part or parts thereof, after the exhaustion of the benefit rights
with respect to the employee or other member of the insured group, or
after the death of an active or retired employee or other member of the
insured group.
(4) Notwithstanding any provisions of a policy of group accident,
group health or group accident and health insurance, whenever such
policy provides for reimbursement for:
(A) any physical and occupational therapy service which is within the
lawful scope of practice of a licensed physical and occupational
therapist, a subscriber to such policy shall be entitled to
reimbursement for such service, whether the said service is performed by
a physician or licensed physical and occupational therapist pursuant to
prescription or referral by a physician;
(B) any podiatrical service which is within the lawful scope of
practice of a licensed podiatrist, a subscriber to such policy shall be
entitled to reimbursement for such service, whether the said service is
performed by a physician or licensed podiatrist and when such policy or
any certificate issued thereunder is delivered or issued for delivery
without this state by an authorized insurer, covered persons residing in
this state shall be entitled to reimbursement for podiatric services as
herein provided;
(C) any optometric service which is within the lawful scope of
practice of a licensed optometrist, a subscriber to such policy shall be
entitled to reimbursement for such service, whether the said service is
performed by a physician or licensed optometrist and when such policy or
any certificate issued thereunder or delivered or issued for delivery
without the state by an authorized insurer so provides, covered persons
residing in this state shall be entitled to reimbursement for that
service which may be rendered by an optometrist as herein provided.
Unless such policy shall otherwise provide, there shall be no
reimbursement for ophthalmic materials, lenses, spectacles, eyeglasses,
and/or appurtenances thereto;
(D) any dental service which is within the lawful scope of practice of
a licensed dentist, a subscriber to such policy shall be entitled to
reimbursement for such service whether the said service is performed by
a physician or licensed dentist and when such policy or any certificate
issued thereunder or delivered or issued for delivery without the state
by an authorized insurer so provides, covered persons residing in this
state shall be entitled to reimbursement for dental services as herein
provided;
(E) The services of licensed health professionals who can bill for
services, a subscriber to such policy 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;
(F) any speech-language pathology or audiology service which is within
the lawful scope of practice of a duly licensed speech-language
pathologist or audiologist, a subscriber to such policy 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; and when such
policy or any certificate issued thereunder is delivered or issued for
delivery without the state by an authorized insurer, covered persons
residing in this state shall be entitled to reimbursement for
speech-language pathology or audiology service as herein provided.
(G) psychiatric or psychological services or for the diagnosis and
treatment of mental, nervous, or emotional disorders or ailments,
however defined in such policy, a subscriber to such policy shall be
entitled to reimbursement for such psychiatric or psychological services
or 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, and when such policy or
any certificate issued thereunder is delivered or issued for delivery
without this state by an authorized insurer, covered persons residing in
this state shall be entitled to reimbursement for such diagnosis and
treatment by a physician, psychiatrist or a certified and registered
psychologist as hereinabove provided; and
(H) any service which is within the lawful scope of practice of a
licensed chiropractor, a subscriber to such policy shall be entitled to
reimbursement for such service when such service is performed by a
licensed chiropractor.
(g) (1) No domestic insurer and no foreign or alien insurer doing
business in this state shall hereafter issue, within or without this
state, any policy of group accident, group health or group accident and
health insurance, other than a policy issued pursuant to subparagraph
(J) of paragraph one of subsection (c) hereof, which shall not appear to
be self-supporting on reasonable assumptions as to morbidity or other
appropriate claim rate, interest and expense.
(2) The superintendent may require all such insurers to file with him,
either directly or through such agency as he may approve, at such times
and in such manner and for such forms of insurance as he prescribes,
their experience under such forms and such other information as the
superintendent may deem necessary or expedient for the administration of
this section and such experience and other information shall be compiled
and analyzed as the superintendent prescribes.
(h) (1) Each domestic insurer and each foreign or alien insurer doing
business in this state shall file with the superintendent its schedules
of premium rates, rules and classification of risks for use in
connection with the issuance of its policies of group accident, group
health or group accident and health insurance, and of its rates of
commissions, compensation or other fees or allowances to agents and
brokers pertaining to the solicitation or sale of such insurance and of
such fees or allowances, exclusive of amounts payable to persons who are
in the regular employ of the insurer, other than as agent or broker to
any individuals, firms or corporations pertaining to such class of
business, whether transacted within or without the state.
(2) An insurer may revise such schedules from time to time, and shall
file such revised schedules with the superintendent.
(3) No insurer shall issue any policy of group accident, group health
or group accident and health insurance the premium rate under which for
the first policy year is less than that determined by the schedules of
such insurer as then on file with the superintendent; nor shall it pay
to the agent or agents or to a broker or brokers for the solicitation or
sale of such policy or for any other purpose related to such policy any
commission, compensation or other fees or allowances in excess of that
determined on the basis of the schedules of such insurer as then on file
with the superintendent; nor shall such insurer pay for services
pertaining to the service or administration thereof to any individual,
firm or corporation any fees, commissions or allowances in excess of
that determined on the basis of the schedules of such insurer as then on
file with the superintendent or for such services not rendered in behalf
of such insurer; provided, however, that nothing contained herein shall
apply to or affect the computation of dividends or experience rating
credits.
(4) Nothing herein shall prohibit the state insurance fund from taking
into account peculiar hazards of individual risks in establishing higher
premium rates to be charged for insurance providing for the payment of
disability benefits in accordance with article nine of the workers'
compensation law.
(i) (1) Whenever the superintendent determines, after notice to all
insurers doing the business of group accident, group health or group
accident and health insurance in this state and a hearing at which such
insurers may present pertinent statistics and other available data, that
it is advisable in the administration of this section to adopt a
schedule of minimum premium rates for any type of benefit provided under
policies of group accident, group health or group accident and health
insurance, the superintendent shall thereupon file in his office such a
schedule which shall include a description of the benefit or benefits
for which minimum premium rates are being prescribed and of the minimum
premium rates applicable thereto.
(2) Such schedule may be revised by the superintendent from time to
time or withdrawn, after a similar notice and hearing.
(3) The effective date of such schedule, or of any such revision or
withdrawal thereof, shall be specified by the superintendent. After the
effective date of the first schedule no domestic insurer and no foreign
or alien insurer doing business in this state shall issue, within or
without this state, any policy of group accident, group health or group
accident and health insurance providing any benefit to which the
schedule of minimum premium rates then in effect applies, unless the
premium for such benefit for the first policy year shall be at least
equal to that determined on the basis of such schedule.
(4) If an insurer desires to provide a benefit of the same general
type as, but not identical with, one described in said schedule, it
shall before issuing any policy providing for such different benefit
obtain the superintendent's approval of the premium proposed to be
charged therefor. The superintendent shall grant such approval if he is
satisfied that the proposed premium is not less than that which would
have to be charged consistent with the schedule of minimum premium rates
then in effect.
(j) (1) Anything in this chapter to the contrary notwithstanding, any
policy of group accident, group health or group accident and health
insurance may provide for readjustment of the rate of premium based on
the experience thereunder at the end of the first year or of any
subsequent year of insurance thereunder, and such readjustment may be
made retroactive only for such policy year.
(2) Any such rate readjustment shall be computed on a basis which is
equitable to all group accident, group health or group accident and
health insurance policies.
(3) Any refund under any plan for readjustment of the rate of premium
based on the experience under group policies and any dividend paid under
such policies may be used to reduce the employer's contribution to group
insurance for the employees of the employer, and the excess over such
contribution by the employer shall be applied by the employer for the
sole benefit of the employees.
(k) Whenever an insurer elects to terminate any policy as described in
this section, such insurer shall include in his notification of intent
to terminate such policy reference to the policyholder's
responsibilities under section two hundred seventeen of the labor law.
Whenever any policy as described in this section terminates as a result
of a default in payment of premiums, the insurer shall notify the
policyholder that termination has occurred or will occur and shall
include in his notification reference to the policyholder's
responsibilities under section two hundred seventeen of the labor law.
(l) The superintendent shall promulgate rules and regulations
concerning the method, manner and time for a policyholder to provide
written notice of termination to the certificate holders as required by
subdivision three of section two hundred seventeen of the labor law.
(m) This section shall not apply to any contract issued by any article
forty-three corporation except as provided in section four thousand
three hundred five of this chapter.
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