26-22-202. Issuance of a converted policy; conditions.

(a) Issuance of a converted policy is subject to the following conditions:

(i) Written application for the converted policy shall be made and the first premium paid to the insurer not later than thirty-one (31) days after termination of the insured's coverage by the group policy and termination of the subsequent continuation rights offered by the group policy;

(ii) The effective date of the converted policy is the day following the termination of the insured's coverage under the group policy and termination of the subsequent continuation rights offered by the group policy;

(iii) The converted policy shall:

(A) Cover the employee or member and his dependents who were covered by the group policy on the date of termination of insurance, and at the insurer's option, a separate converted policy may be issued to cover any dependent;

(B) Be issued without evidence of insurability;

(C) Not exclude a preexisting condition not excluded by the group policy.

(iv) The insurer is not required to issue a converted policy:

(A) Covering any person if the person is or could be covered by Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded);

(B) Covering any person if:

(I) The person is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or

(II) The person is eligible for similar benefits, whether or not covered therefor, under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or

(III) Similar benefits are provided for or available to the person, pursuant to or in accordance with the requirements of any state or federal law; and

(IV) The benefits provided under the sources referred to in subdivision (B)(I) of this paragraph for the person or benefits provided or available under the sources referred to in subdivisions (B)(II) and (III) of this paragraph for the person, together with the benefits provided by the converted policy, would result in overinsurance according to the insurer's standards. The insurer's standards must bear some reasonable relationship to actual health care costs in the area in which the insured lives at the time of conversion and must be filed with the commissioner prior to their use in denying coverage;

(V) Which provides benefits in excess of those provided under the group policy from which conversion is made.

(v) A converted policy may:

(A) Include a provision whereby the insurer may request information in advance of any premium due date of the policy of any person covered thereunder as to whether:

(I) He is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program;

(II) He is covered for similar benefits under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or

(III) Similar benefits are provided for or available to the person, pursuant to or in accordance with the requirements of any state or federal law.

(B) Provide that the insurer may refuse to renew the policy or the coverage of any person insured thereunder for the following reasons only:

(I) Either the benefits provided under the sources referred to in subdivisions (A)(I) and (II) of this paragraph for the person or benefits provided or available under the sources referred to in subdivision (A)(III) of this paragraph for the person, together with the benefits provided by the converted policy, would result in overinsurance according to the insurer's standards on file with the commissioner, or the converted policyholder fails to provide the requested information;

(II) Fraud or material misrepresentation in applying for any benefits under the converted policy;

(III) Eligibility of the insured person for coverage under Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded) or under any other state or federal law providing for benefits similar to those provided by the converted policy;

(IV) Other reasons the commissioner approves.

(C) Provide that any hospital, surgical or medical benefits payable thereunder may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance under the group policy;

(D) Provide that during the first policy year the benefits payable under the converted policy, together with the benefits payable under the group policy, shall not exceed those that would have been payable had the individual's insurance under the group policy remained in force and effect;

(E) Provide for reduction of coverage on any person upon his eligibility for coverage under Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded) or under any other state or federal law providing for benefits similar to those provided by the converted policy.

(vi) Subject to the provisions and conditions of this section:

(A) If the group insurance policy from which conversion is made insures the employee or member for:

(I) Basic hospital or surgical expense insurance, the employee or member is entitled to obtain a converted policy providing, at his option, coverage on an expense incurred basis under any one (1) of the plans meeting the following requirements:

(1) Plan A:

a. Hospital room and board daily expense benefits in a maximum dollar amount approximating the average semiprivate rate charged in metropolitan areas of this state, for a maximum duration of seventy (70) days;

b. Miscellaneous hospital expense benefits of a maximum amount of ten (10) times the hospital room and board daily expense benefits; and

c. Surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of eight hundred dollars ($800.00); or

(2) Plan B:

a. Hospital room and board daily expense benefits in a maximum dollar amount equal to seventy-five percent (75%) of the maximum dollar amount determined for Plan A, for a maximum duration of seventy (70) days;

b. Miscellaneous hospital expense benefits of a maximum amount of ten (10) times the hospital room and board daily expense benefits; and

c. Surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of six hundred dollars ($600.00); or

(3) Plan C:

a. Hospital room and board daily expense benefits in a maximum dollar amount equal to fifty percent (50%) of the maximum dollar amount determined for Plan A, for a maximum duration of seventy (70) days;

b. Miscellaneous hospital benefits of a maximum amount of ten (10) times the hospital room and board daily expense benefits; and

c. Surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of four hundred dollars ($400.00);

d. The maximum dollar amounts in Plan A shall be determined by the commissioner and may be redetermined by him from time to time as to converted policies issued subsequent to the redetermination, except that no redetermination shall be made more often than once in three (3) years and the maximum dollar amounts in Plans A, B and C shall be rounded to the nearest multiple of ten dollars ($10.00).

(II) Major medical expense insurance, the employee or member is entitled to obtain a converted policy providing catastrophic or major medical coverage under a plan meeting the following requirements:

(1) A maximum benefit at least equal to either, at the insurer's option, subdivisions (1) or (2) of this subdivision:

a. The smaller of the following amounts:

i. The maximum benefit provided under the group policy;

ii. A maximum payment of two hundred fifty thousand dollars ($250,000.00) per covered person for all covered medical expenses incurred during the covered person's lifetime.

b. The smaller of the following amounts:

(2) Payment of benefits at the rate of eighty percent (80%) of covered medical expenses which are in excess of the deductible, until twenty percent (20%) of those expenses in a benefit period reaches one thousand dollars ($1,000.00), after which benefits will be paid at the rate of one hundred percent (100%) during the remainder of the benefit period, except that payment of benefits for outpatient treatment of mental illness, if provided in the converted policy, may be at a lesser rate but not less than fifty percent (50%);

i. The maximum benefit provided under the group policy;

ii. A maximum payment of two hundred fifty thousand dollars ($250,000.00) for each unrelated injury or sickness.

(3) A deductible for each benefit period which, at the insurer's option, shall be either the sum of the benefits deductible and one hundred dollars ($100.00), or the corresponding deductible in the group policy.

(B) The conversion privilege shall also be available to:

(I) The surviving spouse, if any, at the death of the employee or member, with respect to the spouse and the children whose coverage under the group policy terminates by reason of the death, otherwise to each surviving child whose coverage under the group policy terminates by reason of the death, or if the group policy provides for continuation of dependent's coverage following the employee's or member's death, at the end of the continuation;

(II) The spouse of the employee or member upon termination of coverage of the spouse, while the employee or member remains insured under the group policy, by reason of ceasing to be a qualified family member under the group policy, with respect to the spouse and the children whose coverage under the group policy terminates at the same time; or

(III) A child solely with respect to himself upon termination of his coverage by reason of ceasing to be a qualified member under the group policy, if a conversion privilege is not otherwise provided in this section with respect to the termination.

(vii) If the maximum benefit is determined by subdivision (A)(II)(1)b. of this paragraph, the insurer may require that the deductible be satisfied during a period of not less than three (3) months if the deductible is one hundred dollars ($100.00) or less, and not less than six (6) months if the deductible exceeds one hundred dollars ($100.00);

(viii) The benefit period shall be each calendar year when the maximum benefit is determined by subdivision (A)(II)(1) of this paragraph or twenty-four (24) months when the maximum benefit is determined by subdivision (A)(II)(1)b. of this paragraph;

(ix) Any surgical schedule shall be consistent with those customarily offered by the insurer under group or individual health insurance policies and shall provide at least a one thousand two hundred dollar ($1,200.00) maximum benefit;

(x) As used in paragraph (vi) of this subsection:

(A) "Benefits deductible" means the value of any benefits provided on an expense incurred basis which are provided with respect to covered medical expenses by any other hospital, surgical or medical insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan, or any other plan or program whether on an insured or uninsured basis, or in accordance with the requirements of any state or federal law and, if pursuant to paragraph (viii) of this subsection, the converted policy provides both basic hospital or surgical coverage and major medical coverage, the value of the basic benefits;

(B) "Covered medical expenses" includes, at least, in the case of hospital room and board charges, the lesser of the dollar amount in Plan A and the average semiprivate room and board rate for the hospital in which the individual is confined and twice that amount for charges in an intensive care unit.

(xi) The conversion privilege required by this section shall, if the group insurance policy insures the employee or member for basic hospital or surgical expense insurance as well as major medical expense insurance, make available the plans of benefits set forth in paragraph (vi) of this subsection;

(xii) An insurer may:

(A) Provide the plans of benefits specified in paragraph (vi) of this subsection under one (1) policy;

(B) Instead of the plans of benefits set forth in paragraph (vi) of this subsection, provide a policy of comprehensive medical expense benefits without first dollar coverage, which policy shall conform to the requirements of subparagraph (vi)(B) of this subsection, except that an insurer electing to provide such a policy shall make available a low deductible option, not to exceed one hundred dollars ($100.00), a high deductible option between five hundred dollars ($500.00) and one thousand dollars ($1,000.00) and a third deductible option midway between the high and low deductible options;

(C) Offer alternative plans for group health conversion in addition to those required by this section;

(D) Provide group insurance coverage instead of issuing a converted individual policy.

(xiii) If coverage would be continued under the group policy on an employee following his retirement prior to the time he is or could be covered by Medicare, he may elect instead of continuation of group insurance, to have the same conversion rights as would apply if his insurance terminated at retirement by reason of termination of employment or membership;

(xiv) If the benefit levels required in paragraph (vi) of this subsection exceed the benefit levels provided under the group policy, the conversion policy may offer benefits which are substantially similar to those provided under the group policy instead of those required in paragraph (vi) of this subsection;

(xv) Maternity benefits may be included at the insured's option and may be subject to the preexisting conditions limitations as discussed under paragraph (v) of this subsection;

(xvi) A notification of the conversion privilege shall be included in each certificate of coverage;

(xvii) A converted policy which is delivered outside this state must be on a form which could be delivered in the other jurisdiction as a converted policy had the group policy been issued in that jurisdiction.