Source: http://www.ldi.state.la.us/ldipolicymatrix/pfm_product.aspx?product=12294
Timestamp: 2014-04-19 22:16:52
Document Index: 119264369

Matched Legal Cases: ['§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§10107', '§973', '§973', '§1023', '§213', '§901', '§901', '§1000', '§1004', '§1004', '§1000', '§215', '§1000', '§1061', '§10107', '§973', '§1000', '§1000', '§973', '§975', '§975', '§975', '§975', '§1023', '§995', '§997', '§1000', '§1000', '§975', '§2625', '§901', '§1000', '§1012', '§1068', '§1068', '§1068', '§887', '§1000', '§1074', '§1074', '§1074', '§215', '§1000', '§1000', '§975', '§978', '§973', '§975', '§1001', '§975', '§1000', '§1091', '§1095', '§1095', '§2707', '§978', '§977', '§973', '§975', '§975', '§1023', '§1023', '§1023', '§1023', '§1023', '§1023', '§2098', '§1000', '§215', '§1023', '§981', '§989', '§992']

LA Product Code: H-Ind01.LB-01D Policyholder Type: Assn Grp - Individual Members / Ltd Benefit Plans
Organ & Tissue Transplant Plan issued to Individual Members of an Assn - Health insurance providing benefits for treatment related to human and/or non-human organ transplant. Benefits are specific to the delivery of care associated with the covered organ or tissue and may be paid as expense incurred, per diem, or a principle sum.
Continuation of Benefits / Coverage
Policyholder Requirements
Premium Payment / Grace Period Prov.
LDI Reg 78:§10107.C.1
The department shall designate, by directive, those insurance products which must be filed pursuant to the requirements for certified approval as set forth in §10107.F hereof. A directive issued pursuant to this Subsection may also designate those insurance products which may, at the discretion of the insurer, be filed either pursuant to said requirements for Certified Approval, or as ordinary filings subject to review as set forth in §10107.E hereof. All insurance products not so designated shall be filed pursuant to the requirements for Compliance Review as set forth in §10107.E hereof.
LDI Reg 78:§10107.C.2.a.i
All filings of an insurance product must include the required filing fee, per insurance product, per insurance company.
LDI Reg 78:§10107.C.2.a.ii
All filings of an insurance product must include a completed Health and Accident Transmittal Document, as prescribed by the department.
The Transmittal Document requirement has been waived for Health and Accident form filings being submitted through SERFF.
LDI Reg 78:§10107.C.2.a.iii
All filings of an insurance product must include a Statement of Compliance for said product.
Insurers are required to indicate the policy form section and/or page number where compliance with a legal reference is demonstrated or, indicate "N/A" where inapplicable to the specific product being filed. All entries of "N/A" must be explained in an addendum to the Statement of Compliance. FAILURE TO PROPERLY COMPLETE THE STATEMENT OF COMPLIANCE (including correct section and page numbers) WILL RESULT IN AN INCOMPLETE FILING AND DISAPPROVAL THEREOF.
LDI Reg 78:§10107.C.2.a.iv
All filings of an insurance product must include the policy forms filed for approval.
LDI Reg 78:§10107.C.2.a.ix
All filings of an insurance product must include stamped, self-addressed envelope of sufficient size for use in returning the company's set of the policy forms filed, unless filed electronically.
LDI Reg 78:§10107.C.2.a.v
All filings of an insurance product must include the application form.
LDI Reg 78:§10107.C.2.a.vi
All filings of an insurance product must include the rider or endorsement forms.
LDI Reg 78:§10107.C.2.a.vii
All filings of an insurance product must include copies of any sample identification card intended for issue to covered persons.
LDI Reg 78:§10107.C.2.a.viii
All filings of an insurance product must include the initial premium rates and classification of risks.
LDI Reg 78:§10107.C.2.d
Filings of all group insurance products must include the group master contract, individual certificates or subscriber agreements or other statements of coverage, group application, individual enrollment forms, and any conversion insurance policy and application for conversion, if offered under the group master contract.
LDI Reg 78:§10107.C.2.e
Filings of group health and accident products intended for issue to an association are limited to associations as defined in Regulation 78 and must include the association's constitution, by-laws, membership application, membership agreement and brochure of membership benefits other than the insurance products offered.
Time Periods and Requirements for Certified Approval of Policy Form Filings.
LDI Reg 78:§10107.F.1
The department will make available Statements of Compliance setting forth the statutory and regulatory requirements specific to the various forms of coverage and contract types, as well as Certification of Compliance forms.
LDI Reg 78:§10107.F.2
2. A policy form filing submitted for certified approval must include the following documents: a. Statement of Compliance applicable to the form of coverage and contract type being submitted; b. signed and dated Certification of Compliance; c. all other items as set forth in Paragraph C.2 hereof.
LDI Reg 78:§10107.F.3
If the filing is incomplete, notice of disapproval in accordance with LRS-22:862(6) will be issued for failure to comply with the requirements of LDI Reg 78.
LDI Reg 78:§10107.F.4
At the expiration of 15 days from acknowledged receipt of a filing by the department, if no order has been issued affirming certified approval or disapproving the policy form filing, the insurer shall submit written notice to the department if the policy form filing has been deemed approved on a specific date, or advise when the policy form filing is withdrawn from consideration. Such date specified by the insurer shall be on or after day 16, but not earlier than the 15-day expiration period. Such written notice shall be sent to the department within 30 days after the expiration of the 15-day period clearly stating the date deemed approved or withdrawn from consideration and the anticipated date to be used by the insurer (if different from the date deemed approved). Deemed approval shall not be effective until the insurer has so notified the commissioner, by certified mail/return receipt requested.
LDI Reg 78:§10107.F.5
No insurer, through an officer or authorized representative, shall file a certification of compliance containing false attestations, or from which material facts or information have been omitted. In the event that the department subsequently learns that a certification of compliance contains any inaccuracies, false attestations, or material omissions, approval of the subject forms may be withdrawn, and the insurer may be subjected to the provisions of 10107.I hereof.
La. R.S. 22:§973 (6)
Each form must be identified by a form number in the lower left hand corner.
LDI Dir 174:Dir 174
Insurance coverages and contracts for which the Certified Approval procedure is required, or which may, at the filer's option, be filed utilizing the Certified Approval procedure.
La. R.S. 22:§973 (7)(a)
No health and accident policy or contract shall be delivered or issued for delivery on risks in this state unless there is prominently printed on or attached, a notice to the insured that ten days are allowed, from the date of his receipt of the policy, to examine its provisions. If such policy was solicited by deceptive advertising or negotiated by deceptive, misleading, or untrue statements of the insurer or any agent on behalf of the insurer, such policy may be surrendered within said ten-day period. Any premium advanced by the insured, upon such surrender, shall be immediately returned to him; however, the insurer shall have the option of printing or attaching the notice required by this Subparagraph or a notice of equal prominence which, in the opinion of the commissioner of insurance, is not less favorable to the policyholder. This Paragraph shall not apply to travel insurance policies which by their terms are not renewable.
La. R.S. 22:§1023 A
Definitions for this Section regarding prohibited discrimination based upon genetic information.
Under LRS 22::§213.7 A (12), reference to "franchise" coverage was redesignated to "association" coverage pursuant to ACT No. 129 of the 2003 Regular Session of the Lousiana Legislature
La. R.S. 22:§901 A
No person shall procure insurance upon the life or body of another individual unless the benefits are payable to the individual insured or his personal representatives or a person having an insurable interest in the insured at the time the contract is made.
La. R.S. 22:§901 B
The insured, his executor or administrator may maintain an action to recover benefits paid to an individual that did not have an insurable interest in the insured at the time the contract was made.
"Insurable interest" includes only interest as follows: (1) In the case of individuals related closely by blood or by law, a substantial interest engendered by love and affection; (2) In the case of other persons, a lawful and substantial economic interest in having the life, health or bodily safety of the individual insured continue, as distinguished from an interest which would arise only by, or would be enhanced in value by, the death, disablement or injury of the individual insured; and (3) A party to an agreement has an insurable interest in the life of each individual party to such agreement for the purposes of such agreement in addition to any insurable interest which may otherwise exist as to the life of such individual party.
La. R.S. 22:§1000 A (1)(a)(vi)(bb)
Eligible dependents include unmarried children or grandchildren in the legal custody of and residing with the grandparent until the age of twenty-one and unmarried children or grandchildren if enrolled as a full time student until the age of twenty-four.
La. R.S. 22:§1004 A
Any unmarried child who is placed in the home of an insured pursuant to an adoption placement agreement executed with a licensed adoption agency shall be considered a dependent child of the insured from the date of placement in the home of the insured.
La. R.S. 22:§1004 B
Any unmarried child who is placed in the home of an insured following execution of an act of voluntary surrender in favor of the insured or the insured's legal representative shall be considered a dependent child of the insured effective on the date on which the act of voluntary surrender becomes irrevocable.
La. R.S. 22:§1000 A(1)(a)
Group policy issued to an employer or association or trustees of a fund established by an employer or association, covering one or more employees or one or members or employee of members of such association.
22:§215 A(1) was amended under ACT No. 129 of the 2003 Regular Session of the Louisiana Legislature to include Health Maintenance Organization to the definition of Group health and accident insurance. Also, reference to "franchise" coverage was redesignated to "association" coverage.
Note - the Louisiana Insurance Code extraterritorially applies to any group policy of health and accident insurance covering residents of Louisiana, regardless of from where it was issued or delivered.
La. R.S. 22:§1000 A(1)(a)(iv)
La. R.S. 22:§1061 (5)(b)
LDI Reg 78:§10107.C.2.f
Insurance coverage may be issued under individual certificates via a group policy issued to an association provided the association has a constitution and by laws, has been organized and is maintained in good faith for purposes other than those of obtaining insurance.
Pursuant to Act No. 325, of the 2004 Regular Legislative Session, associations are required to have an active existence for at least five years.
La. R.S. 22:§973 (3)
La. R.S. 22:§1000 A(2)
La. R.S. 22:§1000 A(3)
The policy or contract may insure only one person, unless written as individual family group or otherwise specifically provided in Part VI, i.e. group policy issued to an employer, association, or trust or a blanket group policy.
La. R.S. 22:§973 (5)
Exceptions and Reductions of indemnity (Exclusions / Limitations) are clearly set forth in the policy, either with the applicable benefit or under an appropriate caption.
La. R.S. 22:§975 B(1)
OPTIONAL PROVISION for reduction in coverage due to an insured's "Change of occupation".
La. R.S. 22:§975 B(10)
OPTIONAL PROVISION excluding coverage for any loss in consequence of the insured's involvement with "Intoxicants and narcotics", unless administered on the advice of a physician.
Limitation provisions referring to "any drug" are ambiguous and may unreasonably be construed to include accidental overdose of over-the-counter medicines.
La. R.S. 22:§975 B(5)
OPTIONAL PROVISION for reduction in benefits payable in "Relation of earnings to insurance".
La. R.S. 22:§975 B(9)
OPTIONAL PROVISION excluding coverage for any loss contributed by the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an "Illegal occupation".
La. R.S. 22:§1023 B(1)
No insurer shall discriminate on the basis of any genetic information concerning an individual or family member or on the basis of an individual's or family member's request for or receipt of genetic services, or the refusal to submit to a genetic test or make available the results of a genetic test.
La. R.S. 22:§995
LDI Dir 20:Dir 20
LDI Dir 73:Dir 73
Policies or contracts providing payment or reimbursement for services that may be legally performed by a chiropractor licensed in this state, such payment or reimbursement shall not be denied when such service is rendered by a person so licensed. Terminology in such policy or contract deemed discriminatory against any such person or method of practice shall be void.
La. R.S. 22:§997
Any contract of insurance providing for reimbursement of any visual services which are within the lawful scope of practice of a duly licensed optometrist as defined in R.S. 37:1041, shall not discriminate in the amount of reimbursement allowed for such visual services, whether performed by an optometrist or physician, in instances where the services performed are within the lawful scope of practice of both professions.
LDI Dir 203:Dir 203
PAYMENT AND REIMBURSEMENT FOR HEALTH CARE SERVICES RENDERED BY A LICENSED CHIROPRACTOR AND THE CO-PAYMENT, COINSURANCE, DEDUCTIBLE OR BENEFIT LIMITATION IMPOSED ON AN ENROLLEE OR INSURED FOR HEALTH CARE SERVICES RENDERED BY A LICENSED CHIROPRACTOR.
Notice of insurers, medical service plan corporations, hospital service corporations, and medical service corporations - "Chiropractors".
Prohibitions on the Use of Medical Information and Genetic Test Results.
La. R.S. 22:§1000 A(1)(b)
The benefits payable under any policy or contract of group health and accident insurance shall be payable to the employee, members or employees of members of multiple associations or to some beneficiary or beneficiaries designated by him, other than the employer or association or multiple associations, but if there is no designated beneficiary as to all or any part of the insurance at the death of the employee, member or employee of members, then the amount of insurance payable for which there is no designated beneficiary shall be payable to the estate of the employee, member or employee of members, except that the insurer may in such case, at its option, pay such insurance to any one or more of the following surviving relatives of the employee, member or employee of members: wife, husband, mother, father, child, or children, brothers or sisters; and except that payment of benefits for expenses incurred on account of hospitalization or medical or surgical aid, may be made by the insurer to the hospital or other person or persons furnishing such aid. Payment so made shall discharge the insurer's obligations with respect to the amount of insurance so paid.
22:§1000 A(1) was amended under ACT No. 129 of the 2003 Regular Session of the Louisiana Legislature to include Health Maintenance Organization to the definition of Group health and accident insurance. Also, reference to "franchise" coverage was redesignated to "association" coverage.
REQUIRED PROVISION for Time of payment of claims: Indemnity claims payable under this policy for any loss other than loss of time on account of disability will be paid immediately upon receipt of written proof of such loss. Subject to written proof of loss, accrued indemnity claims for loss of time on account of disability will be paid (insert period of payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately.
La. R.S. 22:§975 A(7)
REQUIRED PROVISION for payment of claims: Indemnity for loss of life and any other accrued indemnity claims unpaid at the insured's death will be paid to the beneficiary, if surviving the insured, and otherwise to the estate of the insured. All other indemnity claims will be paid to the insured. The policy may, at the insurer's option, provide that if there is no beneficiary, or the beneficiary is the estate of the insured, or the insured or beneficiary is a minor or not competent to give a valid release, the insurer may pay any amount not exceeding one thousand dollars, otherwise payable to the insured or his estate to any relative by blood or connection by marriage of the insured appearing to the insurer to which they may be equitably entitled, and may make payment of any amount not exceeding one thousand dollars, otherwise payable to the beneficiary to any relative by blood or connection by marriage of such beneficiary appearing to the insurer to which they may be equitably entitled. The policy may, at the insurer's option, also provide that all or a portion of any indemnities provided by any such policy on account of hospital, nursing, medical, or surgical services may be paid directly to the hospital or person rendering such services; however, the policy may not require that the services be rendered by a particular hospital or person.
LDI Dir 157:Dir 157
La. R.S. 46:§2625
La. R.S. 22:§901 D
No benefits may be paid upon the death, disablement, or injury of an individual insured if the payee is held criminally responsible for the loss; or judicially determined to have participated in the intentional, unjustified killing of the insured.
La. R.S. 22:§1000 A(1)(c)
La. R.S. 22:§1012
La. R.S. 22:§1068 C(1)
La. R.S. 22:§1068 C(2)(a)
La. R.S. 22:§1068 D
La. R.S. 22:§887 F
Agreement to modify, amend or cancel shall be without prejudice to any prior claim for benefits accrued or expenses incurred.
La. R.S. 22:§1000 A(1)(c)**
La. R.S. 22:§1074 C(1)
La. R.S. 22:§1074 C(2)(a)
La. R.S. 22:§1074 D
22:§215 A(1) was amended under ACT No. 129 of the 2003 Regular Session of the Louisiana Legislature to include Health Maintenance Organization to the definition of Group health and accident insurance. Also, reference to "franchise" coverage was redesignated to "association" coverage. La. R.S. 22:§1000 A(1)(d)
La. R.S. 22:§1000 A(1)(c)*
Insurer shall not be liable for coverage after such termination date where the policyholder failed to pay premium or maintain eligibility requirements.
No insurer shall unilaterally cancel a policy after the insurer has received any covered claim or notice of any covered claim for a terminal, incapacitating, or debilitating condition if the insured continues to meet all other eligibility criteria.
La. R.S. 22:§975 A(9)
REQUIRED PROVISION for cancellation by insured: If the insured shall at any time change his occupation to one classified by the insurer as less hazardous than that stated in the policy, the insurer, upon written request of the insured, and at the insured's option, will either cancel the policy upon its surrender and refund the unearned premium or will reduce the premium rate accordingly and refund the excess pro rata unearned premium from the date of receipt of proof of such change of occupation.
La. R.S. 22:§978*
The insurer shall notify the policyholder in writing at least sixty days before any cancellation or nonrenewal.
No insurer shall cancel or refuse to renew any policy of group or family group health and accident insurance except for nonpayment of premium or failure to meet the requirements for being a group or family group insurance policy until sixty days after the insurer has mailed written notice of such cancellation or nonrenewal by certified mail to the policyholder. The notice shall also include the reason the policy is being cancelled.
La. R.S. 22:§973 (8)
Policies subject to cancellation or renewal at the option of the insurer must include a statement prominently printed on face page so informing the policyholder.
La. R.S. 22:§975 A(2)
REQUIRED PROVISION for reinstatement of a policy following default in payment of premium shall cover only loss resulting from accidental injury thereafter sustained or loss due to sickness beginning more than ten days after the date of such acceptance.
La. R.S. 22:§1001
Any policy which provides that coverage of a dependent child shall terminate upon attainment of the limiting age shall also provide that coverage shall continue while the child is and continues to be both (1) incapable of self sustaining employment, and (2) chiefly dependent upon the policyholder, employee or member for support and maintenance. Proof of such incapacity and dependency may be furnished to the insurer by the employee or member within 31 days of the child's attainment of the limiting age and subsequently may be required by the insurer not more frequently than annually after the 2-year period following the child's attainment of the limiting age.
Policy provisions limiting mental handicaps to those caused by "mental retardation" or similar language are too restrictive. Such provisions are unacceptable conditions to the mandated continuation of coverage for handicapped dependents.
La. R.S. 22:§975 B(7)
OPTIONAL PROVISION for "Cancellation" by the insurer by written notice and with refund of the pro rata unearned portion of any premium paid. Such cancellation shall be without prejudice to any claim incurred prior to cancellation. The insured may likewise cancel this policy on the above terms. Upon cancellation by the insurer, the insurer shall only be liable for any claim for expenses incurred subsequent to the cancellation date if the subsequent claim is for an illness or condition which was the basis of any claim prior to cancellation and for which the insurer had notice and if the policy of insurance is cancelled for reasons other than failure of the policyholder to pay premiums or failure of the insured to maintain eligibility as provided in the policy.
La. R.S. 22:§1000 D
La. R.S. 22:§1091
La. R.S. 22:§1095 A
La. R.S. 22:§1095 B
LDI Reg 51:§2707
Readjustment of the rate of premium based on the experience maybe retroactive only for the prior year.
La. R.S. 22:§978
The insurer shall notify the policyholder in writing at least forty-five days before any increase of twenty percent or more in the policy rates.
Reference to "franchise" coverage was redesignated to "association" coverage pursuant to ACT No. 129 of the 2003 Regular Session of the Louisiana Legislature
La. R.S. 22:§977
Whenever an insurer does not receive a premium payment fifteen days prior to the end of the grace period, the insurer shall mail, by first class mail, a notice to the policyholder. The notice shall state that if the premium has not been paid by the end of the grace period, the policy will lapse as provided by the provisions of the policy. The notice shall also state that the policy will be reinstated with no penalties whatsoever to the insured if the full premium payment is received within the period allowed for reinstatement.
La. R.S. 22:§973 (1)
La. R.S. 22:§975 A(10)
REQUIRED PROVISION for consent of beneficiary: Consent of the beneficiary shall not be requisite to surrender or assignment of this policy, nor to change of beneficiary, nor to any other changes in this policy.
La. R.S. 22:§975 A(13)(a)
REQUIRED PROVISION for "Time Limit on Certain Defenses" / Incontestability is three years of the date of issue of the policy after which the policy becomes incontestable as to the statements contained in the application.
REQUIRED PROVISION for processing of claims in conformity with the "Uniform claim forms" issued by the Department of Insurance pursuant LRS-22:1824.
La. R.S. 22:§1023 B(2)
No insurer shall require an applicant for coverage or an individual or family member who is presently covered under a policy or plan, to be the subject of a genetic test or to be subjected to questions relating to genetic information.
Applications should request information specifically from persons applying for coverage only. Medical questions and authorizations to release medical information should not refer to "any family member".
La. R.S. 22:§1023 B(3)
All insurers shall, in the application or enrollment information provided by the insurer concerning a policy or plan, provide an applicant or enrollee with a written statement disclosing the rights of the applicant or enrollee under this Section. Such statement shall be in a form and manner that is noticeable to and understandable by an average applicant or enrollee.
La. R.S. 22:§1023 C(2)
Requirements to assure valid authorization for disclosure of genetic information.
La. R.S. 22:§1023 C(3)
A copy of the authorization shall be provided to the individual.
La. R.S. 22:§1023 C(4)
An individual may revoke or amend the authorization, in whole or in part, at any time.
La. R.S. 22:§1023 C(5)
A general authorization for the release of medical records or medical information shall not be construed as an authorization for disclosure of genetic information.
La. R.S. 22:§2098 A
La. R.S. 22:§1000 A(1)(a)(v)
Insurer shall issue to the employer or association individual certificates of coverage for delivery to each insured employee or member.
22:§215 A(1) was amended under ACT No. 129 of the 2003 Regular Session of the Lousiiana Legislature to include Health Maintenance Organization to the definition of Group health and accident insurance. Also, reference to "franchise" coverage was sredesignated to "association" coverage.
La. R.S. 22:§1023 C(1)
No insurer shall obtain genetic information from an insured or enrollee, or from their DNA sample, without first obtaining written informed consent from the insured, enrollee, or their representative.
Fees on health care providers; disposition of fees.
La. R.S. 22:§981
Any rejection for individual health and accident insurance shall contain information stating that health insurance may be available through the Louisiana Health Insurance Plan and include the address and telephone number at which information on the Louisiana Health Insurance Plan can be obtained.
La. R.S. 22:§989
Any insurer authorized to write health and accident insurance in this state shall have power to issue industrial health and accident policies wherein the premium is payable weekly. Every such policy must have printed thereon the words "Industrial Policy" and must contain in substance those provisions in R.S. 22:975 as may be applicable. Insurers issuing policies under this Section shall be subject to all the other applicable provisions of this Subpart.
La. R.S. 22:§992
A transportation ticket policy, which may be issued by a health and accident insurer, is any ticket policy sold at stations, ticket offices or travel bureaus by employees of railroads, steamship lines, air lines and other common carriers, or by individuals or employees of persons engaged in selling transportation on such common carriers, having as its dominant feature the protection of the insured from a transportation hazard.