Conn. Gen. Stat. § 38a-472f — Connecticut Code / Title 38a / Chapter 700c / Section 38a-472f
Sec. 38a-472f. Network adequacy. Health carrier duties and responsibilities. Access plan filing.
Status: in_force

(1) “Authorized representative” means (A) an individual to whom a covered person has given express written consent to represent the covered person, (B) an individual authorized by law to provide substituted consent for a covered person, or (C) the covered person's treating health care provider when the covered person is unable to provide consent or a family member of the covered person;

(2) “Covered benefit” or “benefit” means those health care services to which a covered person is entitled under the terms of a health benefit plan;

(3) “Covered person” has the same meaning as provided in section 38a-591a ;

(4) “Essential community provider” means a health care provider or facility that (A) serves predominantly low-income, medically underserved individuals and includes covered entities, as defined in 42 USC 256b, as amended from time to time, or (B) is described in 42 USC 1396r-8(c)(1)(D)(i)(IV), as amended from time to time;

(5) “Facility” has the same meaning as provided in section 38a-591a ;

(6) (A) “Health benefit plan” means an insurance policy or contract, certificate or agreement offered, delivered, issued for delivery, renewed, amended or continued in this state to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services;

(B) “Health benefit plan” does not include:

(i) Coverage of the type specified in subdivisions (5) to (9), inclusive, (14) and (15) of section 38a-469 or any combination thereof;

(ii) Coverage issued as a supplement to liability insurance;

(iii) Liability insurance, including general liability insurance and automobile liability insurance;

(iv) Workers' compensation insurance;

(v) Automobile medical payment insurance;

(vi) Credit insurance;

(vii) Coverage for on-site medical clinics;

(viii) Other insurance coverage similar to the coverages specified in subparagraphs (B)(ii) to (B)(vii), inclusive, of this subdivision that are specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, under which benefits for health care services are secondary or incidental to other insurance benefits;

(ix) (I) Benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof, or (II) other similar, limited benefits that are specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, provided any benefits specified in subparagraphs (B)(ix)(I) and (B)(ix)(II) of this subdivision are provided under a separate insurance policy, certificate or contract and are not otherwise an integral part of a health benefit plan; or

(x) Coverage of the type specified in subdivisions (3) and (13) of section 38a-469 or other fixed indemnity insurance if (I) such coverage is provided under a separate insurance policy, certificate or contract, (II) there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and (III) the benefits are paid with respect to an event without regard to whether benefits were also provided under any group health plan maintained by the same plan sponsor;

(7) “Health care provider” has the same meaning as provided in section 38a-477aa ;

(8) “Health care services” has the same meaning as provided in section 38a-478 ;

(9) “Health carrier” has the same meaning as provided in section 38a-591a ;

(10) “Intermediary” means a person, as defined in section 38a-1 , authorized to negotiate and execute health care provider contracts with health carriers on behalf of health care providers or a network;

(11) “Network” means the group or groups of participating providers providing health care services under a network plan;

(12) “Network plan” means a health benefit plan that requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, health care providers or facilities that are managed, owned, under contract with or employed by the health carrier;

(13) “Participating provider” means a health care provider or a facility that, under a contract with a health carrier or such health carrier's contractor or subcontractor, has agreed to provide health care services to such health carrier's covered persons, with an expectation of receiving payment or reimbursement directly or indirectly from the health carrier, other than coinsurance, copayments or deductibles;

(14) “Primary care” means health care services for a range of common physical, mental or behavioral health conditions, provided by a health care provider;

(15) “Primary care provider” means a participating health care provider designated by a health carrier to supervise, coordinate or provide initial health care services or continuing health care services to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services provided to the covered person;

(16) “Specialist” means a health care provider who (A) focuses on a specific area of physical, mental or behavioral health or a specific group of patients, and (B) has successfully completed required training and is recognized by this state to provide specialty care. “Specialist” includes a subspecialist who has additional training and recognition beyond that required for a specialist;

(17) “Specialty care” means advanced medically necessary care and treatment of specific physical, mental or behavioral health conditions, or those conditions that may manifest in particular ages or subpopulations, that are provided by a specialist in coordination with a health care provider; and

(18) “Tiered network” means a network that identifies and groups some or all types of health care providers and facilities into specific groups to which different participating provider reimbursement, covered person cost-sharing or participating provider access requirements, or any combination thereof, apply for the same health care services.

(b) The provisions of this section and sections 38a-477g and 38a-477h shall apply to all health carriers that deliver, issue for delivery, renew, amend or continue a network plan in this state.

(c) (1) (A) Each health carrier shall establish and maintain a network that includes a sufficient number and appropriate types of participating providers, including those that serve predominantly low-income, medically underserved individuals, to assure that all covered benefits will be accessible to all such health carrier's covered persons without unreasonable travel or delay.

(B) Covered persons shall have access to emergency services and, to the extent urgent crisis center services are available, urgent crisis center services, twenty-four hours a day, seven days a week. For the purposes of this subparagraph, “emergency services” and “urgent crisis center services” have the same meanings as provided in section 38a-477aa .

(2) The Insurance Commissioner shall determine the sufficiency of a health carrier's network in accordance with the provisions of this subsection and may establish sufficiency by reference to any reasonable criteria, including, but not limited to, (A) the ratio of participating providers to covered persons by specialty, (B) the ratio of primary care providers to covered persons, (C) the geographic accessibility of participating providers, (D) the geographic variation and dispersion of the state's population, (E) the wait times for appointments with participating providers, (F) the hours of operation of participating providers, (G) the ability of the network to meet the needs of covered persons that may include low-income individuals, children and adults with serious, chronic or complex conditions or physical or mental disabilities or individuals with limited English proficiency, (H) the availability of other health care delivery system options, such as centers of excellence and mobile clinics, (I) the volume of technological and specialty care services available to serve the needs of covered persons who require technologically advanced or specialty care services, (J) the extent to which participating health care providers are accepting new patients, (K) the degree to which (i) participating health care providers are authorized to admit patients to hospitals participating in the network, and (ii) hospital-based health care providers are participating providers, and (L) the regionalization of specialty care.

(d) (1) Each health carrier shall establish and maintain a process to ensure that a covered person receives a covered benefit at an in-network level, including an in-network level of cost-sharing, from a nonparticipating provider, or shall make other arrangements acceptable to the commissioner, when:

(A) The health carrier has a sufficient network but does not have (i) a type of participating provider available to provide the covered benefit to the covered person, or (ii) a participating provider available to provide the covered benefit to the covered person without unreasonable travel or delay; or

(B) The health carrier has an insufficient number or type of participating providers available to provide the covered benefit to the covered person without unreasonable travel or delay.

(2) Each health carrier shall disclose to a covered person the process to request a covered benefit from a nonparticipating provider, as provided under subdivision (1) of this subsection, when:

(A) The covered person is diagnosed with a condition or disease that requires specialty care; and

(B) The health carrier (i) does not have a participating provider of the required specialty with the professional training and expertise to treat or provide health care services for the condition or disease, or (ii) cannot provide reasonable access to a participating provider of the required specialty with the professional training and expertise to treat or provide health care services for the condition or disease without unreasonable travel or delay.

(3) The health carrier shall deem the health care services such covered person receives from a nonparticipating provider pursuant to subdivision (2) of this subsection to be health care services provided by a participating provider, including counting the covered person's cost-sharing for such health care services toward the maximum out-of-pocket expenses limit applicable to health care services received from participating providers under the health benefit plan.

(4) The health carrier shall ensure that the processes described under subdivisions (1) and (2) of this subsection address a covered person's request to obtain a covered benefit from a nonparticipating provider in a timely fashion appropriate to the covered person's condition. The time frames for such processes shall mirror those set forth in subsections (e) and (f) of section 38a-591g for external reviews of adverse determinations and final adverse determinations.

(5) The health carrier shall document all requests from its covered persons to obtain a covered benefit from a nonparticipating provider pursuant to this subsection and shall provide such documentation to the commissioner upon request.

(6) No health carrier shall use the process described in subdivisions (1) and (2) of this subsection as a substitute for establishing and maintaining a sufficient network as required under subsection (b) of this section. No covered person shall use such process to circumvent the use of covered benefits available through a health carrier's network delivery system options.

(7) Nothing in this subsection shall be construed to affect any rights or remedies available to a covered person under sections 38a-591a to 38a-591g , inclusive, or federal law relating to internal or external claims grievance and appeals processes.

(e) (1) Each health carrier shall:

(A) Maintain adequate arrangements to assure that such health carrier's covered persons have reasonable access to participating providers located near such covered persons' places of residence or employment. In determining whether a health carrier has complied with this subparagraph, the commissioner shall give due consideration to the availability of health care providers with the requisite expertise and training in the service area under consideration;

(B) Monitor on an ongoing basis the ability, clinical capacity and legal authority of its participating providers to provide all covered benefits to its covered persons;

(C) Establish and maintain procedures by which a participating provider will be notified on an ongoing basis of the specific covered health care services for which such participating provider will be responsible, including any limitations on or conditions of such services;

(D) Notify participating providers of their obligations, if any, (i) to collect applicable coinsurance, deductibles or copayments from covered persons pursuant to a covered person's health benefit plan, and (ii) to notify covered persons, prior to delivery of health care services if possible, of such covered persons' financial obligations for noncovered benefits;

(E) Establish and maintain procedures by which a participating provider may determine in a timely manner at the time benefits are provided whether an individual is a covered person or is within a grace period for payment of premium during which such health carrier may hold a claim for health care services pending receipt of payment of premium by such health carrier;

(F) Timely notify a health care provider or facility, when such health carrier has included such health care provider or facility as a participating provider for any of such health carrier's health benefit plans, of such health care provider's or facility's network participation status;

(G) Notify participating providers of the participating provider's responsibilities with respect to such health carrier's applicable administrative policies and programs, including, but not limited to, payment terms, utilization review, quality assessment and improvement programs, credentialing, grievance and appeals processes, date reporting requirements, reporting requirements for timely notice of changes in practice such as discontinuance of accepting new patients, confidentiality requirements, any applicable federal or state programs and obtaining necessary approval of referrals to nonparticipating providers; and

(H) Establish and maintain procedures for the resolution of administrative, payment or other disputes between the health carrier and a participating provider.

(2) No health carrier shall:

(A) Offer or provide an inducement to a participating provider that would encourage or otherwise incentivize a participating provider to provide less than medically necessary health care services to a covered person;

(B) Prohibit a participating provider from (i) discussing any specific or all treatment options with covered persons, irrespective of such health carrier's position on such treatment options, or (ii) advocating on behalf of covered persons within the utilization review or grievance and appeals processes established by such health carrier or a person contracting with such health carrier or in accordance with any rights or remedies available to covered persons under sections 38a-591a to 38a-591g , inclusive, or federal law relating to internal or external claims grievance and appeals processes; or

(C) Penalize a participating provider because such participating provider reports in good faith to state or federal authorities any act or practice by such health carrier that jeopardizes patient health or welfare.

(f) (1) Each health carrier shall develop standards, to be used by such health carrier and its intermediaries, for selecting and tiering, as applicable, participating providers and each health care provider specialty. Each contract involving a tiered network entered into, renewed or amended on or after July 1, 2024, between a health carrier and participating provider shall include a provision requiring that such health carrier provide to the participating provider, upon request, such participating provider's calculated score and related data, as available, and a description of the standards used for selecting and tiering such participating provider, including:

(A) Definitions and specifications of measures related to quality, cost, efficiency, satisfaction and any other factors used to develop such standards and measure performance under such standards, with delineation of any inclusions or exclusions under each measure;

(B) A defined time period of not less than one year to measure performance based on such standards; and

(C) A summary of the grievance process established pursuant to subdivision (2) of this subsection for a participating provider to appeal the results of such health carrier's tiering decisions and performance measures.

(2) The standards developed by each health carrier pursuant to subdivision (1) of this subsection shall remain in effect for not less than one year. Each health carrier shall (A) provide not less than ninety days' written notice to each participating provider before such health carrier may implement any changes to such standards and measures, and (B) establish a grievance process for a participating provider to appeal such health carrier's tiering decisions and performance measures for such participating provider.

(3) No health carrier shall establish selection or tiering criteria in a manner that would (A) allow the health carrier to discriminate against high-risk populations by excluding or tiering participating providers because they are located in a geographic area that contains populations or participating providers that present a risk of higher-than-average claims, losses or health care services utilization, or (B) exclude participating providers because they treat or specialize in treating populations that present a risk of higher-than-average claims, losses or health care services utilization. Nothing in this subdivision shall be construed to prohibit a health carrier from declining to select a health care provider or facility for participation in such health carrier's network who fails to meet legitimate selection criteria established by such health carrier.

(4) No health carrier shall establish selection criteria that would allow the health carrier to discriminate, with respect to participation in a network plan, against any health care provider who is acting within the scope of such health care provider's license or certification under state law. Nothing in this subdivision shall be construed to require a health carrier to contract with any health care provider or facility willing to abide by the terms and conditions for participation established by such health carrier.

(5) Each health carrier shall make the standards required under subdivision (1) of this subsection available to the commissioner for review and shall post on its Internet web site and make available to the public a plain language description of such standards, including all measures and corresponding definitions and specifications used to tier participating providers and to evaluate participating provider performance in each tier. Each health carrier shall post on its Internet web site a plain language description of the grievance process established pursuant to subdivision (2) of this subsection for a participating provider to appeal the results of such health carrier's tiering decisions and performance measures.

(6) Nothing in this subsection shall require a health carrier, its intermediaries or health care provider networks with which such health carrier or intermediary contracts to (A) employ specific health care providers acting within the scope of such health care providers' license or certification under state law who meet such health carrier's selection criteria, or (B) contract with or retain more health care providers acting within the scope of such health care providers' license or certification under state law than are necessary to maintain a sufficient network.

(g) (1) (A) A health carrier and participating provider shall provide not less than ninety days' written notice to each other of any intent to terminate a contract between such health carrier and such participating provider prior to the proposed date of termination or, in the case of a nonrenewal, from the end of the contract period.

(B) A health carrier shall make a good faith effort to provide written notice, not less than thirty days before the proposed date of termination of the contract or, in the case of a nonrenewal, from the end of the contract period, to all covered persons who are patients being treated on a regular basis by or at the participating provider. The notice requirements set forth in this subparagraph shall not apply if the health carrier and participating provider agree, in writing, on an extension of such contract for a period not to exceed one year.

(C) For each contract entered into, renewed, amended or continued on or after July 1, 2023, between a health carrier and a participating provider that is a hospital, as defined in section 38a-493 , or a parent corporation of a hospital or an intermediary of a hospital, if the contract is not renewed or is terminated by either the health carrier or the participating provider, the health carrier and the participating provider shall continue to abide by the terms of such contract, including reimbursement terms for all health care services and provisions provided under such contract, for a period of sixty days from the date of termination or, in the case of a nonrenewal, from the end of the contract period. Except as otherwise agreed between such health carrier and such participating provider, the reimbursement terms of any contract entered into by such health carrier and such participating provider during said sixty-day period shall be retroactive to the date of termination or, in the case of a nonrenewal, the end date of the contract period. This subparagraph shall not apply if the health carrier and participating provider agree, in writing, to the termination or nonrenewal of the contract and the health carrier and participating provider provide the notices required under subparagraphs (A) and (B) of this subdivision.

(2) (A) For the purposes of this subdivision:

(i) “Active course of treatment” means (I) a medically necessary, ongoing course of treatment for a life-threatening condition, (II) a medically necessary, ongoing course of treatment for a serious condition, (III) medically necessary care provided during the second or third trimester of pregnancy, or (IV) a medically necessary, ongoing course of treatment for a condition for which a treating health care provider attests that discontinuing care by such health care provider would worsen the covered person's condition or interfere with anticipated outcomes;

(ii) “Life-threatening condition” means a disease or condition for which the likelihood of death is probable unless the course of such disease or condition is interrupted;

(iii) “Serious condition” means a disease or condition that requires complex ongoing care such as chemotherapy, radiation therapy or postoperative visits, which the covered person is currently receiving; and

(iv) “Treating provider” means a covered person's treating health care provider or a facility at which a covered person is receiving treatment, that is removed from or leaves a health carrier's network pursuant to subdivision (1) of this subsection.

(B) (i) Each health carrier shall establish and maintain reasonable procedures to transition a covered person, who is in an active course of treatment with a participating health care provider or at a participating facility that becomes a treating provider, to another participating provider in a manner that provides for continuity of care.

(ii) In addition to the notice required under subparagraph (B) of subdivision (1) of this subsection, the health carrier shall provide to such covered person (I) a list of available participating providers in the same geographic area as such covered person who are of the same health care provider or facility type, and (II) the procedures for how such covered person may request continuity of care as set forth in this subparagraph.

(iii) Such procedures shall provide that:

(I) Any request for a continuity of care period shall be made by the covered person or the covered person's authorized representative;

(II) A request for a continuity of care period, made by a covered person who meets the requirements under subparagraph (B)(i) of this subdivision or such covered person's authorized representative and whose treating provider was not removed from or did not leave the network for cause, shall be reviewed by the health carrier's medical director after consultation with such treating provider; and

(III) For a covered person who is in the second or third trimester of pregnancy, the continuity of care period shall extend through the postpartum period.

(iv) The continuity of care period for a covered person who is undergoing an active course of treatment shall extend to the earliest of the following: (I) Termination of the course of treatment by the covered person or the treating provider; (II) ninety days after the date the participating provider is removed from or leaves the network, unless the health carrier's medical director determines that a longer period is necessary; (III) the date that care is successfully transitioned to another participating provider; (IV) the date benefit limitations under the health benefit plan are met or exceeded; or (V) the date the health carrier determines care is no longer medically necessary.

(v) The health carrier shall only grant a continuity of care period as provided under subparagraph (B)(iv) of this subdivision if the treating provider agrees, in writing, (I) to accept the same payment from such health carrier and abide by the same terms and conditions as provided in the contract between such health carrier and treating provider when such treating provider was a participating provider, and (II) not to seek any payment from the covered person for any amount for which such covered person would not have been responsible if the treating provider was still a participating provider.

(h) (1) (A) Beginning January 1, 2017, a health carrier shall file with the commissioner for review each existing network as of said date and an access plan for each such network.

(B) For each new network a health carrier intends to offer after January 1, 2017, such health carrier shall file with the commissioner for review, within thirty days prior to the date such health carrier will offer such new network, the new network and an access plan for such new network.

(C) A health carrier shall notify the commissioner of any material change to an existing network not later than fifteen business days after such change and shall file with the commissioner an update to such existing network not later than thirty days after such material change. For the purposes of this subparagraph, “material change” means (i) a change of twenty-five per cent or more in the participating providers in a health carrier's network or the type of participating providers available in a health carrier's network to provide health care services or specialty care to covered persons, or (ii) any change that renders a health carrier's network noncompliant with one or more network adequacy standards, including, but not limited to, (I) a significant reduction in the number of primary care or specialty care providers available in the network, (II) a reduction in a specific type of participating provider such that a specific covered benefit is no longer available to covered persons, (III) a change to a tiered, multitiered, layered or multilevel network plan structure, (IV) a change in inclusion of a major health system, as defined in section 19a-508c , that causes a network to be significantly different from what a covered person initially purchased, or (V) after notice, any other change the commissioner deems to be a material change.

(2) Each access plan required under subdivision (1) of this subsection shall be in a form and manner prescribed by the commissioner and shall contain descriptions of at least the following:

(A) The health carrier's procedures for making and authorizing referrals within and outside its network, if applicable;

(B) The health carrier's procedures for monitoring and assuring on an ongoing basis the sufficiency of its network to meet the health care needs of the populations that enroll in its network plans;

(C) The factors used by the health carrier to build its network, including a description of the network and the criteria used to select and tier health care providers and facilities;

(D) The health carrier's efforts to address the needs of covered persons, including, but not limited to, children and adults, including those with limited English proficiency or illiteracy, diverse cultural or ethnic backgrounds, physical or mental disabilities and serious, chronic or complex conditions. Such description shall include the health carrier's efforts, when appropriate, to include various types of essential community providers in its network;

(E) The health carrier's methods for assessing the health care needs of covered persons and covered persons' satisfaction with the health care services provided;

(F) The health carrier's method of informing covered persons of the network plan's covered benefits, including, but not limited to, (i) the network plan's grievance and appeals processes, (ii) the network plan's process for covered persons to choose or change participating providers in the network plan, (iii) the health carrier's process for updating its participating provider directories for each of its network plans, (iv) a statement of the health care services offered by the network plan, including those health care services offered through the preventive care benefit, if applicable, and (v) the network plan's procedures for covering and approving emergency, urgent and specialty care, if applicable;

(G) The health carrier's system for ensuring the coordination and continuity of care for covered persons (i) referred to specialty physicians, or (ii) using ancillary services that are covered benefits, including, but not limited to, social services and other community resources and for ensuring appropriate discharge planning for covered persons using such ancillary services;

(H) The health carrier's process for enabling covered persons to change their designation of a primary care provider, if applicable;

(I) The health carrier's proposed plan for providing continuity of care to covered persons in the event of contract termination between the health carrier and any of its participating providers or in the event of the health carrier's insolvency or other inability to continue operations. Such description shall explain how covered persons will be notified of such contract termination, insolvency or other cessation of operations and transitioned to other participating providers in a timely manner;

(J) The health carrier's process for monitoring access to specialist services in emergency room care, anesthesiology, radiology, hospitalist care and pathology and laboratory services at such health carrier's participating hospitals;

(K) The health carrier's efforts to ensure that its participating providers meet available and appropriate quality of care standards and health outcomes for network plans that such health carrier has designed to include health care providers and facilities that provide high quality of care and health outcomes;

(L) The health carrier's accreditation by the National Committee for Quality Assurance that such health carrier meets said committee's network adequacy requirements or by URAC that such health carrier meets URAC's provider network access and availability standards; and

(M) Any other information required by the commissioner to determine the health carrier's compliance with this section.

(3) A health carrier shall post each access plan on its Internet web site and make such access plan available at the health carrier's business premises in this state and to any person upon request, except that such health carrier may exclude from such posting or publicly available access plan any information such health carrier deems to be proprietary information that, if disclosed, would cause the health carrier's competitors to obtain valuable business information. A health carrier may request the commissioner not to disclose such information under section 1-210 .

(i) (1) If the commissioner determines that (A) a health carrier has not contracted with a sufficient number of participating providers to assure that its covered persons have accessible health care services in a geographic area, (B) a health carrier's access plan does not assure reasonable access to covered benefits, (C) a health carrier has entered into a contract that does not conform to the requirements of this section or section 38a-477g , or (D) a health carrier has not complied with a provision of this section or section 38a-477g or 38a-477h , the health carrier shall modify its access plan or implement a corrective action plan, as appropriate, and as directed by the commissioner. The commissioner may take any other action authorized under this title to bring a health carrier into compliance with this section and sections 38a-477g and 38a-477h .

(2) The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section and sections 38a-477g and 38a-477h .

See Sec. 38a-477h re provider directories.
Conn. Gen. Stat. § 38a-482a — Connecticut Code / Title 38a / Chapter 700c / Section 38a-482a
Sec. 38a-482a. Individual health insurance policy to contain definition of “medically necessary” or “medical necessity”.
Status: in_force

(b) The provisions of subsection (a) of this section shall not apply to any insurer, health care center, hospital service corporation, medical service corporation or other entity that has entered into any national settlement agreement until the expiration of any such agreement.

See Sec. 38a-513c for similar provisions re group policies.
Conn. Gen. Stat. § 38a-816 — Connecticut Code / Title 38a / Chapter 704 / Section 38a-816
Sec. 38a-816. (Formerly Sec. 38-61). Unfair practices defined.
Status: in_force

(1) Misrepresentations and false advertising of insurance policies. Making, issuing or circulating, or causing to be made, issued or circulated, any estimate, illustration, circular or statement, sales presentation, omission or comparison which: (A) Misrepresents the benefits, advantages, conditions or terms of any insurance policy; (B) misrepresents the dividends or share of the surplus to be received, on any insurance policy; (C) makes any false or misleading statements as to the dividends or share of surplus previously paid on any insurance policy; (D) is misleading or is a misrepresentation as to the financial condition of any person, or as to the legal reserve system upon which any life insurer operates; (E) uses any name or title of any insurance policy or class of insurance policies misrepresenting the true nature thereof; (F) is a misrepresentation, including, but not limited to, an intentional misquote of a premium rate, for the purpose of inducing or tending to induce to the purchase, lapse, forfeiture, exchange, conversion or surrender of any insurance policy; (G) is a misrepresentation for the purpose of effecting a pledge or assignment of or effecting a loan against any insurance policy; or (H) misrepresents any insurance policy as being shares of stock.

(2) False information and advertising generally. Making, publishing, disseminating, circulating or placing before the public, or causing, directly or indirectly, to be made, published, disseminated, circulated or placed before the public, in a newspaper, magazine or other publication, or in the form of a notice, circular, pamphlet, letter or poster, or over any radio or television station, or in any other way, an advertisement, announcement or statement containing any assertion, representation or statement with respect to the business of insurance or with respect to any person in the conduct of his insurance business, which is untrue, deceptive or misleading.

(3) Defamation. Making, publishing, disseminating or circulating, directly or indirectly, or aiding, abetting or encouraging the making, publishing, disseminating or circulating of, any oral or written statement or any pamphlet, circular, article or literature which is false or maliciously critical of or derogatory to the financial condition of an insurer, and which is calculated to injure any person engaged in the business of insurance.

(4) Boycott, coercion and intimidation. Entering into any agreement to commit, or by any concerted action committing, any act of boycott, coercion or intimidation resulting in or tending to result in unreasonable restraint of, or monopoly in, the business of insurance.

(5) False financial statements. Filing with any supervisory or other public official, or making, publishing, disseminating, circulating or delivering to any person, or placing before the public, or causing, directly or indirectly, to be made, published, disseminated, circulated or delivered to any person, or placed before the public, any false statement of financial condition of an insurer with intent to deceive; or making any false entry in any book, report or statement of any insurer with intent to deceive any agent or examiner lawfully appointed to examine into its condition or into any of its affairs, or any public official to whom such insurer is required by law to report, or who has authority by law to examine into its condition or into any of its affairs, or, with like intent, wilfully omitting to make a true entry of any material fact pertaining to the business of such insurer in any book, report or statement of such insurer.

(6) Unfair claim settlement practices. Committing or performing with such frequency as to indicate a general business practice any of the following: (A) Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue; (B) failing to acknowledge and act with reasonable promptness upon communications with respect to claims arising under insurance policies; (C) failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies; (D) refusing to pay claims without conducting a reasonable investigation based upon all available information; (E) failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed; (F) not attempting in good faith to effectuate prompt, fair and equitable settlements of claims in which liability has become reasonably clear; (G) compelling insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insureds; (H) attempting to settle a claim for less than the amount to which a reasonable man would have believed he was entitled by reference to written or printed advertising material accompanying or made part of an application; (I) attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of the insured; (J) making claims payments to insureds or beneficiaries not accompanied by statements setting forth the coverage under which the payments are being made; (K) making known to insureds or claimants a policy of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration; (L) delaying the investigation or payment of claims by requiring an insured, claimant, or the physician of either to submit a preliminary claim report and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information; (M) failing to promptly settle claims, where liability has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage; (N) failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement; (O) using as a basis for cash settlement with a first party automobile insurance claimant an amount which is less than the amount which the insurer would pay if repairs were made unless such amount is agreed to by the insured or provided for by the insurance policy.

(7) Failure to maintain complaint handling procedures. Failure of any person to maintain complete record of all the complaints which it has received since the date of its last examination. This record shall indicate the total number of complaints, their classification by line of insurance, the nature of each complaint, the disposition of these complaints, and the time it took to process each complaint. For purposes of this subdivision “complaint” means any written communication primarily expressing a grievance.

(8) Misrepresentation in insurance applications. Making false or fraudulent statements or representations on or relative to an application for an insurance policy for the purpose of obtaining a fee, commission, money or other benefit from any insurer, producer or individual.

(9) Any violation of any one of sections 38a-358 , 38a-446 , 38a-447 , 38a-488 , 38a-825 , 38a-826 , 38a-828 and 38a-829 . None of the following practices shall be considered discrimination within the meaning of section 38a-446 or 38a-488 or a rebate within the meaning of section 38a-825 : (A) Paying bonuses to policyholders or otherwise abating their premiums in whole or in part out of surplus accumulated from nonparticipating insurance, provided any such bonuses or abatement of premiums shall be fair and equitable to policyholders and for the best interests of the company and its policyholders; (B) in the case of policies issued on the industrial debit plan, making allowance to policyholders who have continuously for a specified period made premium payments directly to an office of the insurer in an amount which fairly represents the saving in collection expense; (C) readjustment of the rate of premium for a group insurance policy based on loss or expense experience, or both, at the end of the first or any subsequent policy year, which may be made retroactive for such policy year.

(10) Notwithstanding any provision of any policy of insurance, certificate or service contract, whenever such insurance policy or certificate or service contract provides for reimbursement for any services which may be legally performed by any practitioner of the healing arts licensed to practice in this state, reimbursement under such insurance policy, certificate or service contract shall not be denied because of race, color or creed nor shall any insurer make or permit any unfair discrimination against particular individuals or persons so licensed.

(11) Favored agent or insurer: Coercion of debtors. (A) No person may (i) require, as a condition precedent to the lending of money or extension of credit, or any renewal thereof, that the person to whom such money or credit is extended or whose obligation the creditor is to acquire or finance, negotiate any policy or contract of insurance through a particular insurer or group of insurers or producer or group of producers; (ii) unreasonably disapprove the insurance policy provided by a borrower for the protection of the property securing the credit or lien; (iii) require directly or indirectly that any borrower, mortgagor, purchaser, insurer or producer pay a separate charge, in connection with the handling of any insurance policy required as security for a loan on real estate or pay a separate charge to substitute the insurance policy of one insurer for that of another; or (iv) use or disclose information resulting from a requirement that a borrower, mortgagor or purchaser furnish insurance of any kind on real property being conveyed or used as collateral security to a loan, when such information is to the advantage of the mortgagee, vendor or lender, or is to the detriment of the borrower, mortgagor, purchaser, insurer or the producer complying with such a requirement.

(B) (i) Subparagraph (A)(iii) of this subdivision shall not include the interest which may be charged on premium loans or premium advancements in accordance with the security instrument. (ii) For purposes of subparagraph (A)(ii) of this subdivision, such disapproval shall be deemed unreasonable if it is not based solely on reasonable standards uniformly applied, relating to the extent of coverage required and the financial soundness and the services of an insurer. Such standards shall not discriminate against any particular type of insurer, nor shall such standards call for the disapproval of an insurance policy because such policy contains coverage in addition to that required. (iii) The commissioner may investigate the affairs of any person to whom this subdivision applies to determine whether such person has violated this subdivision. If a violation of this subdivision is found, the person in violation shall be subject to the same procedures and penalties as are applicable to other provisions of section 38a-815 , subsections (b) and (e) of section 38a-817 and this section. (iv) For purposes of this section, “person” includes any individual, corporation, limited liability company, association, partnership or other legal entity.

(12) Refusing to insure, refusing to continue to insure or limiting the amount, extent or kind of coverage available to an individual or charging an individual a different rate for the same coverage because of physical disability, mental or nervous condition as set forth in section 38a-488a or intellectual disability, except where the refusal, limitation or rate differential is based on sound actuarial principles or is related to actual or reasonably anticipated experience.

(13) Refusing to insure, refusing to continue to insure or limiting the amount, extent or kind of coverage available to an individual or charging an individual a different rate for the same coverage solely because of blindness or partial blindness. For purposes of this subdivision, “refusal to insure” includes the denial by an insurer of disability insurance coverage on the grounds that the policy defines “disability” as being presumed in the event that the insured is blind or partially blind, except that an insurer may exclude from coverage any disability, consisting solely of blindness or partial blindness, when such condition existed at the time the policy was issued. Any individual who is blind or partially blind shall be subject to the same standards of sound actuarial principles or actual or reasonably anticipated experience as are sighted persons with respect to all other conditions, including the underlying cause of the blindness or partial blindness.

(14) Refusing to insure, refusing to continue to insure or limiting the amount, extent or kind of coverage available to an individual or charging an individual a different rate for the same coverage because of exposure to diethylstilbestrol through the female parent.

(15) (A) Failure by an insurer, or any other entity responsible for providing payment to a health care provider pursuant to an insurance policy, to pay accident and health claims, including, but not limited to, claims for payment or reimbursement to health care providers, within the time periods set forth in subparagraph (B) of this subdivision, unless the Insurance Commissioner determines that a legitimate dispute exists as to coverage, liability or damages or that the claimant has fraudulently caused or contributed to the loss. Any insurer, or any other entity responsible for providing payment to a health care provider pursuant to an insurance policy, who fails to pay such a claim or request within the time periods set forth in subparagraph (B) of this subdivision shall pay the claimant or health care provider the amount of such claim plus interest at the rate of fifteen per cent per annum, in addition to any other penalties which may be imposed pursuant to sections 38a-11 , 38a-25 , 38a-41 to 38a-53 , inclusive, 38a-57 to 38a-60 , inclusive, 38a-62 to 38a-64 , inclusive, 38a-76 , 38a-83 , 38a-84 , 38a-117 to 38a-124 , inclusive, 38a-129 to 38a-140 , inclusive, 38a-146 to 38a-155 , inclusive, 38a-283 , 38a-288 to 38a-290 , inclusive, 38a-319 , 38a-320 , 38a-459 , 38a-464 , 38a-815 to 38a-819 , inclusive, 38a-824 to 38a-826 , inclusive, and 38a-828 to 38a-830 , inclusive. Whenever the interest due a claimant or health care provider pursuant to this section is less than one dollar, the insurer shall deposit such amount in a separate interest-bearing account in which all such amounts shall be deposited. At the end of each calendar year each such insurer shall donate such amount to The University of Connecticut Health Center.

(B) Each insurer or other entity responsible for providing payment to a health care provider pursuant to an insurance policy subject to this section, shall pay claims not later than:

(i) For claims filed in paper format, sixty days after receipt by the insurer of the claimant's proof of loss form or the health care provider's request for payment filed in accordance with the insurer's practices or procedures, except that when there is a deficiency in the information needed for processing a claim, as determined in accordance with section 38a-477 , the insurer shall (I) send written notice to the claimant or health care provider, as the case may be, of all alleged deficiencies in information needed for processing a claim not later than thirty days after the insurer receives a claim for payment or reimbursement under the contract, and (II) pay claims for payment or reimbursement under the contract not later than thirty days after the insurer receives the information requested; and

(ii) For claims filed in electronic format, twenty days after receipt by the insurer of the claimant's proof of loss form or the health care provider's request for payment filed in accordance with the insurer's practices or procedures, except that when there is a deficiency in the information needed for processing a claim, as determined in accordance with section 38a-477 , the insurer shall (I) notify the claimant or health care provider, as the case may be, of all alleged deficiencies in information needed for processing a claim not later than ten days after the insurer receives a claim for payment or reimbursement under the contract, and (II) pay claims for payment or reimbursement under the contract not later than ten days after the insurer receives the information requested.

(C) As used in this subdivision, “health care provider” means a person licensed to provide health care services under chapter 368d, chapter 368v, chapters 370 to 373, inclusive, 375 to 383c, inclusive, 384a to 384c, inclusive, or chapter 400j.

(16) Failure to pay, as part of any claim for a damaged motor vehicle under any automobile insurance policy where the vehicle has been declared to be a constructive total loss, an amount equal to the sum of (A) the settlement amount on such vehicle plus, whenever the insurer takes title to such vehicle, (B) an amount determined by multiplying such settlement amount by a percentage equivalent to the current sales tax rate established in section 12-408 . For purposes of this subdivision, “constructive total loss” means the cost to repair or salvage damaged property, or the cost to both repair and salvage such property, equals or exceeds the total value of the property at the time of the loss.

(17) Any violation of section 42-260 , by an extended warranty provider subject to the provisions of said section, including, but not limited to: (A) Failure to include all statements required in subsections (c) and (f) of section 42-260 in an issued extended warranty; (B) offering an extended warranty without being (i) insured under an adequate extended warranty reimbursement insurance policy or (ii) able to demonstrate that reserves for claims contained in the provider's financial statements are not in excess of one-half the provider's audited net worth; (C) failure to submit a copy of an issued extended warranty form or a copy of such provider's extended warranty reimbursement policy form to the Insurance Commissioner.

(18) With respect to an insurance company, hospital service corporation, health care center or fraternal benefit society providing individual or group health insurance coverage of the types specified in subdivisions (1), (2), (4), (5), (6), (10), (11) and (12) of section 38a-469 , refusing to insure, refusing to continue to insure or limiting the amount, extent or kind of coverage available to an individual or charging an individual a different rate for the same coverage because such individual has been a victim of domestic violence, as defined in section 17b-112a .

(19) With respect to a property and casualty insurer delivering, issuing for delivery, renewing, amending, continuing or endorsing a property or casualty insurance policy, making any distinction or discrimination against an individual in delivering, issuing for delivery, renewing, amending, continuing, endorsing, offering, withholding, cancelling or setting premiums for such policy, or in the terms of such policy, because the individual has been a victim of domestic violence, as defined in section 17b-112a .

(20) With respect to an insurance company, hospital service corporation, health care center or fraternal benefit society providing individual or group health insurance coverage of the types specified in subdivisions (1), (2), (3), (4), (6), (9), (10), (11) and (12) of section 38a-469 , refusing to insure, refusing to continue to insure or limiting the amount, extent or kind of coverage available to an individual or charging an individual a different rate for the same coverage because of genetic information. Genetic information indicating a predisposition to a disease or condition shall not be deemed a preexisting condition in the absence of a diagnosis of such disease or condition that is based on other medical information. An insurance company, hospital service corporation, health care center or fraternal benefit society providing individual health coverage of the types specified in subdivisions (1), (2), (3), (4), (6), (9), (10), (11) and (12) of section 38a-469 , shall not be prohibited from refusing to insure or applying a preexisting condition limitation, to the extent permitted by law, to an individual who has been diagnosed with a disease or condition based on medical information other than genetic information and has exhibited symptoms of such disease or condition. For the purposes of this subdivision, “genetic information” means the information about genes, gene products or inherited characteristics that may derive from an individual or family member.

(21) Any violation of sections 38a-465 to 38a-465q , inclusive.

(22) With respect to a managed care organization, as defined in section 38a-478 , failing to establish a confidentiality procedure for medical record information, as required by section 38a-999 .

(23) Any violation of sections 38a-591d to 38a-591f , inclusive.

(24) Any violation of section 38a-472j .

(25) Any violation of section 38a-833 .

(26) Any violation of section 38a-834 .

Annotations to former section 38-61:

Cited. 186 C. 507; 192 C. 124. Legislative intent is to make insurance practices subject to both the Connecticut Unfair Insurance Practices Act and the Connecticut Unfair Trade Practices Act. 199 C. 651. Cited. 206 C. 668; 212 C. 652; 216 C. 830; 225 C. 566.

Cited. 13 CA 208; 23 CA 585.

Cited. 40 CS 299; Id., 336.

Annotations to present section:

Cited. 219 C. 644; 229 C. 842; 231 C. 756; 238 C. 216; 239 C. 658.

Cited. 28 CA 660; 45 CA 368.

Subdiv. (1):

Trial court properly determined that plaintiff failed to allege facts sufficient to state a cause of action under CUIPA, which prohibits, inter alia, misrepresentations in insurance policies; although plaintiff alleged in complaint that certificate of liability insurance concerning home improvement contractor's coverage under an insurance policy issued by defendant insurance liability carrier was deceptive insofar as it would lead a reasonable person to believe that the contractor had secured insurance coverage for a full year, such an allegation was in direct conflict with certificate language, which repeatedly distinguished between policy expiration and cancellation. 280 C. 619.

Subdiv. (6):

Right to assert a private cause of action for CUIPA violations through CUTPA does not extend to third parties absent subrogation or a judicial determination of insured's liability. 94 CA 41.

Subdiv. (10):

“Practitioner of the healing arts” is defined pursuant to Sec. 20-1 and includes podiatrists; insurer's practice of reimbursing podiatrists and medical doctors at different rates for same services does not constitute “unfair discrimination”; Subdiv. bars denial of reimbursement based on particular license held, but does not preclude setting different reimbursement rates based on particular license held. 302 C. 464.
Conn. Gen. Stat. § 38a-508 — Connecticut Code / Title 38a / Chapter 700c / Section 38a-508
Sec. 38a-508. Coverage for adopted children.
Status: in_force

(b) Coverage for such child legally placed for adoption shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

(c) If payment of a specific premium or subscription fee is required to provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, the policy or contract may require that notification of acceptance of such child and payment of the required premium or fees be furnished to the insurer, hospital service corporation, medical service corporation or health care center within thirty-one days after the acceptance of such child in order to continue coverage beyond such thirty-one-day period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such thirty-one-day period.

(d) Such policy (1) shall cover such child legally placed for adoption on the same basis as other dependents, and (2) may not contain any provision concerning preexisting conditions, insurability, eligibility or health underwriting approval for a child legally placed for adoption, except that an insurer, hospital service corporation, medical service corporation or health care center may require health underwriting for a child legally placed for adoption if a required premium or subscription fee and completed application materials are not provided to the insurer, hospital service corporation, medical service corporation or health care center before the expiration of the thirty-one-day period following the date the child was legally placed for adoption.

See Sec. 38a-549 for similar provisions re group policies.
Conn. Gen. Stat. § 38a-477i — Connecticut Code / Title 38a / Chapter 700c / Section 38a-477i
Sec. 38a-477i. Contract provisions containing all-or-nothing clauses, anti-steering clauses, anti-tiering clauses or gag clauses prohibited.
Status: in_force

(1) “All-or-nothing clause” means any provision in a health care contract that:

(A) Requires the health carrier or health plan administrator to include all members of a health care provider in a network plan; or

(B) Requires the health carrier or health plan administrator to enter into any additional contract with an affiliate of the health care provider as a condition to entering into a contract with such health care provider;

(2) “Anti-steering clause” means any provision in a health care contract that restricts the ability of the health carrier or health plan administrator from encouraging an enrollee to obtain a health care service from a competitor of a hospital or health system, including offering incentives to encourage enrollees to utilize specific health care providers such as centers of excellence or any other pay-for-performance program;

(3) “Anti-tiering clause” means any provision in a health care contract that:

(A) Restricts the ability of the health carrier or health plan administrator to introduce and modify a tiered network plan or assign health care providers into tiers, including a network that tiers providers by cost or quality; or

(B) Requires the health carrier or health plan administrator to place all members of a health care provider in the same tier of a tiered network plan;

(4) “Gag clause” means any provision in a health care contract that:

(A) Restricts the ability of the health care provider, health carrier or health plan administrator to disclose any price or quality information, including, but not limited to, the allowed amount, negotiated rates or discounts, any fees for services or any other claim-related financial obligations included in the provider contract, to any governmental entity as authorized by law or such government entity's contractors or agents, any enrollee, any treating health care provider of an enrollee, plan sponsor or potential eligible enrollees and plan sponsors; or

(B) Restricts the ability of either any health care provider, health carrier or health plan administrator to disclose out-of-pocket costs to any enrollee;

(5) “Health benefit plan”, “network”, “network plan” and “tiered network” have the same meanings as provided in section 38a-472f ;

(6) “Health care contract” means any contract, agreement or understanding, either orally or in writing, entered into, amended, restated or renewed between a health care provider and a health carrier, health plan administrator, plan sponsor or its contractors or agents for delivery of health care services to an enrollee of a health benefit plan;

(7) “Health care provider” means any for-profit or nonprofit entity, corporation or organization, parent corporation, member, affiliate, subsidiary or entity under common ownership that is or whose members are licensed or otherwise authorized by this state to furnish, bill for or receive payment for health care service delivery in the normal course of business, including, but not limited to, a health system, hospital, hospital-based facility, freestanding emergency department, imaging center, physician group with eight or more physicians, urgent care center, as defined in section 19a-493d , and any physician or physician group in a practice of fewer than eight physicians that is employed by or an affiliate of any hospital, medical foundation or insurance company;

(8) “Health carrier” has the same meaning as provided in section 38a-591a ; and

(9) “Health plan administrator” means any third-party administrator who acts on behalf of a plan sponsor to administer a health benefit plan.

(b) No health care provider, health carrier, health plan administrator or any agent or other entity that contracts on behalf of a health care provider, health carrier, or health plan administrator, may offer, solicit, request, amend, renew or enter into a health care contract on or after July 1, 2024, that directly or indirectly includes any of the following provisions:

(1) An all-or-nothing clause;

(2) An anti-steering clause;

(3) An anti-tiering clause; or

(4) A gag clause.

(c) Any clause in a health care contract, written policy, written procedure or agreement entered into, renewed or amended on or after July 1, 2024, that is contrary to the provisions set forth in subsection (b) of this section shall be null and void. All remaining clauses of such health care contract, written policy, written procedure or agreement shall remain in effect for the duration of the contract term.

(d) Nothing in this section shall be construed to modify, reduce or eliminate the existing privacy protections and standards pursuant to the federal Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, the federal Genetic Information Nondiscrimination Act of 2008, P.L. 110-233, as amended from time to time, or the federal Americans with Disabilities Act of 1990, 42 USC 12101, as amended from time to time.
Conn. Gen. Stat. § 38a-352 — Connecticut Code / Title 38a / Chapter 700 / Section 38a-352
Sec. 38a-352. (Formerly Sec. 38-175s). Motor vehicle claims to be paid by check, electronic transfer or other immediately accessible means.
Status: in_force

See Sec. 14-151a re filing of police report as condition precedent to settling a motor vehicle theft claim.
Conn. Gen. Stat. § 38a-843 — Connecticut Code / Title 38a / Chapter 704a / Section 38a-843
Sec. 38a-843. (Formerly Sec. 38-280). Insolvent insurers. Penalty. Petition to show cause.
Status: in_force

(b) The commissioner may: (1) Require that said association notify those persons insured by the insolvent insurer, and any other interested parties, of the entry of a final order of liquidation with a finding of insolvency and of their rights under sections 38a-836 to 38a-853 , inclusive. Such notification shall be by mail sent to their last-known address, where available, provided if sufficient information for such notification by mail is not available, notice by publication in a newspaper of general circulation shall be sufficient to satisfy the requirements of this subsection; (2) suspend or revoke, after notice and hearing, the certificate of authority to transact insurance in this state of any member insurer that fails to pay an assessment when due or which fails to comply with said plan of operation. In lieu of such suspension or revocation, the commissioner may levy a fine on any member insurer that fails to pay an assessment when due, provided no such fine shall exceed five per cent of the unpaid assessment per month, and provided no fine shall be less than five hundred dollars per month; (3) revoke the designation of any servicing facility if the commissioner finds claims are being handled unsatisfactorily.

(c) Any person aggrieved by any final action or order of the commissioner under sections 38a-836 to 38a-853 , inclusive, may, not later than thirty days from the date of such action or order, petition the superior court for the judicial district of Hartford to require the commissioner to show cause why such action or order should not be reversed or eliminated, and, if said court finds that the action or order of the commissioner was arbitrary and unjustified it shall take such action in the premises as may seem equitable. The pendency of any such petitions to show cause shall act as a stay of execution of any such order. Petitions under this section shall be privileged in respect of trial assignment.
Conn. Gen. Stat. § 38a-1047 — Connecticut Code / Title 38a / Chapter 706b / Section 38a-1047
Sec. 38a-1047. Conflicts of interest.
Status: in_force

(1) Have a direct involvement in the licensing, certification or accreditation of a managed care organization;

(2) Have a direct ownership or investment interest in a managed care organization;

(3) Be employed by or participate in the management of a managed care organization; or

(4) Receive or have the right to receive, directly or indirectly, remuneration under a compensation arrangement with a managed care organization.

(b) No Healthcare Advocate or person employed by the Office of the Healthcare Advocate may knowingly accept employment with a managed care organization for a period of one year following termination of that person's services with the Office of the Healthcare Advocate.
Conn. Gen. Stat. § 38a-222 — Connecticut Code / Title 38a / Chapter 698a / Section 38a-222
Sec. 38a-222. (Formerly Sec. 33-176). Workers' compensation law not affected.
Status: in_force

Annotation to former section 33-176:

Cited. 29 CS 474.
Conn. Gen. Stat. § 38a-478k — Connecticut Code / Title 38a / Chapter 700c / Section 38a-478k
Sec. 38a-478k. Gag clauses prohibited.
Status: in_force

(b) No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit the provider from disclosing, to an enrollee who inquires, the method the managed care organization uses to compensate the provider.
Conn. Gen. Stat. § 38a-591b — Connecticut Code / Title 38a / Chapter 700c / Section 38a-591b
Sec. 38a-591b. Health carrier responsibilities re utilization review.
Status: in_force

(b) Each health carrier shall be responsible for monitoring all utilization review program activities carried out by or on behalf of such health carrier. Such health carrier shall comply with the provisions of sections 38a-591a to 38a-591n , inclusive, and any regulations adopted thereunder, and shall be responsible for ensuring that any utilization review company or other entity such health carrier contracts with to perform utilization review complies with said sections and regulations. Each health carrier shall ensure that appropriate personnel have operational responsibility for the activities of the health carrier's utilization review program.

(c) (1) A health carrier that requires utilization review of a benefit request under a health benefit plan shall implement a utilization review program and develop a written document that describes all utilization review activities and procedures, whether or not delegated, for (A) the filing of benefit requests, (B) the notification to covered persons of utilization review and benefit determinations, and (C) the review of adverse determinations and grievances in accordance with sections 38a-591e and 38a-591f .

(2) Such document shall describe the following:

(A) Procedures to evaluate the medical necessity, appropriateness, health care setting, level of care or effectiveness of health care services;

(B) Data sources and clinical review criteria used in making determinations;

(C) Procedures to ensure consistent application of clinical review criteria and compatible determinations;

(D) Data collection processes and analytical methods used to assess utilization of health care services;

(E) Provisions to ensure the confidentiality of clinical, proprietary and protected health information;

(F) The health carrier's organizational mechanism, such as a utilization review committee or quality assurance or other committee, that periodically assesses the health carrier's utilization review program and reports to the health carrier's governing body; and

(G) The health carrier's staff position that is responsible for the day-to-day management of the utilization review program.

(d) Each health carrier shall:

(1) Include in the insurance policy, certificate of coverage or handbook provided to covered persons a clear and comprehensive description of:

(A) Its utilization review and benefit determination procedures;

(B) Its grievance procedures, including the grievance procedures for requesting a review of an adverse determination;

(C) A description of the external review procedures set forth in section 38a-591g , in a format prescribed by the commissioner and including a statement that discloses that:

(i) A covered person may file a request for an external review of an adverse determination or a final adverse determination with the commissioner and that such review is available when the adverse determination or the final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness. Such disclosure shall include the contact information of the commissioner; and

(ii) When filing a request for an external review of an adverse determination or a final adverse determination, the covered person shall be required to authorize the release of any medical records that may be required to be reviewed for the purpose of making a decision on such request;

(D) A statement of the rights and responsibilities of covered persons with respect to each of the procedures under subparagraphs (A) to (C), inclusive, of this subdivision. Such statement shall include a disclosure that a covered person has the right to contact the commissioner's office or the Office of Healthcare Advocate at any time for assistance and shall include the contact information for said offices;

(E) A description of what constitutes a surprise bill, as defined in subsection (a) of section 38a-477aa ;

(2) Inform its covered persons, at the time of initial enrollment and at least annually thereafter, of its grievance procedures. This requirement may be fulfilled by including such procedures in an enrollment agreement or update to such agreement;

(3) Inform a covered person or the covered person's health care professional, as applicable, at the time the covered person or the covered person's health care professional requests a prospective or concurrent review: (A) The network status under such covered person's health benefit plan of the health care professional who will be providing the health care service or course of treatment; (B) an estimate of the amount the health carrier will reimburse such health care professional for such service or treatment; and (C) how such amount compares to the usual, customary and reasonable charge, as determined by the Centers for Medicare and Medicaid Services, for such service or treatment;

(4) Inform a covered person and the covered person's health care professional of the health carrier's grievance procedures whenever the health carrier denies certification of a benefit requested by a covered person's health care professional;

(5) Prominently post on its Internet web site the description required under subparagraph (E) of subdivision (1) of this subsection;

(6) Include in materials intended for prospective covered persons a summary of its utilization review and benefit determination procedures;

(7) Print on its membership or identification cards a toll-free telephone number for utilization review and benefit determinations;

(8) Maintain records of all benefit requests, claims and notices associated with utilization review and benefit determinations made in accordance with section 38a-591d for not less than six years after such requests, claims and notices were made. Each health carrier shall make such records available for examination by the commissioner and appropriate federal oversight agencies upon request; and

(9) Maintain records in accordance with section 38a-591h of all grievances received. Each health carrier shall make such records available for examination by covered persons, to the extent such records are permitted to be disclosed by law, the commissioner and appropriate federal oversight agencies upon request.
Conn. Gen. Stat. § 38a-1041 — Connecticut Code / Title 38a / Chapter 706b / Section 38a-1041
Sec. 38a-1041. Office of the Healthcare Advocate established. Duties.
Status: in_force

(b) The Office of the Healthcare Advocate may:

(1) Assist health insurance consumers with managed care plan selection by providing information, referral and assistance to individuals about means of obtaining health insurance coverage and services;

(2) Assist health insurance consumers to understand their rights and responsibilities under managed care plans;

(3) Provide information to the public, agencies, legislators and others regarding problems and concerns of health insurance consumers and make recommendations for resolving those problems and concerns;

(4) Assist consumers with the filing of complaints and appeals, including filing appeals with a managed care organization's internal appeal or grievance process and the external appeal process established under sections 38a-591d to 38a-591g , inclusive;

(5) Analyze and monitor the development and implementation of federal, state and local laws, regulations and policies relating to health insurance consumers and recommend changes it deems necessary;

(6) Facilitate public comment on laws, regulations and policies, including policies and actions of health insurers;

(7) Ensure that health insurance consumers have timely access to the services provided by the office;

(8) Review the health insurance records of a consumer who has provided written consent for such review;

(9) Create and make available to employers a notice, suitable for posting in the workplace, concerning the services that the Healthcare Advocate provides;

(10) Establish a toll-free number, or any other free calling option, to allow customer access to the services provided by the Healthcare Advocate;

(11) Pursue administrative remedies on behalf of and with the consent of any health insurance consumers;

(12) Adopt regulations, pursuant to chapter 54, to carry out the provisions of sections 38a-1040 to 38a-1050 , inclusive; and

(13) Take any other actions necessary to fulfill the purposes of sections 38a-1040 to 38a-1050 , inclusive.

(c) The Office of the Healthcare Advocate shall make a referral to the Insurance Commissioner if the Healthcare Advocate finds that a preferred provider network may have engaged in a pattern or practice that may be in violation of sections 38a-479aa to 38a-479gg , inclusive, or 38a-815 to 38a-819 , inclusive.

(d) The Healthcare Advocate and the Insurance Commissioner shall jointly compile a list of complaints received against managed care organizations and preferred provider networks and the commissioner shall maintain the list, except the names of complainants shall not be disclosed if such disclosure would violate the provisions of section 4-61dd or 38a-1045 .

(e) The Managed Care Ombudsman shall establish a process to provide ongoing communication among mental health care providers, patients, state-wide and regional business organizations, managed care companies and other health insurers to assure: (1) Best practices in mental health treatment and recovery; (2) compliance with the provisions of sections 38a-476a , 38a-476b , 38a-488a and 38a-489 ; and (3) the relative costs and benefits of providing effective mental health care coverage to employees and their families. On or before January 1, 2006, and annually thereafter, the Healthcare Advocate shall report, in accordance with the provisions of section 11-4a , on the implementation of this subsection to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance.

(f) The Office of the Healthcare Advocate shall, within available appropriations, establish and maintain a health care consumer information Internet web site for use by the public in obtaining health care information, including, but not limited to: (1) The availability of wellness programs in various regions of Connecticut, such as disease prevention and health promotion programs; (2) quality and experience data from hospitals licensed in this state; and (3) a link to the consumer report card developed and distributed by the Insurance Commissioner pursuant to section 38a-478 l .

(g) The Office of the Healthcare Advocate shall establish an information and referral service to help residents and providers receive behavioral health care information, timely referrals and access to behavioral health care providers. In developing and implementing such service, the Healthcare Advocate, or the Healthcare Advocate's designee, shall: (1) Collaborate with stakeholders, including, but not limited to, (A) state agencies, (B) the Behavioral Health Partnership established pursuant to section 17a-22h , (C) community collaboratives, (D) the United Way's 2-1-1 Infoline program, and (E) providers; (2) identify any basis that prevents residents from obtaining adequate and timely behavioral health care services, including, but not limited to, (A) gaps in private behavioral health care services and coverage, and (B) barriers to access to care; (3) coordinate a public awareness and educational campaign directing residents to the information and referral service; and (4) develop data reporting mechanisms to determine the effectiveness of the service, including, but not limited to, tracking (A) the number of referrals to providers by type and location of providers, (B) waiting time for services, and (C) the number of providers who accept or reject requests for service based on type of health care coverage. Not later than February 1, 2016, and annually thereafter, the Office of the Healthcare Advocate shall submit a report, in accordance with the provisions of section 11-4a , to the joint standing committees of the General Assembly having cognizance of matters relating to children, human services, public health and insurance. The report shall identify gaps in services and the resources needed to improve behavioral health care options for residents.

(h) Not later than October 1, 2022, the Healthcare Advocate shall designate an employee of the Office of the Healthcare Advocate to be responsible for: (1) Performing the office's duties to minors; and (2) coordinating state-wide efforts to ensure that minors have coverage, and access to services, for behavioral health conditions, mental health conditions and substance use disorders.

See Sec. 4-38f for definition of “administrative purposes only”.
Conn. Gen. Stat. § 38a-477ff — Connecticut Code / Title 38a / Chapter 700c / Section 38a-477ff
Sec. 38a-477ff. Third-party discounts and payments for covered benefits. Credit required.
Status: in_force

(b) The provisions of subsection (a) of this section shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493 or subsection (f) of section 38a-520 , as applicable, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of said subsection (a) shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.
Conn. Gen. Stat. § 38a-415 — Connecticut Code / Title 38a / Chapter 700a / Section 38a-415
Sec. 38a-415. Division of premiums and charges.
Status: in_force

(b) Notwithstanding subsection (a) of this section, for any title insurance policy issued after October 1, 1990, no title insurer shall pay to any title insurance agent or permit such agent to retain any amount exceeding sixty per cent of the gross premium for any policy of the title insurer issued by such agent. The maximum commission to a title insurance agent shall not be increased directly or indirectly by an insurer providing anything of value, including services, to an agent for less than the actual cost or fair market value.
Conn. Gen. Stat. § 38a-865 — Connecticut Code / Title 38a / Chapter 704a / Section 38a-865
Sec. 38a-865. (Formerly Sec. 38-308). Powers.
Status: repealed

(1) Guarantee, assume, reissue or reinsure, or cause to be guaranteed, assumed, reissued or reinsured, any or all of the policies or contracts of the impaired insurer; or

(2) Provide such moneys, pledges, loans, notes, guarantees or other means as are proper to effectuate subdivision (1) of this subsection and assure payment of the contractual obligations of the impaired insurer pending action under subdivision (1) of this subsection.

(b) If a member insurer is an insolvent insurer, the association shall, in its discretion, either:

(1) (A) (i) Guarantee, assume, reissue or reinsure, or cause to be guaranteed, assumed, reissued or reinsured, the policies or contracts of the insolvent insurer, or (ii) assure payment of the contractual obligations of the insolvent insurer, and (B) provide moneys, pledges, loans, notes, guarantees or other means reasonably necessary to discharge the association's duties; or

(2) Provide benefits and coverages in accordance with the following provisions:

(A) With respect to policies and contracts, assure payment of benefits that would have been payable under the policies or contracts of the insolvent insurer, for claims incurred: (i) With respect to group policies and contracts, not later than the earlier of the next renewal date under those policies or contracts or forty-five days, but in no event less than thirty days after the date on which the association becomes obligated with respect to the policies and contracts; (ii) with respect to nongroup policies, contracts and annuities, not later than the earlier of the next renewal date, if any, under the policies or contracts or one year, but in no event less than thirty days from the date on which the association becomes obligated with respect to the policies or contracts;

(B) Make diligent efforts to provide all known insureds, enrollees or annuitants, for nongroup policies and contracts, or group policy or contract owners with respect to group policies and contracts, thirty days' notice of the termination of benefits pursuant to subparagraph (A) of this subdivision;

(C) With respect to nongroup policies and contracts covered by the association, make available to each known insured or annuitant, or owner if other than the insured, enrollee or annuitant, and with respect to an individual formerly an insured, enrollee or annuitant under a group policy or contract who is not eligible for replacement group coverage, make available substitute coverage on an individual basis in accordance with the provisions of subparagraph (D) of this subdivision, if the insureds, enrollees or annuitants had a right under law or the terminated policy, contract or annuity to convert coverage to individual coverage or to continue an individual policy, contract or annuity in force until a specified age or for a specified time during which the insurer or health care center had no right to make unilateral changes in any provision of the policy, contract or annuity or had a right only to make changes in premium by class;

(D) In providing the substitute coverage required under subparagraph (C) of this subdivision, the association may offer either to reissue the terminated coverage or to issue an alternative policy or contract at actuarially justified rates. Alternative or reissued policies shall be offered without requiring evidence of insurability, and shall not provide for any waiting period or exclusion that would not have applied under the terminated policy or contract. The association may reinsure any alternative or reissued policy or contract;

(E) Alternative policies or contracts adopted by the association shall be subject to the approval of the commissioner. The association may adopt alternative policies or contracts of various types for future issuance without regard to any particular impairment or insolvency;

(F) Alternative policies or contracts adopted by the association shall contain at least the minimum statutory provisions required in this state and provide benefits that are not unreasonable in relation to the premium charged. The association shall set the premium in accordance with a table of rates that it shall adopt. The premium shall reflect the amount of insurance to be provided and the age and class of risk of each insured, but shall not reflect any changes in the health of the insured after the original policy or contract was last underwritten;

(G) Any alternative policy or contract issued by the association shall provide coverage of a type similar to that of the policy or contract issued by the impaired or insolvent insurer as determined by the association;

(H) If the association elects to reissue terminated coverage at a premium rate different from that charged under the terminated policy or contract, the premium shall be actuarially justified and set by the association in accordance with the amount of insurance or coverage provided and the age and class of risk, subject to prior approval of the commissioner;

(I) The association's obligations with respect to coverage under any policy or contract of the impaired or insolvent insurer or under any reissued or alternative policy or contract shall cease on the date the coverage or policy or contract is replaced by another similar policy or contract by the owner, the insured, the enrollee or the association;

(J) When proceeding under this subdivision with respect to a policy or contract carrying guaranteed minimum interest rates, the association shall assure the payment or crediting of a rate of interest consistent with subparagraph (C) of subdivision (2) of subsection (f) of section 38a-860 .

(c) Nonpayment of premiums by the thirty-first day after the date required under the terms of any guaranteed, assumed, alternative or reissued policy or contract or substitute coverage shall terminate the association's obligations under the policy, contract or coverage under sections 38a-858 to 38a-875 , inclusive, with respect to the policy, contract or coverage, except with respect to any claims incurred or any net surrender value that may be due in accordance with the provisions of sections 38a-858 to 38a-875 , inclusive.

(d) Premiums due for coverage after entry of an order of liquidation of an insolvent insurer shall belong to and be payable at the direction of the association, and the association shall be liable for unearned premiums due to policy or contract owners arising after the entry of the order.

(e) The protection provided by sections 38a-858 to 38a-875 , inclusive, shall not apply where any guaranty protection is provided to residents of this state by the laws of the domiciliary state or jurisdiction of the impaired or insolvent insurer other than this state.

(f) Repealed by P.A. 87-290, S. 7, 8.

(g) In carrying out its duties under subsection (b) of this section, the association may:

(1) Subject to approval by a court in this state, impose permanent policy or contract liens in connection with a guarantee, assumption or reinsurance agreement, if the association finds that the amounts which can be assessed under sections 38a-858 to 38a-875 , inclusive, are less than the amounts needed to assure full and prompt performance of the association's duties under sections 38a-858 to 38a-875 , inclusive, or that the economic or financial conditions as they affect member insurers are sufficiently adverse to render the imposition of such permanent policy or contract liens to be in the public interest;

(2) Subject to approval by a court in this state, impose temporary moratoriums or liens on payments of cash values and policy loans, or any other right to withdraw funds held in conjunction with policies or contracts, in addition to any contractual provisions for deferral of cash or policy loan value. In addition, in the event of a temporary moratorium or moratorium charge imposed by the receivership court on payment of cash values or policy loans, or on any other right to withdraw funds held in conjunction with policies or contracts, out of the assets of the impaired or insolvent insurer, the association may defer the payment of cash values, policy loans or other rights by the association for the period of the moratorium or moratorium charge imposed by the receivership court, except for claims covered by the association to be paid in accordance with a hardship procedure established by the liquidator or rehabilitator and approved by the receivership court.

(h) If the association fails to act within a reasonable period of time with respect to any insolvent insurer, as provided in subsection (b) of this section, the commissioner shall have the powers and duties of the association under sections 38a-858 to 38a-875 , inclusive, with respect to the insolvent insurer.

(i) The association may render assistance and advice to the commissioner, upon the commissioner's request, concerning rehabilitation, payment of claims, continuation of coverage, or the performance of other contractual obligations of an impaired or insolvent insurer.

(j) The association shall have standing to appear or intervene before a court or agency in this state with jurisdiction over an impaired or insolvent insurer concerning which the association is or may become obligated under sections 38a-858 to 38a-875 , inclusive, or with jurisdiction over any person or property against which the association may have rights through subrogation or otherwise. Such standing shall extend to all matters germane to the powers and duties of the association, including, but not limited to, proposals for reinsuring, reissuing, modifying or guaranteeing the policies or contracts and contractual obligations. The association shall also have the right to appear or intervene before a court or agency in another state with jurisdiction over an impaired or insolvent insurer for which the association is or may become obligated or with jurisdiction over any person or property against whom the association may have rights through subrogation or otherwise.

(k) (1) A person receiving benefits under sections 38a-858 to 38a-875 , inclusive, whether the benefits are payments of or on account of contractual obligations, continuation of coverage or provision of substitute or alternative policies, contracts or coverages, shall be deemed to have assigned (A) the rights under the covered policy or contract to the association to the extent of the benefits received under sections 38a-858 to 38a-875 , inclusive, and (B) any causes of action against any person for losses arising under, resulting from or otherwise relating to, the covered policy or contract to the association to the extent of the benefits received because of sections 38a-858 to 38a-875 , inclusive. The association may require an assignment to it of such rights or cause of action by any enrollee, payee, policy or contract owner, beneficiary, insured or annuitant as a condition precedent to the receipt of any right or benefits under sections 38a-858 to 38a-875 , inclusive, upon the person.

(2) The subrogation rights of the association under this subsection shall have the same priority against the assets of the impaired or insolvent insurer as that possessed by the person entitled to receive benefits under sections 38a-858 to 38a-875 , inclusive.

(3) In addition to subdivisions (1) and (2) of this subsection, the association shall have, originally or by succession, all common law rights of subrogation and any other equitable or legal remedy that would have been available to the impaired or insolvent insurer or owner, beneficiary, enrollee or payee of a policy or contract with respect to the policy or contracts, against a person responsible for the losses arising from the personal injury relating to the annuity or payment thereof, except any such person responsible solely by reason of serving as an assignee with respect to a qualified assignment under Section 130 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as from time to time amended. Such rights of the association shall include, but are not limited to, in the case of a structured settlement annuity, any rights of the owner, beneficiary or payee of the annuity, to the extent of benefits received pursuant to sections 38a-858 to 38a-875 , inclusive.

(4) If the provisions of subdivisions (1) to (3), inclusive, of this subsection are invalid or ineffective with respect to any person or claim for any reason, the amount payable by the association with respect to the related covered obligations shall be reduced by the amount realized by any other person with respect to the person or claim that is attributable to the policies or contracts, or portion thereof, covered by the association.

(5) If the association has provided benefits with respect to a covered obligation and a person recovers amounts as to which the association has rights as described in subdivisions (1) to (4), inclusive, of this subsection, the person shall pay to the association the portion of the recovery attributable to the policies or contracts, or portion thereof, covered by the association.

(l) In addition to the rights and powers otherwise provided in sections 38a-858 to 38a-875 , inclusive, the association may:

(1) Enter into such contracts as are necessary or proper to carry out the provisions and purposes of sections 38a-858 to 38a-875 , inclusive;

(2) Sue or be sued, including, but not limited to, taking any legal actions necessary or proper to recover any unpaid assessments under section 38a-866 , and to settle claims or potential claims against it;

(3) Borrow money to effect the purposes of sections 38a-858 to 38a-875 , inclusive, and any notes or other evidence of indebtedness of the association not in default shall be legal investments for domestic member insurers and may be carried as admitted assets;

(4) Employ or retain such persons as are necessary or proper to handle the financial transactions of the association, and to perform such other functions as become necessary or proper under sections 38a-858 to 38a-875 , inclusive;

(5) Take such legal action as may be necessary or proper to avoid or recover payment of improper claims;

(6) Exercise, for the purposes of sections 38a-858 to 38a-875 , inclusive, and to the extent approved by the commissioner, the powers of a domestic life insurer, health insurer or health care center, but in no case may the association issue insurance policies or annuity contracts other than those issued to perform its obligations under sections 38a-858 to 38a-875 , inclusive;

(7) Request information from a person seeking coverage from the association in order to aid the association in determining its obligations under sections 38a-858 to 38a-875 , inclusive, with respect to the person, and the person shall promptly comply with the request;

(8) Unless otherwise prohibited by law, file for an actuarially justified rate or premium increase for any policy or contract for which the association provides coverage under sections 38a-858 to 38a-875 , inclusive, provided such increase is in accordance with the terms and conditions set forth in such policy or contract; and

(9) Take other necessary or proper action to discharge its duties and obligations under sections 38a-858 to 38a-875 , inclusive, or to exercise its powers under sections 38a-858 to 38a-875 , inclusive.

(m) The association may join an organization of one or more other state associations of similar purposes to further the purposes and administer the powers and duties of the association.

(n) (1) At any time within one year after the date on which the association becomes responsible for the obligations of a member insurer, which date shall be deemed the coverage date, the association may elect to succeed to the rights and obligations of the member insurer that accrue on or after the coverage date and that relate to policies, contracts or annuities covered, in whole or in part, by the association, under any one or more indemnity reinsurance agreements entered into by the member insurer as a ceding insurer and selected by the association, except that the association may not exercise an election with respect to a reinsurance agreement if the receiver, rehabilitator or liquidator of a member insurer has previously and expressly disaffirmed the reinsurance agreement. The election shall be effected by a notice to the receiver, rehabilitator or liquidator and to the affected reinsurers. If the association makes an election, then subparagraphs (A) to (D), inclusive, of this subdivision shall apply with respect to the reinsurance agreements selected by the association:

(A) The association shall be responsible for all unpaid premiums due under the agreements for periods before, on and after the coverage date, and shall be responsible for the performance of all other obligations to be performed after the coverage date, in each case which relate to policies, contracts or annuities covered in whole or in part by the association. The association may charge policies, contracts or annuities covered in part by the association, through reasonable allocation methods, the costs for reinsurance in excess of the obligations of the association.

(B) The association shall be entitled to any amounts payable by the reinsurer under the agreements with respect to losses or events that occur in periods after the coverage date and that relate to policies, contracts or annuities covered by the association in whole or in part, and upon the association's receipt of any such amount, the association shall pay any beneficiary under the policy, contract or annuity under which the association paid only a portion of the policy, contract or annuity amount:

(i) The amount received by the association that exceeds the benefits paid the beneficiary under the policy, contract or annuity; less

(ii) The benefits paid by the association on account of the policy, contract or annuity less the retention of the impaired or insolvent member insurer applicable to the loss or event.

(C) Not later than thirty days after the association's election, the association and each reinsurer shall calculate the net balance due to or from the association under each reinsurance agreement as of the date of the association's election with respect to policies, contracts or annuities covered, in whole or in part by the association, giving full credit to all items paid by either the member insurer or its receiver, rehabilitator or liquidator or the reinsurer during the period between the coverage date and the date of the association's election. Either the association or reinsurer shall pay the net balance due the other not later than five days after the completion of the calculation. If the receiver, rehabilitator or liquidator has received any amounts due the association pursuant to subparagraph (B) of this subdivision, the receiver, rehabilitator or liquidator shall remit the same to the association as promptly as practicable.

(D) If the association or receiver, on behalf of the association, not later than sixty days after the election, pays the premiums due for periods before, on and after the coverage date that relate to policies, contracts or annuities covered by the association in whole or in part, the reinsurer shall not be entitled to terminate the reinsurance agreements insofar as the agreements relate to policies, contracts or annuities covered by the association in whole or in part and shall not be entitled to set off any unpaid premium due for periods prior to the coverage date against amounts due the association.

(2) If the association does not elect to assume a reinsurance contract by the date of the association election pursuant to subdivision (1) of this subsection, the association shall have no rights or obligations in each case for periods both before and after the date of the order of liquidation with respect to the reinsurance contract.

(3) If the association transfers policies, contracts or annuities, or covered obligations with respect to such policies, contracts or annuities, to another assuming insurer, and if the association and the other insurer agree, the other insurer shall succeed to the rights and obligations of the association under subdivision (1) of this subsection, provided:

(A) The reinsurance agreements shall automatically terminate for new reinsurance unless the reinsurer and the other insurer agree to the contrary;

(B) The association's obligation to pay the beneficiary pursuant to subparagraph (B) of subdivision (1) of this subsection shall no longer apply on or after the date the reinsurance agreement is transferred to the assuming insurer; and

(C) The transferring party shall give written notice to the affected reinsurer at least thirty days prior to the effective date of the transfer.

(4) The provisions of this subsection shall supersede the provisions of any law of this state or of any affected reinsurance agreement that provides for or requires any payment of reinsurance proceeds on account of losses or events that occur in periods after the date of the order of liquidation, to the receiver, liquidator or rehabilitator of the insolvent member insurer or any other person. The receiver, rehabilitator or liquidator shall remain entitled to any amount payable by the reinsurer under the reinsurance agreement with respect to losses or events that occur in periods prior to the coverage date subject to applicable setoff provisions.

(5) Except as otherwise expressly provided in this section, nothing in this subsection shall alter or modify the terms and conditions of the reinsurance agreements of the insolvent member insurer. Nothing in this section shall abrogate or limit any rights of any reinsurer to claim that it is entitled to rescind a reinsurance agreement. Nothing in this section shall give a policy owner, contract owner, enrollee, certificate holder or beneficiary an independent cause of action against a reinsurer that is not otherwise set forth in the reinsurance agreement. Nothing in this section shall limit or affect the association's rights as a creditor of an estate against the assets of the estate. Nothing in this section shall apply to reinsurance agreements covering property or casualty risks.

(o) The board of directors of the association shall have discretion and may exercise reasonable business judgment to determine the means by which the association is to provide the benefits under sections 38a-858 to 38a-875 , inclusive, in an economical and efficient manner.

(p) Where the association has arranged or offered to provide the benefits under sections 38a-858 to 38a-875 , inclusive, to a covered person under a plan or arrangement that fulfills the association's obligations under sections 38a-858 to 38a-875 , inclusive, the person shall not be entitled to benefits from the association in addition to or other than those provided under the plan or arrangement.

(q) Venue in a suit against the association arising under sections 38a-858 to 38a-875 , inclusive, shall be in the superior court for the judicial district of Hartford. The association shall not be required to give an appeal bond in an appeal that relates to a cause of action arising under sections 38a-858 to 38a-875 , inclusive.

(r) In carrying out its duties in connection with guaranteeing, assuming, reissuing or reinsuring policies or contracts under subsections (a) or (b) of this section, the association may issue substitute coverage for a policy or contract that provides an interest rate, crediting rate or similar factor determined by use of an index or other external reference stated in the policy or contract employed in calculating returns or changes in value by issuing an alternative policy or contract in accordance with subdivisions (1) to (3), inclusive, of this subsection:

(1) In lieu of the index or other external reference provided for in the original policy or contract, the alternative policy or contract provides for (A) a fixed interest rate, (B) payment of dividends with minimum guarantees, or (C) a different method for calculating interest or changes in value;

(2) There is no requirement for evidence of insurability, waiting period or other exclusion that would not have applied under the replaced policy or contract; and

(3) The alternative policy or contract is substantially similar to the replaced policy or contract in all other material terms.

Annotations to former section 38-308:

Cited. 173 C. 352.

Cited. 35 CS 13; Id., 186.
Conn. Gen. Stat. § 38a-432 — Connecticut Code / Title 38a / Chapter 700b / Section 38a-432
Sec. 38a-432. (Formerly Sec. 38-154). Annuities.
Status: in_force

Annotation to former section 38-154:

Amount of benefit implies amount in dollars. 144 C. 346.
Conn. Gen. Stat. § 38a-142a — Connecticut Code / Title 38a / Chapter 698 / Section 38a-142a
Sec. 38a-142a. Corporate governance annual disclosures. Confidentiality of documents, materials or other information. CGAD reviews. Penalty.
Status: in_force

(1) “Board” means the board of directors of an insurer or insurance group;

(2) “CGAD” or “corporate governance annual disclosure” means a confidential report filed by an insurer or insurance group in accordance with the provisions of this section;

(3) “Insurance group” has the same meaning as provided in section 38a-142 ;

(4) “Insurer” means any person or combination of persons doing any kind or form of insurance business, including a fraternal benefit society, as described in chapter 700d, and a health care center, as defined in section 38a-175 , and includes a receiver of any insurer when the context reasonably permits. “Insurer” does not include agencies, authorities or instrumentalities of the United States, its possessions and territories, the Commonwealth of Puerto Rico, the District of Columbia, or a state or political subdivision of a state;

(5) “NAIC” means the National Association of Insurance Commissioners;

(6) “ORSA Summary Report” has the same meaning as provided in section 38a-142 ; and

(7) “Senior management” means any corporate officer of an insurer or insurance group responsible for reporting information to the board at regular intervals or providing information to shareholders or regulators, and includes, but is not limited to, a chief executive officer, chief financial officer, chief operations officer, chief procurement officer, chief legal officer, chief information officer, chief technology officer, chief revenue officer and chief visionary officer.

(b) (1) Not later than June 1, 2017, and annually thereafter, each domestic insurer or the insurance group of which such insurer is a member shall submit to the Insurance Commissioner a CGAD that contains the information required under subsection (c) of this section, except that if the insurer is a member of an insurance group, such insurer shall submit the CGAD to the lead state commissioner, as determined by the procedures in NAIC's applicable financial analysis handbook, of the insurance group of which such insurer is a member. If the commissioner is the lead state commissioner of such insurance group, the commissioner shall provide, in a manner consistent with the provisions of subdivision (3) of subsection (e) of this section, a copy of the CGAD upon request to the insurance regulatory official of any state in which such insurance group has a domestic insurer. A domestic insurer that is not required to submit a CGAD to the commissioner under this subdivision shall do so if requested by the commissioner.

(2) Each year after the initial submission of the CGAD, such insurer or insurance group shall submit an amended version of the previous year's CGAD that indicates where changes have been made. If no changes were made, such submission shall so state.

(c) Each CGAD shall contain the following information:

(1) A description of the insurer's or insurance group's corporate governance framework and structure, including (A) (i) its board and each significant committee thereof that is responsible for oversight of the insurer or insurance group and the level at which such oversight occurs, such as the ultimate control level, an intermediate holding company level or an individual legal entity level, and (ii) a description and discussion of its rationale for the current board size and structure, and (B) the duties of the board and such committees, the method by which each is governed, such as through bylaws, a charter or informal mandates, and a description of how the board's leadership is structured, including a discussion of the roles of the chief executive officer and the chairman of the board within the organization;

(2) A description of the policies and practices of the board and each significant committee thereof, including a discussion of (A) how the qualifications, expertise and experience of each board member meet the needs of the insurer or insurance group, (B) how the insurer or insurance group ensures an appropriate amount of independence is maintained on the board and such committees, (C) the number of meetings held by the board and such committees during the previous year and information on board member attendance, and (D) how the insurer or insurance group identifies, nominates and elects members to the board and such committees, including (i) whether a nomination committee is in place to identify and select individuals for consideration, (ii) whether term limits are placed on board members, (iii) how the election and reelection processes function, and (iv) whether a board diversity policy is in place and if so, how it functions;

(3) A description of the board's processes to evaluate its performance and the performance of its committees and any recent measures taken to improve performance, including any board or committee training programs that have been put in place;

(4) A description of the insurer's or insurance group's policies and practices for directing senior management, including (A) any processes or practices, such as suitability standards, to determine whether officers and key individuals in control functions have the appropriate background, experience and integrity to fulfill their roles, including (i) identification of specific positions for which suitability standards have been developed and a description of the standards applied, and (ii) the standards and procedures to monitor and evaluate an officer's or key individual's suitability and any changes in an officer's or key individual's suitability in the previous year as a result of applying such standards or procedures, (B) its code of business conduct and ethics, including a discussion of its compliance with laws, rules and regulations and its proactive reporting of any illegal or unethical conduct, (C) its senior management succession plans, and (D) its processes for performance evaluation, compensation and corrective action, to ensure effective senior management throughout the organization, including a description of the general objectives of its significant compensation programs and what such programs are designed to reward. The description under this subdivision shall contain sufficient detail to allow the commissioner to understand how the insurer or insurance group ensures that such compensation programs do not encourage or reward excessive risk-taking, and may include (i) the board's role in overseeing management compensation programs and practices, (ii) the elements of compensation awarded in a compensation program and how the insurer or insurance group determines and calculates the amount of each element of compensation paid, (iii) how the insurer's or insurance group's compensation programs are related to both organizational and individual performance over time, (iv) whether the insurer's or insurance group's compensation programs include risk adjustments and how such adjustments are incorporated into its employee compensation programs at different levels, (v) any clawback provisions built into the insurer's or insurance group's compensation programs to recover awards or payments if the performance measures upon which such awards or payments were based are restated or otherwise adjusted, and (vi) any other factors relevant to understanding how the insurer or insurance group monitors its compensation programs to determine whether its risk management objectives are met by incentivizing its employees.

(5) A description of the insurer's or insurance group's processes by which the board, each significant committee thereof and senior management ensure an appropriate amount of oversight of the critical risk areas impacting the insurer's or insurance group's business activities, including a discussion of (A) how oversight and management responsibilities are delegated between the board, such committees and senior management, (B) how the board is kept informed of the insurer's or insurance group's strategic plans, the associated risks and the steps senior management takes or has taken to monitor and manage such risks, and (C) how reporting responsibilities are organized for each critical risk area. The description under subparagraph (C) of this subdivision shall contain sufficient detail to allow the commissioner to understand the frequency at which information on each critical risk area is reported to and reviewed by the board and senior management, and may include the following critical risk areas: (i) Risk management processes. An insurer or insurance group that is required to file an ORSA Summary Report pursuant to section 38a-142 may refer to such report; (ii) actuarial function; (iii) investment decision-making processes; (iv) reinsurance decision-making processes; (v) business strategy and financial decision-making processes; (vi) compliance function; (vii) financial reporting and internal auditing; and (viii) market conduct decision-making processes.

(d) (1) For the purposes of completing the CGAD, the insurer or insurance group may provide the required information at the ultimate control level, an intermediate holding company level or an individual legal entity level, depending on the structure of such insurer's or insurance group's corporate governance system. Such insurer or insurance group may report information for the CGAD at the level at which (A) such insurer's or insurance group's risk appetite is determined, (B) such insurer's or insurance group's earnings, capital, liquidity, operations and reputation are overseen collectively and the supervision of such factors are coordinated and exercised, or (C) legal liability would be placed for such insurer's or insurance group's failure to comply with its corporate governance duties. An insurer or insurance group that determines its level of CGAD reporting based on the criteria specified in this subdivision shall indicate in the CGAD which of the three criteria was used to determine its level of reporting and explain any subsequent changes in its level of reporting.

(2) The insurer or insurance group may utilize and reference other existing documents such as ORSA Summary Reports, Holding Company Form B or F filings, Securities and Exchange Commission proxy statements or foreign regulatory required filings, that furnish information comparable to that required under subsection (c) of this section. The insurer or insurance group shall attach such other documents to the CGAD, if such documents are not already filed with or available to the commissioner, and clearly reference the applicable information within the CGAD that such other documents are intended to supply.

(3) The insurer or insurance group shall have discretion over the information it provides in a CGAD, provided such CGAD is consistent with subsection (c) of this section and contains the material information necessary to allow the commissioner to understand the insurer's or insurance group's corporate governance structure, policies and practices. The insurer or insurance group shall be as descriptive as possible in completing a CGAD and shall include attachments or document examples that such insurer or insurance group uses in its governance process. The commissioner may request additional information the commissioner deems material and necessary to understand the insurer's or insurance group's corporate governing policies, reporting or information system or controls over such policies or systems. The insurer or insurance group shall maintain any CGAD-related documents and supporting information and make such documents and information available to the commissioner upon request.

(4) Each CGAD shall be signed by the chief executive officer or corporate secretary of the insurer or insurance group, attesting that to the best of such individual's belief and knowledge, such insurer or insurance group has implemented the corporate governance practices described in the CGAD and that a copy of such CGAD has been provided to the insurer's or insurance group's board or appropriate committee thereof.

(e) (1) All documents, materials or other information, including the CGAD, in the possession or control of the Insurance Department that are obtained by, created by or disclosed to the commissioner or any other person pursuant to this section are deemed to be proprietary and to contain trade secrets and shall be confidential by law and privileged, shall not be subject to disclosure under section 1-210 , shall not be subject to subpoena and shall not be subject to discovery or admissible in evidence in any civil action in this state. The commissioner may use such documents, materials or information in the furtherance of any regulatory or legal action brought as a part of the commissioner's official duties. The commissioner shall not otherwise make such documents, materials or other information public without the prior written consent of the insurer, except that nothing in this subsection shall be construed to require written consent of the insurer prior to the commissioner sharing or receiving CGAD-related documents, materials or other information pursuant to subdivision (3) of this subsection.

(2) Neither the commissioner nor any person who, while acting under the authority of the commissioner, obtained or received CGAD-related documents, materials or other information, or to whom such documents, materials or other information were disclosed, shall be permitted or required to testify in any civil action in this state concerning any such documents, materials or information.

(3) To assist the commissioner in the performance of the commissioner's regulatory duties, the commissioner:

(A) May share upon request CGAD-related documents, materials or other information, including documents, materials or information deemed proprietary and containing trade secrets, confidential and privileged or not disclosable pursuant to this subsection, with (i) other state, federal and international financial regulatory officials, including members of a supervisory college as described in section 38a-135 , (ii) NAIC, and (iii) any third-party consultants engaged by the commissioner pursuant to subsection (f) of this section, provided the recipient of any such documents, materials or other information agrees, in writing, to maintain the confidentiality and privileged status of such documents, materials or other information and has verified, in writing, the recipient's legal authority to maintain confidentiality; and

(B) May receive CGAD-related documents, materials or other information, including documents, materials or information deemed proprietary and containing trade secrets, confidential and privileged, from other state, federal and international financial regulatory officials, including members of a supervisory college and NAIC. The commissioner shall maintain as confidential and privileged any such documents, materials or information received with notice or the understanding that such documents, materials or information are confidential and privileged under the laws of the jurisdiction that is the source of such documents, materials or information.

(4) A written agreement between the commissioner and NAIC or a third-party consultant governing the sharing and use of documents, materials and information shared or received pursuant to subdivision (3) of this subsection shall expressly require the prior written consent of the insurer to NAIC or such third-party consultant making such documents, materials or information public and shall (A) specify policies and procedures for maintaining the confidentiality and security of such documents, materials or other information that are shared with NAIC or the third-party consultant, including (i) procedures and protocols limiting sharing by NAIC to only regulatory officials of states in which other member insurers of the insurance group of which a domestic insurer is a member are domiciled, and (ii) a provision requiring NAIC or a third-party consultant to agree, in writing, and if applicable, a provision requiring NAIC to obtain from a regulatory official under subparagraph (A)(i) of this subdivision an agreement, in writing, to maintain the confidentiality and privileged status of such documents, materials or other information, and verifying the recipient's legal authority to maintain confidentiality, (B) specify that the commissioner shall retain ownership of such documents, materials or other information and that the use of such documents, materials or other information is subject to the commissioner's discretion, (C) prohibit NAIC or the third-party consultant from storing such documents, materials or other information in a permanent database after the underlying analysis is completed, (D) require NAIC or the third-party consultant to promptly notify the commissioner and the insurer or insurance group whose confidential information is in the possession of NAIC or the third-party consultant if NAIC or the third-party consultant is subject to a request or subpoena for disclosure or production of such documents, materials or other information, and (E) require NAIC or the third-party consultant, if NAIC or such consultant is subject to disclosure of an insurer's or insurance group's confidential documents, materials or other information that has been shared with NAIC or such consultant pursuant to subparagraph (A) of subdivision (3) of this subsection, to allow such insurer or insurance group to intervene in any judicial or administrative action regarding such disclosure.

(5) No waiver of any applicable privilege or claim of confidentiality in any CGAD-related documents, materials or other information shall occur as a result of sharing by or disclosure to the commissioner in accordance with this section. Nothing in this subsection shall be construed to delegate any regulatory authority of the commissioner to any person or entity with which any such documents, materials or other information have been shared.

(f) (1) Any review of a CGAD or a request for CGAD-related documents, materials or other information shall be conducted by or made through the lead state commissioner, as determined by the procedures in NAIC's applicable financial analysis handbook, of the insurance group of which the insurer is a member.

(2) The commissioner may engage the services of third-party consultants including attorneys, actuaries, accountants and other experts not otherwise a part of the commissioner's staff, at the insurer's or insurance group's expense, as shall be reasonably necessary to assist the commissioner in a review of such insurer's or insurance group's CGAD and related documents, materials and other information or of such insurer's or insurance group's compliance with the requirements of this section. Any such consultant shall (A) be under the direction and control of the commissioner and act in an advisory capacity only, and (B) verify to the commissioner and provide notice to the insurer or insurance group that such consultant is free of any conflict of interest regarding such insurer or insurance group and has internal procedures in place to monitor conflicts of interest that may arise and to comply with the confidentiality standards and requirements of this section.

(3) Nothing in this section shall be construed to (A) prescribe or impose corporate governance standards or internal procedures beyond that required under state corporation laws, or (B) affect the provisions of section 38a-14 or 38a-14a .

(g) The commissioner, after notice and hearing, may impose a civil penalty on an insurer or insurance group that fails, without just cause, to timely file a CGAD, of one hundred seventy-five dollars for each day the failure to file a CGAD continues. The commissioner may reduce the penalty if the insurer or insurance group demonstrates to the commissioner that the imposition of the penalty would constitute a financial hardship to the insurer or insurance group.
Conn. Gen. Stat. § 38a-591e — Connecticut Code / Title 38a / Chapter 700c / Section 38a-591e
Sec. 38a-591e. Internal grievance process of adverse determinations based on medical necessity. Expedited review of adverse determinations of urgent care requests.
Status: in_force

(2) Each health carrier shall file with the commissioner a copy of such procedures, including all forms used to process requests, and any subsequent material modifications to such procedures.

(3) In addition to a copy of such procedures, each health carrier shall file annually with the commissioner, in a form prescribed by the commissioner, a certificate of compliance stating that the health carrier has established and maintains grievance procedures for each of its health benefit plans that are fully compliant with the provisions of sections 38a-591a to 38a-591n , inclusive.

(b) (1) A covered person or a covered person's authorized representative may file a grievance of an adverse determination that was based, in whole or in part, on medical necessity with the health carrier not later than one hundred eighty calendar days after the covered person or the covered person's authorized representative, as applicable, receives the notice of an adverse determination.

(2) For prospective or concurrent urgent care requests, a covered person or a covered person's authorized representative may make a request for an expedited review orally or in writing.

(c) (1) (A) When conducting a review of an adverse determination under this section, the health carrier shall ensure that such review is conducted in a manner to ensure the independence and impartiality of the clinical peer or peers involved in making the review decision.

(B) If the adverse determination involves utilization review, the health carrier shall designate an appropriate clinical peer or peers to review such adverse determination. Such clinical peer or peers shall not have been involved in the initial adverse determination.

(C) The clinical peer or peers conducting a review under this section shall take into consideration all comments, documents, records and other information relevant to the covered person's benefit request that is the subject of the adverse determination under review, that are submitted by the covered person or the covered person's authorized representative, regardless of whether such information was submitted or considered in making the initial adverse determination.

(D) Prior to issuing a decision, the health carrier shall provide free of charge, by facsimile, electronic means or any other expeditious method available, to the covered person or the covered person's authorized representative, as applicable, any new or additional documents, communications, information and evidence relied upon and any new or additional scientific or clinical rationale used by the health carrier in connection with the grievance. Such documents, communications, information, evidence and rationale shall be provided sufficiently in advance of the date the health carrier is required to issue a decision to permit the covered person or the covered person's authorized representative, as applicable, a reasonable opportunity to respond prior to such date.

(2) If the review under subdivision (1) of this subsection is an expedited review, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or the covered person's authorized representative, as applicable, by telephone, facsimile, electronic means or any other expeditious method available.

(3) If the review under subdivision (1) of this subsection is an expedited review of a grievance involving an adverse determination of a concurrent review request, pursuant to 45 CFR 147.136, as amended from time to time, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.

(d) (1) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative, in writing or by electronic means, of its decision within a reasonable period of time appropriate to the covered person's medical condition, but not later than:

(A) For prospective review and concurrent review requests, thirty calendar days after the health carrier receives the grievance;

(B) For retrospective review requests, sixty calendar days after the health carrier receives the grievance;

(C) For expedited review requests, except as specified under subparagraph (D) of this subdivision, forty-eight hours after the health carrier receives the grievance or seventy-two hours after such health carrier receives such grievance if any portion of such forty-eight-hour period falls on a weekend; and

(D) For expedited review requests of a health care service or course of treatment specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a , twenty-four hours after the health carrier receives the grievance.

(2) The time periods set forth in subdivision (1) of this subsection shall apply regardless of whether all of the information necessary to make a decision accompanies the filing.

(e) (1) The notice required under subsection (d) of this section shall set forth, in a manner calculated to be understood by the covered person or the covered person's authorized representative:

(A) The titles and qualifying credentials of the clinical peer or peers participating in the review process;

(B) Information sufficient to identify the claim involved with respect to the grievance, including the date of service, if applicable, the health care professional and the claim amount;

(C) A statement of such clinical peer's or peers' understanding of the covered person's grievance;

(D) The clinical peer's or peers' decision in clear terms and the health benefit plan contract basis or scientific or clinical rationale for such decision in sufficient detail for the covered person to respond further to the health carrier's position;

(E) Reference to the evidence or documentation used as the basis for the decision;

(F) For a decision that upholds the adverse determination:

(i) The specific reason or reasons for the final adverse determination, including the denial code and its corresponding meaning, as well as a description of the health carrier's standard, if any, that was used in reaching the denial;

(ii) Reference to the specific health benefit plan provisions on which the decision is based;

(iii) A statement that the covered person may receive from the health carrier, free of charge and upon request, reasonable access to and copies of, all documents, records, communications and other information and evidence not previously provided regarding the adverse determination under review;

(iv) If the final adverse determination is based on a health carrier's internal rule, guideline, protocol or other similar criterion, (I) the specific rule, guideline, protocol or other similar criterion, or (II) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the final adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request and instructions for requesting such copy;

(v) If the final adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the final adverse determination and (I) an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances, or (II) a statement that an explanation will be provided to the covered person free of charge upon request and instructions for requesting a copy of such explanation;

(vi) A statement describing the procedures for obtaining an external review of the final adverse determination;

(G) If applicable, the following statement: “You and your plan may have other voluntary alternative dispute resolution options such as mediation. One way to find out what may be available is to contact your state Insurance Commissioner.”; and

(H) A statement, expressed in language approved by the Healthcare Advocate and prominently displayed on the first page or cover sheet of the notice using a call-out box and large or bold text, disclosing the covered person's right to contact the commissioner's office or the Office of the Healthcare Advocate at any time. Such disclosure shall include the contact information for said offices.

(2) Upon request pursuant to subparagraph (F)(iii) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (b) of section 38a-591n .

(f) (1) Whenever a health carrier fails to strictly adhere to the requirements of this section with respect to receiving and resolving grievances involving an adverse determination, the covered person shall be deemed to have exhausted the internal grievance process of such health carrier and may file a request for an external review, regardless of whether the health carrier asserts that it substantially complied with the requirements of this section, or that any error it committed was de minimis.

(2) A covered person who has exhausted the internal grievance process of a health carrier may, in addition to filing a request for an external review, pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal grievance process that would yield a decision on the merits of the claim.
Conn. Gen. Stat. § 38a-179 — Connecticut Code / Title 38a / Chapter 698a / Section 38a-179
Sec. 38a-179. (Formerly Sec. 33-179g). Management of domestic health care center. Directors.
Status: in_force

(b) If a domestic health care center is not organized as a nonprofit, nonstock corporation, management of its affairs shall be in accordance with other applicable laws of the state, provided such health care center shall establish and maintain a mechanism to afford its members an opportunity to participate in matters of policy and operation such as an advisory panel, advisory referenda on major policy decisions or other similar mechanisms.
Conn. Gen. Stat. § 38a-678 — Connecticut Code / Title 38a / Chapter 701 / Section 38a-678
Sec. 38a-678. (Formerly Sec. 38-201p). Complaint and hearing. Practices prohibited. Suspension and revocation of certificate of authority or license. Appeals.
Status: in_force

(b) If after examination of an insurer, rating organization, advisory organization, or group, association or other organization of insurers which engages in joint underwriting or joint reinsurance, or upon the basis of other information, or upon sufficient complaint as provided in subsection (a) of this section, the Insurance Commissioner has good cause to believe that such insurer, organization, group or association or any rate, rating plan or rating system made or used by any such insurer or rating organization, does not comply with the requirements and standards of said sections applicable to it, he shall, unless he has good cause to believe such noncompliance is wilful, give notice in writing to such insurer, organization, group or association stating therein what manner and to what extent such noncompliance is alleged to exist and specifying therein a reasonable time, not less than ten days thereafter, in which such noncompliance may be corrected. Notices under this section shall be confidential as between said commissioner and the parties unless a hearing is held in accordance with the provisions of subsection (c) of this section.

(c) If the Insurance Commissioner has good cause to believe such noncompliance to be wilful, or if within the period prescribed by said commissioner in the notice required by subsection (b) of this section the insurer, organization, group or association does not make such changes as may be necessary to correct the noncompliance specified by said commissioner or establish to the satisfaction of said commissioner that such specified noncompliance does not exist, then said commissioner may hold a public hearing in connection therewith, provided within a reasonable period of time, which shall be not less than ten days before the date of such hearing, he shall mail a written notice specifying the matters to be considered at such hearings to such insurer, organization, group or association. If no notice has been given as provided in subsection (b) of this section such notice shall state therein in what manner and to what extent noncompliance is alleged to exist. The hearing shall not include any additional subjects not specified in the notices required by said subsection (b).

(d) If after a hearing pursuant to subsection (c) of this section, the Insurance Commissioner finds (1) that any rate, rating plan or rating system violates the provisions of sections 38a-663 to 38a-681 , inclusive, applicable to it, he may issue an order to the insurer or rating organization which has been the subject of the hearing specifying in what respects such violation exists and stating when, within a reasonable period of time, the further use of such rate or rating system by such insurer or rating organization in contracts of insurance made thereafter shall be prohibited; (2) that an insurer, rating organization, advisory organization, or a group, association or other organization of insurers which engages in joint underwriting or joint reinsurance, is in violation of the provisions of said sections applicable to it other than the provisions dealing with rates, rating plans or rating systems, he may issue an order to such insurer, organization, group or association which has been the subject of the hearing specifying in what respects such violation exists and requiring compliance within a reasonable time thereafter; (3) that the violation of any of the provisions of said sections applicable to it by any insurer or rating organization which has been the subject of hearing was wilful, he may suspend or revoke, in whole or in part, the certificate of authority of such insurer or the license of such rating organization with respect to the class of insurance which has been the subject matter of the hearing; (4) that any rating organization has wilfully engaged in any fraudulent or dishonest act or practices, he may suspend or revoke, in whole or in part, the license of such organization in addition to any other penalty provided in said sections; (5) in addition to other penalties provided by law the Insurance Commissioner may suspend or revoke, in whole or in part, the license of any rating organization or the certificate of authority of any insurer with respect to the class or classes of insurance specified in such order, which fails to comply within the time limited by such order or any extension thereof which said commissioner may grant, with an order of said commissioner lawfully made by him pursuant to this subsection and effective pursuant to subdivision (7) of this subsection; (6) except as otherwise provided in sections 38a-663 to 38a-681 , inclusive, all proceedings in connection with the denial, suspension or revocation of a license or certificate of authority under said sections shall be conducted in accordance with the provisions of section 38a-41 and the Insurance Commissioner shall have all the powers granted to him therein; (7) any findings, determination, rule, ruling or order made by the Insurance Commissioner, in accordance with the provisions of said sections, shall be subject to review by appeal in accordance with the provisions of section 4-183 . No such finding, determination, rule, ruling or order shall become effective before the expiration of twenty days after notice and a copy thereof are mailed or delivered to the person affected, and any finding, determination, rule, ruling or order of said commissioner so submitted for review shall not become effective for a further period of fifteen days after the petition for review is filed with the court. The court may stay the effectiveness thereof for a longer period.

Annotation to former section 38-201p:

Cited. 169 C. 267, 303.
Conn. Gen. Stat. § 38a-308 — Connecticut Code / Title 38a / Chapter 700 / Section 38a-308
Sec. 38a-308. (Formerly Sec. 38-99). Provisions of policy or contract.
Status: in_force

(2) There shall be printed at the head of such policy the name of the insurer or insurers issuing the policy, the location of the home office thereof, a statement showing whether such insurer or insurers are stock or mutual corporations or are reciprocal insurers or Lloyd's underwriter, provided any company organized under special charter provisions may so indicate upon its policy and may add a statement of the plan under which it operates in this state, and there may be added thereon such device or devices as the insurer or insurers issuing such policy desire. Such policy shall be clearly designated on the back of the form as “The Standard Fire Insurance Policy of the State of Connecticut”; and this designation may include the names of such other states as have adopted this standard form.

(3) The standard fire insurance policy provided for in section 38a-307 need not be used for effecting reinsurance between insurers. If the policy is issued by a mutual, cooperative or reciprocal insurer having special regulations with respect to the payment by the policyholder of assessments, such regulations shall be printed upon the policy and any such insurer may print upon the policy such regulations as are appropriate to or required by its form of organization. Insurers issuing the standard fire insurance policy pursuant to section 38a-307 are authorized to affix thereto or include therein a written statement that the policy does not cover loss or damage caused by nuclear reaction or nuclear radiation or radioactive contamination, all whether directly or indirectly resulting from an insured peril under such policy; provided nothing herein contained shall be construed to prohibit the attachment to any such policy of an endorsement or endorsements specifically assuming coverage for loss or damage caused by nuclear reaction or nuclear radiation or radioactive contamination.

(b) Any policy or contract that includes, either on an unspecified basis as to coverage or for an indivisible premium, coverage against the peril of fire and substantial coverage against other perils need not comply with the provisions of subsection (a) of this section, provided: (1) Such policy or contract shall afford coverage, with respect to the peril of fire, not less than the substantial equivalent of the coverage afforded by said standard fire insurance policy; (2) except as provided under subdivision (1) of subsection (a) of this section for a policy or contract of fire insurance for a commercial property made, issued or delivered by a nonadmitted insurer or any agent or representative thereof, the following provisions in said standard fire insurance policy are incorporated therein without change: (A) Mortgagee interests and obligations, (B) the definitions of actual cash value and depreciation, (C) the time period for when a loss is payable after proof of loss, and (D) the time period for when a suit or action for the recovery of a claim may be commenced; (3) such policy or contract shall afford coverage, in an amount not greater than the amount specified in such policy or contract, for the increased cost of repair or reconstruction by reason of ordinances or laws regulating such repair or reconstruction; (4) such policy or contract is complete as to all of its terms without reference to any other document; and (5) the commissioner is satisfied that such policy or contract complies with the provisions hereof. The provisions of this subsection shall apply to any such policy or contract issued or renewed on or after July 1, 2014.

(c) None of the provisions of this section shall apply to policies of automobile or aircraft physical damage insurance or to policies of inland marine insurance.

(d) The provisions of section 38a-346 shall apply in the event of cancellation of a policy issued pursuant to this chapter.

(e) Any policies made, issued or delivered through a fire, liability and allied lines underwriting facility established by the Insurance Commissioner pursuant to section 38a-328 shall not be subject to the cancellation of policy provisions or notice of cancellation requirements of section 38a-307 , provided such policies comply with any regulation adopted by the Insurance Commissioner pursuant to subsection (a) of section 38a-328 .

Annotations to former section 38-99:

Cited. 190 C. 594.

Cited. 30 CS 291.

Annotations to present section:

Cited. 219 C. 644.

Standard fraud and concealment provisions. 55 CA 488.
Conn. Gen. Stat. § 38a-982 — Connecticut Code / Title 38a / Chapter 705 / Section 38a-982
Sec. 38a-982. (Formerly Sec. 38-507). Investigative consumer reports.
Status: in_force

(b) If an investigative consumer report is to be prepared by an insurance institution or agent, the institution or agent shall establish reasonable procedures pertaining to the conduct of a personal interview requested by an individual.

(c) If an investigative consumer report is to be prepared by an insurance-support organization, the institution or agent desiring such report shall inform the insurance-support organization whether a personal interview has been requested by the individual. The insurance-support organization shall establish reasonable procedures pertaining to the conduct of such interviews, if requested.
Conn. Gen. Stat. § 38a-639 — Connecticut Code / Title 38a / Chapter 700d / Section 38a-639
Sec. 38a-639. (Formerly Sec. 38-231). Certificate provisions.
Status: in_force

(b) The certificate shall contain in substance the following standard provisions or, in lieu thereof, provisions which are more favorable to the member: (1) Title on the face and filing page of the certificate clearly and correctly describing its form; (2) a provision stating the amount of rates, premiums or other required contributions, by whatever name known, which are payable by the insured under the certificate; (3) a provision that the member is entitled to a grace period of not less than a full month, or thirty days at the option of the society, in which the payment of any premium, after the first, may be made. During such grace period the certificate shall continue in full force, but, in case the certificate becomes a claim during the grace period before the overdue payment is made, the amount of such overdue payment or payments may be deducted in any settlement under the certificate; (4) a provision that the member shall be entitled to have the certificate reinstated at any time within three years from the due date of the premium in default, unless the certificate has been completely terminated through the application of a nonforfeiture benefit, cash surrender value or certificate loan, upon the production of evidence of insurability satisfactory to the society and the payment of all overdue premiums and any other indebtedness to the society upon the certificate, together with interest on such premiums and such indebtedness, if any, at a rate not exceeding six per cent per annum compounded annually; (5) except in the case of pure endowment, annuity or reversionary annuity contracts, reducing term insurance contracts, or contracts of term insurance of uniform amount of fifteen years or less expiring before age sixty-six, a provision that, in the event of default in payment of any premium after three full years' premiums have been paid or after premiums for a lesser period have been paid if the contract so provides, the society will grant, upon proper request not later than sixty days after the due date of the premium in default, a paid-up nonforfeiture benefit on the plan stipulated in the certificate, effective as of such due date. The certificate may provide, if the society's laws so specify or if the member so elects prior to the expiration of the grace period of any overdue premium, that default shall not occur so long as premiums can be paid under the provisions of an arrangement for automatic premium loan as may be set forth in the certificate; (6) a provision that one paid-up nonforfeiture benefit as specified in the certificate shall become effective automatically unless the member elects another available paid-up nonforfeiture benefit, not later than sixty days after the due date of the premium in default; (7) a statement of the mortality table and rate of interest used in determining all paid-up nonforfeiture benefits and cash surrender options available under the certificate, and a brief general statement of the method used in calculating such benefits; (8) a table showing in figures the value of every paid-up nonforfeiture benefit and cash surrender option available under the certificate for each certificate anniversary either during the first twenty certificate years or during the term of the certificate, whichever is shorter; (9) a provision that the certificate shall be incontestable after it has been in force during the lifetime of the member for a period of two years from its date of issue except for nonpayment of premiums, violation of the provisions of the certificate relating to military, aviation or naval service and violation of the provisions relating to suspension or expulsion as substantially set forth in the certificate. At the option of the society, supplemental provisions relating to benefits in the event of temporary or permanent disability or hospitalization and provisions which grant additional insurance specifically against death by accident or accidental means may also be excepted. The certificate shall be incontestable on the ground of suicide after it has been in force during the lifetime of the member for a period of two years from the date of issue. The certificate may provide, as to statements made to procure reinstatement, that the society shall have the right to contest a reinstated certificate within a period of two years from the date of reinstatement with the same exceptions as herein provided; (10) a provision that in case the age or sex of the member or of any other person is considered in determining the premium and it is found at any time before final settlement under the certificate that the age or sex has been misstated, and the discrepancy and premium involved have not been adjusted, the amount payable shall be such as the premium would have purchased at the correct age and sex; but, if the correct age was not an insurable age under the society's charter or laws, only the premiums paid to the society, less any payments previously made to the member, shall be returned or, at the option of the society, the amount payable under the certificate shall be such as the premium would have purchased at the correct age according to the society's promulgated rates and any extension thereof based on actuarial principles; (11) a provision or provisions which recite fully, or which set forth the substance of, all sections of the charter, constitution, laws, rules or regulations of the society, in force at the time of issuance of the certificate, the violation of which will result in the termination of, or in the reduction of, the benefit or benefits payable under the certificate; (12) if the constitution or laws of the society provide for expulsion or suspension of a member, any member so expelled or suspended, except for nonpayment of a premium or within the contestable period for material misrepresentations in such member's application for membership, shall have the privilege of maintaining his insurance in force by continuing payment of the required premium; and (13), in the case of a certificate issued by a foreign or alien society, a provision that the rights or obligations of the member or of any person rightfully claiming under the certificate shall be governed by the laws of this state. Any of the foregoing provisions or portions thereof not applicable by reason of the plan of insurance or because the certificate is an annuity certificate may, to the extent inapplicable, be omitted from the certificate.

(c) No life benefit certificate shall be delivered or issued for delivery in this state containing in substance any of the following provisions: (1) Any provision limiting the time within which any action at law or in equity may be commenced to less than two years after the cause of action shall accrue; (2) any provision by which the certificate purports to be issued or to take effect more than six months before the original application for the certificate was made, except in case of transfer from one form of certificate to another in connection with which the member is to receive credit for any reserve accumulation under the form of certificate from which the transfer is made; or (3) any provision for forfeiture of the certificate for failure to repay any loan thereon or to pay interest on such loan while the total indebtedness, including interest, is less than the loan value of the certificate.

Annotations to former section 38-231:

Bylaws: Member bound by them and amendments thereto. 71 C. 719; 76 C. 52; 77 C. 58; 84 C. 96. Expulsion and reinstatement; discussed. 76 C. 249; 89 C. 249. One forbidding member to engage in liquor business upheld; waiver. 84 C. 346. One providing for expulsion of member for misrepresentation upheld. 89 C. 249.
Conn. Gen. Stat. § 38a-614 — Connecticut Code / Title 38a / Chapter 700d / Section 38a-614
Sec. 38a-614. (Formerly Sec. 38-237). Annual report. Synopsis mailed to members. Valuation of certificates. Reserves.
Status: in_force

(1) Each domestic society transacting business in this state shall, annually, on or before the first day of March, unless the commissioner has extended such time for cause shown, file with the commissioner, and electronically to the National Association of Insurance Commissioners, a true and complete statement of its financial condition, transactions and affairs for the preceding calendar year and pay the fee specified in section 38a-11 for filing such annual statement. The statement shall be in general form and context as approved by the National Association of Insurance Commissioners for fraternal benefit societies and as supplemented by additional information required by the commissioner. An electronically filed true and complete report filed in accordance with section 38a-53a that is timely submitted to the National Association of Insurance Commissioners shall be deemed to have been submitted to the commissioner in accordance with the provisions of this section.

(2) Each foreign society transacting business in this state shall, annually, on or before the first day of March, unless the commissioner has extended such time for cause shown, file with the commissioner, and electronically to the National Association of Insurance Commissioners, a true and complete statement of its financial condition, transactions and affairs for the preceding calendar year and pay the fee specified in section 38a-11 for filing such annual statement. The statement shall be in general form and context as approved by the National Association of Insurance Commissioners for fraternal benefit societies and as supplemented by additional information required by the commissioner. An electronically filed true and complete report filed in accordance with section 38a-53a that is timely submitted to the National Association of Insurance Commissioners shall be deemed to have been submitted to the commissioner in accordance with this subsection.

(3) Not later than June first, annually, each society shall print and mail to each benefit member of the society a synopsis of its annual statement that provides an explanation of the facts thereby disclosed concerning the condition of the society. In lieu thereof, a society may publish such synopsis in the society's official publication.

(4) (A) As part of the annual statement required under this subsection, each society shall, annually, on or before the first day of March, file with the commissioner a valuation of its certificates in force on December thirty-first last preceding, provided the commissioner may, for cause shown, extend the time for filing such valuation for not more than two calendar months. Such report of valuation shall show, as reserve liabilities, the difference between the present midyear value of the promised benefits provided in the certificates of such society in force and the present midyear value of the future net premiums as the same are in practice actually collected, not including therein any value for the right to make extra assessments and not including any amount by which the present midyear value of future net premiums exceeds the present midyear value of promised benefits on individual certificates.

(B) At the option of any society, in lieu of the valuation specified in subparagraph (A) of this subdivision, the valuation may show the net tabular value. Such net tabular value as to certificates issued prior to January 1, 1959, shall be determined in accordance with the provisions of law applicable prior to January 1, 1958, and as to certificates issued on or after January 1, 1959, shall not be less than the reserves determined according to the Commissioners' Reserve Valuation method as hereinafter defined. If the premium charge is less than the tabular net premium according to the basis of valuation used, an additional reserve equal to the present value of the deficiency in such premiums shall be set up and maintained as a liability. The reserve liabilities shall be properly adjusted if the midyear or tabular values are not appropriate.

(5) Reserves according to the Commissioners' Reserve Valuation method, for the life insurance and endowment benefits of certificates providing for a uniform amount of insurance and requiring the payment of uniform premiums, shall be the excess, if any, of the present value, at the date of valuation, of such future guaranteed benefits provided for by such certificates over the then present value of any future modified net premiums therefor. The modified net premiums for any such certificate shall be such uniform percentage of the respective contract premiums for such benefits that the present value, at the date of issue of the certificate, of all such modified net premiums shall be equal to the sum of the then present value of such benefits provided for by the certificate and the excess of (A) over (B), as follows: (A) A net level premium equal to the present value, at the date of issue, of such benefits provided for after the first certificate year, divided by the present value, at the date of issue, of an annuity of one per annum payable on the first and each subsequent anniversary of such certificate on which a premium falls due; provided such net level annual premium shall not exceed the net level annual premium on the nineteen year premium whole life plan for insurance of the same amount at an age one year higher than the age at issue of such certificate; and (B) a net one-year term premium for such benefits provided for in the first certificate year. Reserves according to the Commissioners' Reserve Valuation method for (i) life insurance benefits for varying amounts of benefits or requiring the payment of varying premiums, (ii) annuity and pure endowment benefits, (iii) disability and accidental death benefits in all certificates and contracts, and (iv) all other benefits except life insurance and endowment benefits shall be calculated by a method consistent with the principles of this subdivision.

(6) The present value of deferred payments due under incurred claims or matured certificates shall be deemed a liability of the society and shall be computed upon mortality and interest standards prescribed in subdivision (7) of this subsection.

(7) Such valuation and underlying data shall be certified by a competent actuary or, at the expense of the society, verified by the actuary of the department of insurance of the state of domicile of the society. The minimum standards of valuation for certificates issued prior to January 1, 1959, shall be those provided by the law applicable immediately prior to January 1, 1958, but not lower than the standards used in the calculating of rates for such certificates. The minimum standard of valuation for certificates issued after January 1, 1959, shall be three and one-half per cent interest and the following tables: (A) For certificates of life insurance, American Men Ultimate Table of Mortality, with Bowerman's or Davis' Extension thereof or, with the consent of the Insurance Commissioner, the Commissioner's 1941 Standard Ordinary Mortality Table or the Commissioner's 1941 Standard Industrial Table of Mortality, or the Commissioners' 1958 Standard Ordinary Mortality Table, except that, with the approval of the commissioner, the valuation of contracts on female risks may be calculated, at the option of the society, according to an age not more than three years younger than the actual age of the insured; (B) for annuity certificates, including life annuities provided or available under optional modes of settlement in such certificates, the 1937 Standard Annuity Table; (C) for disability benefits issued in connection with life benefit certificates, Hunter's Disability Table, which, for active lives, shall be combined with a mortality table permitted for calculating the reserves on life insurance certificates, except that the table known as Class III Disability Table (1926), modified to conform to the contractual waiting period, shall be used in computing reserves for disability benefits under a contract which presumes that total disability shall be considered to be permanent after a specified period; (D) for accidental death benefits issued in connection with life benefit certificates, the Inter-Company Double Indemnity Mortality Table combined with a mortality table permitted for calculating the reserves for life insurance certificates; and (E) for noncancellable accident and health benefits, the Class III Disability Table (1926) with conference modifications or, with the consent of the commissioner, tables based upon the society's own experience. The commissioner may accept other standards for valuation if the commissioner finds that the reserves produced thereby will not be less in the aggregate than reserves computed in accordance with the minimum valuation standard herein prescribed. The commissioner may, in his or her discretion, vary the standards of mortality applicable to all certificates of insurance on substandard lives or other extra hazardous lives by any society authorized to do business in this state. Whenever the mortality experience under all certificates valued on the same mortality table is in excess of the expected mortality according to such table for a period of three consecutive years, the commissioner may require additional reserves when deemed necessary in the commissioner's judgment on account of such certificates. Any society, with the consent of the insurance commissioner of the state of domicile of the society and under such conditions, if any, that such commissioner may impose, may establish and maintain reserves on its certificates in excess of the reserves required thereunder, but the contractual rights of any insured member shall not be affected thereby.

(8) A society doing business in this state that fails to file the annual statement in the form and within the time provided by this subsection shall pay a late filing fee of one hundred seventy-five dollars per day for each day from the due date of such statement, and, upon notice by the commissioner to that effect, its authority to do business in this state shall cease while such failure to file continues. The commissioner may waive the late filing fee if (A) the society cannot file such statement because the governor of such society's state of domicile has proclaimed a state of emergency in such state and such state of emergency impairs the society's ability to file the statement, or (B) the insurance regulatory official of the state of domicile of a foreign benefit society has permitted the society to file such statement late.

(9) Notwithstanding the provisions of this subsection, a society may, with the approval of the Insurance Commissioner, use the standards for valuation and nonforfeiture authorized by the provisions of sections 38a-61 , 38a-77 , 38a-78 , 38a-81 , 38a-82 , 38a-284 , 38a-287 , 38a-430 to 38a-454 , inclusive, and 38a-458 .

(b) Each association that is (1) a tax-exempt organization under Section 501(c)(23) of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, (2) doing business in this state, and (3) not licensed under sections 38a-595 to 38a-626 , inclusive, 38a-631 to 38a-640 , inclusive, and 38a-800 , shall, annually, on or before the first day of May, file with the commissioner a true and complete financial statement audited by an independent certified public accountant or accounting firm of its financial condition, transactions and affairs for the preceding calendar year and pay the fee specified in section 38a-11 for filing such annual statement.

See Sec. 38a-610 re authority to maintain institutions for members' benefit.
Conn. Gen. Stat. § 38a-988 — Connecticut Code / Title 38a / Chapter 705 / Section 38a-988
Sec. 38a-988. (Formerly Sec. 38-513). Disclosure limitations and conditions.
Status: in_force

(1) Made with the written authorization of the individual, provided: (A) If such authorization is submitted by another insurance institution, agent or insurance-support organization, it meets the requirements of section 38a-981 , or (B) if such authorization is submitted by a person other than an insurance institution, agent or insurance-support organization, it shall be: (i) Dated, (ii) signed by the individual, and (iii) obtained within one year prior to the date a disclosure is sought pursuant to this subdivision;

(2) Made to a person other than an insurance institution, agent or insurance-support organization, provided such disclosure is reasonably necessary: (A) To enable such person to perform a business, professional or insurance function for the disclosing insurance institution, agent or insurance-support organization, and such person agrees not to disclose the information without the individual's written authorization unless the disclosure: (i) Would otherwise be permitted by this section if made by an insurance institution, agent, or insurance-support organization, or (ii) is reasonably necessary for such person to perform such person's function for the disclosing insurance institution, agent or insurance-support organization; or (B) to enable such person to provide information to the disclosing insurance institution, agent or insurance-support organization for the purpose of: (i) Determining an individual's eligibility for an insurance benefit or payment, or (ii) detecting or preventing criminal activity, fraud, material misrepresentation or material nondisclosure in connection with an insurance transaction;

(3) Made to an insurance institution, agent, insurance-support organization or self-insurer, provided the information disclosed is limited to that which is reasonably necessary: (A) To detect or prevent criminal activity, fraud, material misrepresentation or material nondisclosure in connection with insurance transactions, or (B) for either the disclosing or receiving insurance institution, agent or insurance-support organization to perform its function in connection with an insurance transaction involving the individual;

(4) Made to a medical-care institution or medical professional for the purpose of: (A) Verifying insurance coverage or benefits; (B) informing an individual of a medical problem of which such individual may not be aware; or (C) conducting an operations or services audit, provided only such information is disclosed as is reasonably necessary to accomplish the foregoing purposes;

(5) Made to an insurance regulatory authority;

(6) Made to a law enforcement or other government authority: (A) To protect the interests of the insurance institution, agent or insurance-support organization in preventing or prosecuting the perpetration of fraud upon it; or (B) if the institution, agent or organization reasonably believes that illegal activities have been conducted by the individual;

(7) Otherwise permitted or required by law;

(8) In response to a facially valid administrative or judicial order, including a search warrant or subpoena;

(9) Made for the purpose of conducting actuarial or research studies, provided: (A) No individual may be identified in any actuarial or research report; (B) materials in which the individual may be identified are returned or destroyed as soon as they are no longer necessary; and (C) the actuarial or research organization agrees not to disclose the information unless the disclosure would otherwise be permitted by this section if made by an insurance institution, agent or insurance-support organization;

(10) Made to a party or a representative of a party to a proposed or consummated sale, transfer, merger or consolidation of all or part of the business of the insurance institution, agent or insurance-support organization, provided: (A) Prior to the consummation of the sale, transfer, merger or consolidation only such information is disclosed as is reasonably necessary to enable the recipient to make business decisions about the purchase, transfer, merger or consolidation; and (B) the recipient agrees not to disclose the information unless the disclosure would otherwise be permitted by this section if made by an insurance institution, agent or insurance-support organization;

(11) Made to a person whose only use of such information will be in connection with the marketing of a product or service, provided: (A) No medical-record information, privileged information, or personal information relating to an individual's character, personal habits, mode of living or general reputation is disclosed, and no classification derived from such information is disclosed; (B) the individual has been afforded an opportunity to indicate that the individual does not wish personal information disclosed for marketing purposes and has given no indication that the individual does not wish the information disclosed; and (C) the person receiving such information agrees not to use it except in connection with the marketing of a product or service;

(12) Made to an affiliate whose only use of the information will be in connection with an audit of the insurance institution or agent or the marketing of an insurance product or service, provided (A) with regard to individually identifiable medical records information, written consent of the individual to whom the individually identifiable medical record pertains is obtained prior to disclosure for marketing purposes, and (B) the affiliate agrees not to disclose the information for any other purpose or to unaffiliated persons;

(13) Made by a consumer reporting agency, provided the disclosure is made to a person other than an insurance institution or agent;

(14) Made to a group policyholder for the purpose of reporting claims experience or conducting an audit of the insurance institution's or agent's operations or services, provided the information disclosed is reasonably necessary for the recipient to conduct the audit;

(15) Made to a professional peer review organization for the purpose of reviewing the service or conduct of a medical-care institution or medical professional;

(16) Made to a governmental authority for the purpose of determining the individual's eligibility for health benefits for which the governmental authority may be liable;

(17) Made to a certificate holder or policyholder for the purpose of providing information regarding the status of an insurance transaction;

(18) Made to a lienholder, mortgagee, assignee, lessor or other person shown on the records of an insurance institution or agent as having a legal or beneficial interest in a policy of insurance, provided: (A) No medical-record information is disclosed unless the disclosure would otherwise be permitted by this section; and (B) the information disclosed is limited to that which is reasonably necessary to permit such person to protect its interests in such policy;

(19) Made pursuant to section 53-445 ;

(20) Made to the Department of Public Health in conjunction with the investigation of a health care provider pursuant to section 19a-14 .
Conn. Gen. Stat. § 38a-504b — Connecticut Code / Title 38a / Chapter 700c / Section 38a-504b
Sec. 38a-504b. Clinical trial criteria.
Status: in_force

See Sec. 38a-542b for similar provisions re group policies.
Conn. Gen. Stat. § 38a-91ff — Connecticut Code / Title 38a / Chapter 698 / Section 38a-91ff
Sec. 38a-91ff. Incorporation and formation. Transfer of domicile.
Status: in_force

(b) An association captive insurance company, an industrial insured captive insurance company or a risk retention group may be:

(1) Incorporated as a stock insurer with its capital divided into shares and held by the stockholders;

(2) Incorporated as a mutual corporation without capital stock, the governing body of which is elected by its insureds;

(3) Organized as a reciprocal insurer; or

(4) Organized as a manager-managed limited liability company.

(c) (1) A sponsored captive insurance company shall be incorporated as a stock insurer with its capital divided into shares held by the stockholders, as a mutual corporation, as a nonprofit corporation with one or more members or as a manager-managed limited liability company.

(2) One or more sponsors may apply to the commissioner to form a sponsored captive insurance company. In evaluating the qualifications of a proposed sponsor, the commissioner shall consider the type and structure of the proposed sponsor entity, its experience in financial operations, financial stability and strength, business reputation and such other facts deemed relevant by the commissioner.

(3) (A) Associations, corporations, limited liability companies, partnerships, trusts and other business entities may be participants in a sponsored captive insurance company. No risk retention group shall be a sponsor or a participant of a sponsored captive insurance company.

(B) A sponsor may be a participant in a sponsored captive insurance company.

(C) A participant need not be a stockholder of the sponsored captive insurance company or any affiliate thereof.

(D) A participant shall insure only its own risks through a sponsored captive insurance company.

(d) (1) A special purpose financial captive insurance company may be incorporated as a stock insurer with its capital divided into shares and held by its stockholders or as a manager-managed limited liability company.

(2) A special purpose financial captive insurance company's organizational documents shall limit the special purpose financial captive insurance company's authority to transact the business of insurance or reinsurance to those activities that the special purpose financial captive insurance company conducts to accomplish its purposes described in sections 38a-91aa to 38a-91tt , inclusive. For purposes of this subdivision and section 38a-91bb , in the case of a special purpose financial captive insurance company formed (A) as a stock insurer, “organizational document” means such company's articles of incorporation and bylaws, and (B) as a limited liability company, “organizational document” means such company's articles of organization and operating agreement.

(3) A special purpose financial captive insurance company may reinsure the risks of a ceding insurer only. A special purpose financial captive insurance company may purchase, with the prior approval of the commissioner, reinsurance to cede the risks assumed under a reinsurance contract.

(4) A captive insurance company that is engaged in, or will be engaged in, an insurance securitization on or after July 1, 2012, shall be deemed to be a special purpose financial captive insurance company. The commissioner may require such captive insurance company to take any action that the commissioner determines is reasonably necessary to bring such company into compliance as a special purpose financial captive insurance company. The commissioner may issue an order as described in subparagraph (B) of subdivision (2) of subsection (e) of section 38a-91bb .

(e) No branch captive insurance company shall do any insurance business in this state unless it maintains a principal place of business for its branch operations in this state.

(f) A captive insurance company incorporated or organized in this state shall have not less than three incorporators or three organizers of whom at least one shall be a resident of this state.

(g) In the case of a captive insurance company:

(1) Formed as a corporation, before the articles of incorporation are transmitted to the Secretary of the State, the incorporators shall petition the Insurance Commissioner to issue a certificate setting forth the commissioner's finding that the establishment and maintenance of the proposed corporation will promote the general good of the state. In arriving at such a finding the commissioner shall consider:

(A) The character, reputation, financial standing and purposes of the incorporators;

(B) The character, reputation, financial responsibility, insurance experience and business qualifications of the officers and directors; and

(C) Such other aspects as the commissioner deems advisable.

(2) Formed as a reciprocal insurer, the organizers shall petition the commissioner to issue a certificate setting forth the commissioner's finding that the establishment and maintenance of the proposed association will promote the general good of the state. In arriving at such a finding the commissioner shall consider the items set forth in subdivision (1) of this subsection.

(3) Formed as a limited liability company, before the articles of organization are transmitted to the Secretary of the State, the organizers shall petition the commissioner to issue a certificate setting forth the commissioner's finding that the establishment and maintenance of the proposed company will promote the general good of the state. In arriving at such a finding, the commissioner shall consider the items set forth in subdivision (1) of this subsection.

(4) The articles of incorporation and certificate set forth in subdivisions (1) to (3), inclusive, of this subsection shall be transmitted to the Secretary of the State along with any fees required by the Secretary of the State, who shall record both the articles of incorporation and the certificate.

(h) In the case of a captive insurance company licensed as a branch captive insurance company, the alien captive insurance company or foreign captive insurance company shall petition the commissioner to issue a certificate setting forth the commissioner's finding that, after considering the character, reputation, financial responsibility, insurance experience, and business qualifications of the officers and directors of the alien captive insurance company or foreign captive insurance company, the licensing and maintenance of the branch operations will promote the general good of the state. The alien captive insurance company or foreign captive insurance company may register to do business in this state after the commissioner's certificate is issued.

(i) The capital stock of a captive insurance company incorporated as a stock insurer may be authorized with no par value.

(j) In the case of a captive insurance company:

(1) Formed as a corporation, (A) at least one of the members of the board of directors shall be a resident of this state, and (B) the articles of incorporation or bylaws of such company may authorize a quorum of its board of directors to consist of no fewer than one-third of the fixed or prescribed number of directors;

(2) Formed as a reciprocal insurer, (A) at least one of the members of the subscribers' advisory committee shall be a resident of this state, and (B) the subscribers' agreement or other organizing document of such company may authorize a quorum of its subscribers' advisory committee to consist of no fewer than one-third of the number of its members;

(3) Formed as a limited liability company, at least one of the managers shall be a resident of this state.

(k) Other than captive insurance companies formed as limited liability companies or as nonprofit corporations, captive insurance companies formed as corporations under the provisions of sections 38a-91aa to 38a-91tt , inclusive, shall have the privileges and be subject to the provisions of title 33 as well as the applicable provisions in sections 38a-91aa to 38a-91tt , inclusive. In the event of conflict between the provisions of title 33 and sections 38a-91aa to 38a-91tt , inclusive, the provisions of sections 38a-91aa to 38a-91tt , inclusive, shall control.

(l) Captive insurance companies formed under the provisions of sections 38a-91aa to 38a-91tt , inclusive:

(1) As limited liability companies shall have the privileges and be subject to the provisions of chapter 613 and applicable provisions in sections 38a-91aa to 38a-91tt , inclusive. In the event of a conflict between the provisions of chapter 613 and sections 38a-91aa to 38a-91tt , inclusive, the provisions of sections 38a-91aa to 38a-91tt , inclusive, shall control;

(2) As nonprofit corporations shall have the privileges and be subject to the applicable provisions of title 33 and applicable provisions in sections 38a-91aa to 38a-91tt , inclusive. In the event of conflict between the provisions of title 33 and sections 38a-91aa to 38a-91tt , inclusive, the provisions of sections 38a-91aa to 38a-91tt , inclusive, shall control; or

(3) As reciprocal insurers shall have the privileges and be subject to the provisions of sections 38a-91aa to 38a-91tt , inclusive. In the event of conflict between the provisions of the sections specified in section 38a-91oo and the provisions of sections 38a-91aa to 38a-91tt , inclusive, the provisions of sections 38a-91aa to 38a-91tt , inclusive, shall control.

(m) In the case of captive insurance companies formed as limited liability companies, reciprocal insurers or mutual corporations, any proxy appointed by a member, subscriber or policyholder, as applicable, shall be valid if such proxy is appointed and transmitted in accordance with the provisions of section 33-706 .

(n) The provisions of this chapter pertaining to mergers, consolidations, conversions and transfers of domicile shall apply in determining the procedures to be followed by captive insurance companies in carrying out any of the transactions described in this chapter.

(o) Any pure captive insurance company, association captive insurance company, industrial insured captive insurance company, risk retention group, sponsored captive insurance company or special purposes financial captive insurance company that is organized pursuant to the laws of another state may become a domestic captive insurance company of the same type by complying with the requirements of sections 38a-91bb to 38a-91tt , inclusive, relating to the organization and licensing of such type of company and designating its principal place of business at a location in this state.
Conn. Gen. Stat. § 38a-530 — Connecticut Code / Title 38a / Chapter 700c / Section 38a-530
Sec. 38a-530. Mandatory coverage for diagnostic and screening mammography, diagnostic and screening breast ultrasound, diagnostic and screening magnetic resonance imaging, breast biopsies, prophylactic mastectomies and breast reconstructive surgery. Breast density information included in report.
Status: in_force

(1) “Healthcare Common Procedure Coding System” or “HCPCS” means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association; and

(2) “Mammogram” means mammographic examination or breast tomosynthesis, including, but not limited to, a procedure with a HCPCS code of 77051, 77052, 77055, 77056, 77057, 77063, 77065, 77066, 77067, G0202, G0204, G0206 or G0279, or any subsequent corresponding code.

(b) (1) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for diagnostic and screening mammograms for insureds that are at least equal to the following minimum requirements:

(A) A baseline mammogram, which may be provided by breast tomosynthesis at the option of the insured covered under the policy, for an insured who is:

(i) Thirty-five to thirty-nine years of age, inclusive; or

(ii) Younger than thirty-five years of age if the insured is believed to be at increased risk for breast cancer due to:

(I) A family history of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene variant that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider; and

(B) A mammogram, which may be provided by breast tomosynthesis at the option of the insured covered under the policy, every year for an insured who is:

(i) Forty years of age or older; or

(ii) Younger than forty years of age if the insured is believed to be at increased risk for breast cancer due to:

(I) A family history, or prior personal history, of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider.

(2) Such policy shall provide additional benefits for:

(A) Comprehensive diagnostic and screening ultrasounds of an entire breast or breasts if:

(i) A mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology; or

(ii) An insured is believed to be at increased risk for breast cancer due to:

(I) A family history or prior personal history of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider;

(B) Diagnostic and screening magnetic resonance imaging of an entire breast or breasts:

(i) In accordance with guidelines established by the American Cancer Society for an insured who is thirty-five years of age or older; or

(ii) If an insured is younger than thirty-five years of age and believed to be at increased risk for breast cancer due to:

(I) A family history, or prior personal history, of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider;

(C) Breast biopsies;

(D) Prophylactic mastectomies for an insured who is believed to be at increased risk for breast cancer due to positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer; and

(E) Breast reconstructive surgery for an insured who has undergone:

(i) A prophylactic mastectomy; or

(ii) A mastectomy as part of the insured's course of treatment for breast cancer.

(c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such benefits. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-520 , to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(d) Each mammography report provided to an insured shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: “If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's, physician assistant's or advanced practice registered nurse's office and you should contact your physician, physician assistant or advanced practice registered nurse if you have any questions or concerns about this report.”.

See Sec. 38a-503 for similar provisions re individual policies.