215 ILCS 5/367
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 5/ - Illinois Insurance Code.|Article XX - Accident And Health Insurance

 (from Ch. 73, par. 979)Sec. 367. Group accident and health insurance.(1) Group accident and health insurance is hereby declared to be that  form of accident and health insurance covering not less than 2  employees,  members, or employees of members, written under a  master policy issued to any governmental corporation, unit, agency or  department thereof, or to any corporation, copartnership, individual  employer, or to any association upon application of an executive officer or  trustee of such association having a constitution or bylaws and formed in  good faith for purposes other than that of obtaining insurance, where  officers, members, employees, employees of members or classes or department  thereof, may be insured for their individual benefit.  In addition a group  accident and health policy may be written to insure any group which may be  insured under a group life insurance policy.  The term "employees" shall  include the officers, managers and employees of subsidiary or affiliated  corporations, and the individual proprietors, partners and employees of  affiliated individuals and firms, when the business of such subsidiary or  affiliated corporations, firms or individuals, is controlled by a common  employer through stock ownership, contract or otherwise.(2) Any insurance company authorized to write accident and health  insurance in this State shall have power to issue group accident and  health policies.  No policy of group accident and health insurance may  be issued or delivered in this State unless a copy of the form thereof  shall have been filed with the department and approved by it in  accordance with Section 355, and it contains in substance those  provisions contained in Sections 357.1 through 357.30 as may be applicable  to group accident and health insurance and the following provisions:(a) A provision that the policy, the application of     the employer, or executive officer or trustee of any association, and the individual applications, if any, of the employees, members or employees of members insured shall constitute the entire contract between the parties, and that all statements made by the employer, or the executive officer or trustee, or by the individual employees, members or employees of members shall (in the absence of fraud) be deemed representations and not warranties, and that no such statement shall be used in defense to a claim under the policy, unless it is contained in a written application.(b) A provision that the insurer will issue to the     employer, or to the executive officer or trustee of the association, for delivery to the employee, member or employee of a member, who is insured under such policy, an individual certificate setting forth a statement as to the insurance protection to which he is entitled and to whom payable.(c) A provision that to the group or class thereof     originally insured shall be added from time to time all new employees of the employer, members of the association or employees of members eligible to and applying for insurance in such group or class.(3) Anything in this code to the contrary notwithstanding, any group  accident and health policy may provide that all or any portion of any  indemnities provided by any such policy on account of hospital, nursing,  medical or surgical services, may, at the insurer's option, be paid  directly to the hospital or person rendering such services; but the  policy may not require that the service be rendered by a particular  hospital or person.  Payment so made shall discharge the insurer's  obligation with respect to the amount of insurance so paid. Nothing in this  subsection (3) shall prohibit an insurer from providing incentives for  insureds to utilize the services of a particular hospital or person.(4) Special group policies may be issued to school districts  providing medical or hospital service, or both, for pupils of the  district injured while participating in any athletic activity under the  jurisdiction of or sponsored or controlled by the district or the  authorities of any school thereof.  The provisions of this Section  governing the issuance of group accident and health insurance shall,  insofar as applicable, control the issuance of such policies issued to  schools.(5) No policy of group accident and health insurance may be issued  or delivered in this State unless it provides that upon the death of the  insured employee or group member the dependents' coverage, if any,  continues for a period of at least 90 days subject to any other policy  provisions relating to termination of dependents' coverage.(6) No group hospital policy covering miscellaneous hospital  expenses issued or delivered in this State shall contain any exception  or exclusion from coverage which would preclude the payment of expenses  incurred for the processing and administration of blood and its  components.(7) No policy of group accident and health insurance, delivered in  this State more than 120 days after the effective day of the Section,  which provides inpatient hospital coverage for sicknesses shall exclude  from such coverage the treatment of alcoholism.  This subsection shall  not apply to a policy which covers only specified sicknesses.(8) No policy of group accident and health insurance, which  provides benefits for hospital or medical expenses based upon the actual  expenses incurred, issued or delivered  in this State shall contain any  specific exception to coverage which would preclude the payment of  actual expenses incurred in the examination and testing of a victim of  an offense defined in Sections 11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code  of 1961 or the Criminal Code of 2012, or an attempt to commit such offense,  to establish that sexual contact did occur or did not occur, and to  establish the presence or absence of sexually transmitted  disease or infection, and  examination and treatment of injuries and trauma sustained by the victim of  such offense, arising out of the offense.  Every group policy of accident  and health insurance which specifically provides benefits for routine  physical examinations shall provide full coverage for expenses incurred in  the examination and testing of a victim of an offense defined in Sections  11-1.20 through 11-1.60 or 12-13 through 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012, or an attempt to commit such  offense, as set forth in this  Section. This subsection shall not apply to a policy which covers hospital  and medical expenses for specified illnesses and injuries only.(9) For purposes of enabling the recovery of State funds, any insurance  carrier subject to this Section shall upon reasonable demand by the Department  of Public Health disclose the names and identities of its insureds entitled  to benefits under this provision to the Department of Public Health whenever  the Department of Public Health has determined that it has paid, or is about  to pay, hospital or medical expenses for which an insurance carrier is liable  under this Section. All information received by the Department of Public  Health under this provision shall be held on a confidential basis and shall  not be subject to subpoena and shall not be made public by the Department  of Public Health or used for any purpose other than that authorized by this  Section.(10) Whenever the Department of Public Health finds that it has paid all  or part of any hospital or medical expenses which an insurance carrier is  obligated to pay under this Section, the Department of Public Health shall  be entitled to receive reimbursement for its payments from such insurance  carrier provided that the Department of Public Health has notified the  insurance carrier of its claim before the carrier has paid the benefits to  its insureds or the insureds' assignees.(11) (a) No group hospital, medical or surgical expense     policy shall contain any provision whereby benefits otherwise payable thereunder are subject to reduction solely on account of the existence of similar benefits provided under other group or group-type accident and sickness insurance policies where such reduction would operate to reduce total benefits payable under these policies below an amount equal to 100% of total allowable expenses provided under these policies.(b) When dependents of insureds are covered under 2     policies, both of which contain coordination of benefits provisions, benefits of the policy of the insured whose birthday falls earlier in the year are determined before those of the policy of the insured whose birthday falls later in the year.  Birthday, as used herein, refers only to the month and day in a calendar year, not the year in which the person was born.  The Department of Insurance shall promulgate rules defining the order of benefit determination pursuant to this paragraph (b).(12) Every group policy under this Section shall be subject to the  provisions of Sections 356g and 356n of this Code.(13) No accident and health insurer providing coverage for hospital  or medical expenses on an expense incurred basis shall deny  reimbursement for an otherwise covered expense incurred for any organ  transplantation procedure solely on the basis that such procedure is deemed  experimental or investigational unless supported by the determination of  the Office of Health Care Technology Assessment within the Agency for  Health Care Policy and Research within the federal Department of Health and  Human Services that such procedure is either experimental or investigational or  that there is insufficient data or experience to determine whether an organ  transplantation procedure is clinically acceptable. If an accident and  health insurer has made written request, or had one made on its behalf by a  national organization, for determination by the Office of Health Care  Technology Assessment within the Agency for Health Care Policy and Research  within the federal Department of Health and Human Services as to whether a  specific organ transplantation procedure is clinically acceptable and said  organization fails to respond to such a request within a period of 90 days,  the failure to act may be deemed a determination that the procedure is  deemed to be experimental or investigational.(14) Whenever a claim for benefits by an insured under a dental  prepayment program is denied or reduced, based on the review of x-ray  films, such review must be performed by a dentist.  (Source: P.A. 96-1551, eff. 7-1-11; 97-1150, eff. 1-25-13.)