reglab/statecodes huggingface dataset:
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter V. Pre-Authorization Transparency › § 3586. Length of pre-authorization.

§ 3586. Length of pre-authorization.
(a) A pre-authorization for pharmaceuticals shall be valid for 1 year from the date the health-care provider receives the pre-authorization, subject to confirmation of continued coverage and eligibility and to policy changes validly delivered as per § 3582 of this title and except as otherwise set by evidence-based treatment protocol.
(b) A pre-authorization for a health-care service shall be valid for a period of time that is reasonable and customary for the specific service, but no less than 60 days, from the date the health-care provider receives the pre-authorization, subject to confirmation of continued coverage and eligibility and to policy changes validly delivered as per § 3582 of this title.
80 Del. Laws, c. 310, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter V. Pre-Authorization Transparency › § 3587. Electronic standards for pharmaceutical pre-authorization.

§ 3587. Electronic standards for pharmaceutical pre-authorization.
No later than January 1, 2018, the insurer must accept and respond to pre-authorization requests under the pharmacy benefit through a secure electronic transmission using the NCPDP SCRIPT standard ePA transactions. Facsimile, proprietary payer portals, and electronic forms shall not be considered electronic transmission.
80 Del. Laws, c. 310, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter V. Pre-Authorization Transparency › § 3588. Health-care services deemed preauthorized if a utilization review entity fails to comply with the requirements of this subchapter.

§ 3588. Health-care services deemed preauthorized if a utilization review entity fails to comply with the requirements of this subchapter.
Any failure by a utilization review entity to comply with the deadlines and other requirements specified in this subchapter will result in any health-care services subject to review to be automatically deemed preauthorized.
80 Del. Laws, c. 310, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter V. Pre-Authorization Transparency › § 3589. Waiver prohibited.

§ 3589. Waiver prohibited.
The provisions of this subchapter cannot be waived by contract issued or renewed after January 1, 2017. Any contractual arrangement in conflict with the provisions of this subchapter or that purports to waive any requirements of this subchapter is null and void.
80 Del. Laws, c. 310, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter V. Pre-Authorization Transparency › § 3590. Exemptions.

§ 3590. Exemptions.
This subchapter shall not apply to policies or contracts designed for issuance to persons eligible for coverage under Titles XVIII, XIX, and XXI of the Social Security Act [42 U.S.C. § 1395 et seq., § 1396 et seq. and § 1397aa. et seq.], known as Medicare, Medicaid, or any other similar coverage under state or federal governmental plans.
80 Del. Laws, c. 310, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS › § 3601. Purpose and scope.

§ 3601. Purpose and scope.
(a) The purpose of this chapter shall be to provide reasonable standardization and simplification of terms and coverages of individual health insurance policies and subscriber contracts of health service corporations to facilitate public understanding and comparison, to eliminate provisions contained in individual health insurance policies and subscriber contracts of health service corporations which may be misleading or unreasonably confusing in connection either with the purchase of such coverages or with the settlement of claims, and to provide for full disclosure in the sale of health insurance coverages. Additionally, the purpose of this chapter is to promote the availability of health insurance coverage to recently uninsured individuals, regardless of their health status or claims experience, and to improve the overall fairness and efficiency of the individual health insurance market.
(b) This chapter notwithstanding, Medicare supplement coverage shall be governed by Chapter 34, Medicare Supplement Insurance Minimum Standards, of this title.
64 Del. Laws, c. 142, §  1;  71 Del. Laws, c. 143, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS › § 3603. Standards for policy provisions.

§ 3603. Standards for policy provisions.
(a) The Commissioner shall issue reasonable regulations to establish specific standards, including standards of full and fair disclosure, that set forth the manner, content and required disclosure for the sale of individual policies of health insurance and subscriber contracts of health service corporations, other than conversion policies issued pursuant to a contractual conversion privilege under a group or individual policy of health insurance, when such group or individual contract contains provisions which are inconsistent with the requirements of this chapter or any regulation issued pursuant to this chapter, or to policies being issued to employees or members being added to franchise plans in existence on January 12, 1984, or any regulation issued pursuant to this chapter which shall be in addition to and in accordance with applicable laws of this State including the applicable statutory provisions set forth in §§ 3303-3336 of this title which may cover but shall not be limited to:
(1) Terms of renewability;
(2) Initial and subsequent conditions of eligibility;
(3) Nonduplication of coverage provisions;
(4) Coverage of dependents;
(5) Preexisting conditions;
(6) Termination of insurance;
(7) Probationary periods;
(8) Limitations;
(9) Exceptions;
(10) Reductions;
(11) Elimination periods;
(12) Requirements for replacement;
(13) Recurrent conditions; and
(14) The definition of terms including but not limited to the following:
Hospital, accident, sickness, injury, physician, accidental means, total disability, partial disability, nervous disorder, guaranteed renewable and noncancellable.
(b) Subsection (a) of this section authorizes the Commissioner to establish specific standards for policy provisions which will facilitate public understanding of such provisions. The subsection does not alter the requirements of §§ 3303-3336 (Uniform Health Policy Provisions Law), or other specifically applicable state laws dealing with individual policy provisions. Regulations adopted under the subsection should be consistent with §§ 3303-3336, and other applicable state laws relating to the subject matter.
(c) The Commissioner may issue reasonable regulations that specify prohibited policies or policy provisions not otherwise specifically authorized by statute which in the opinion of the Commissioner, are unjust, unfair or unfairly discriminatory to the policyholder, any person insured under the policy or beneficiary.
64 Del. Laws, c. 142, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS › § 3604. Minimum standards for benefits.

§ 3604. Minimum standards for benefits.
(a) The Commissioner may issue regulations to establish minimum standards for benefits under each of the following categories of coverage in individual policies, other than conversion policies issued pursuant to a contractual conversion privilege under group or individual policy, when such group or individual contract contains provisions which are inconsistent with the requirements of this chapter or any regulation issued pursuant to this chapter or to policies being issued to employees or members being added to franchise plans in existence on January 12, 1984, or any regulation issued pursuant to this chapter, of health insurance and subscriber contracts of health service corporations:
(1) Basic hospital expense coverage;
(2) Basic medical-surgical expense coverage;
(3) Hospital confinement indemnity coverage;
(4) Major medical expense coverage;
(5) Disability income protection coverage;
(6) Accident only coverage;
(7) Specified disease or specified accident coverage; and
(8) Limited benefit health coverage.
(b) Nothing in this section shall preclude the issuance of any policy or contract which combines 2 or more of the categories of coverage enumerated in paragraphs (a)(1)-(6) of this section.
(c) No policy or contract shall be delivered or issued for delivery in this State which does not meet the prescribed minimum standards for the categories of coverage listed in paragraphs (a)(1)-(8) of this section, or which does not meet the other applicable requirements for such coverages as prescribed by this title.
(d) The Commissioner shall prescribe the method of identification of policies and contracts based upon coverages provided.
64 Del. Laws, c. 142, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS › § 3605. Disclosure requirements.

§ 3605. Disclosure requirements.
(a) In order to provide for full and fair disclosure in the sale of individual health insurance policies or subscriber contracts of a health service corporation, no such policy or contract shall be delivered or issued for delivery in this State unless the outline of coverage described in subsection (b) of this section either accompanies the policy or is delivered to the applicant at the time the application is made and an acknowledgement of receipt or certificate of delivery of such outlines is provided the insurer. In the event the policy is issued on a basis other than that applied for, the outline of coverage properly describing the policy or contract must accompany the policy or contract when it is not the policy or contract for which application was made.
(b) The Commissioner shall prescribe by regulation the format and content of the outline of coverage required by subsection (a) of this section. “Format” means style, arrangement and overall appearance, including such items as the size, color and prominence of type and the arrangement of text and captions. Such outline of coverage shall include:
(1) A statement identifying the applicable category or categories of coverage provided by the policy or contract as prescribed in § 3604 of this title;
(2) A description of the principal benefits and coverage provided in the policy or contract;
(3) A statement of the exceptions, reductions and limitations contained in the policy or contract;
(4) A statement of the renewal provisions including any reservation by the insurer or health service corporation of a right to change premiums;
(5) A statement that the outline is a summary of the policy or contract issued or applied for and that the policy or contract should be consulted to determine governing contractual provisions.
(c) The outline of coverage shall not be considered to be part of the policy or subscriber contract for insurance.
(d) Every insurer or health service corporation electing to refuse coverage of an applicant or decline coverage of an insured who is not included within the coverage of Chapter 23 of Title 19 shall disclose to such applicant or insured in writing the fact of such noncoverage or declination of coverage. Any insurer or health insurer failing to disclose in writing such noncoverage or declination of coverage shall be deemed to cover the applicant or insured under the health insurance policy then in effect.
64 Del. Laws, c. 142, §  1;  64 Del. Laws, c. 378, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS › § 3606. Preexisting conditions [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3606. Preexisting conditions [For application of this section, see 79 Del. Laws, c. 99, § 19].
(a) Notwithstanding § 3306 of this title, a policy or contract must not deny, exclude, or limit benefits for a covered individual for losses due to a preexisting condition, and the policy or contract must not include wording that would permit a defense based upon preexisting conditions.
(b) Notwithstanding subsection (a) of this section and § 3306 of this title, an insurer or a health service corporation which issues a specified disease policy, regardless of whether such policy is issued on the basis of a detailed application form, a simplified application for or an enrollment form, may not deny a claim for any covered loss that begins after the policy has been in force. Except for rescission for misrepresentation, no other defenses based upon preexisting conditions are permitted.
64 Del. Laws, c. 142, §  1;  79 Del. Laws, c. 99, §  11;  82 Del. Laws, c. 186, § 9;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS › § 3609. Nondiscrimination in health care [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3609. Nondiscrimination in health care [For application of this section, see 79 Del. Laws, c. 99, § 19].
(a) Providers. — A health insurer offering individual health insurance coverage shall not discriminate with respect to participation under the coverage against any health-care provider who is acting within the scope of that provider's license or certification under applicable state law. This section shall not require that a health insurer contract with any health-care provider willing to abide by the terms and conditions for participation established by the insurer. Nothing in this section shall be construed as preventing a health insurer or the Commissioner from establishing varying reimbursement rates based on quality or performance measures.
(b) Individuals. — The provisions of § 1557 of the Patient Protection and Affordable Care Act (relating to nondiscrimination) [42 U.S.C. § 18116], as the law and its implementing regulations were in effect on January 1, 2018, apply with respect to a health insurer offering individual health insurance coverage.
79 Del. Laws, c. 99, §  13;  82 Del. Laws, c. 186, § 11;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS › § 3610. Comprehensive health insurance coverage [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3610. Comprehensive health insurance coverage [For application of this section, see 79 Del. Laws, c. 99, § 19].
(a) Coverage for essential health benefits package. —
A health insurer that offers health insurance coverage in the individual market shall ensure that such coverage includes the essential health benefits package in conformity with § 1302 of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022], as the law and its implementing regulations were in effect on January 1, 2018, and state law. The Commissioner shall issue a regulation setting forth what constitutes “essential health benefits” for purposes of this section.
(b) Cost-sharing under individual health insurance policies. —
An individual health insurance policy shall ensure that any annual cost-sharing imposed under the plan does not exceed the limitations provided for under § 1302(c)(1) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022(c)(1)], as the law and its implementing regulations were in effect on January 1, 2018, and state law.
(c) Child-only plans. —
If a health insurer offers health insurance coverage in any level of coverage specified under § 1302(d) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022(d)], as the law and its implementing regulations were in effect on January 1, 2018, or state law, the health insurer shall also offer such coverage in that level as a plan in which the only enrollees are individuals who, as of the beginning of the plan year, are under age 21.
(d) Dental only. —
This section does not apply to a plan described in § 1311(d)(2)(B)(ii) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18031(d)(2)(B)(ii)], as the law and its implementing regulations were in effect on January 1, 2018.
79 Del. Laws, c. 99, §  13;  81 Del. Laws, c. 79, § 31;  82 Del. Laws, c. 186, § 12;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS › § 3611. Prohibiting discrimination against individual participants and beneficiaries based on health status [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3611. Prohibiting discrimination against individual participants and beneficiaries based on health status [For application of this section, see 79 Del. Laws, c. 99, § 19].
In general. — A health insurer offering individual health insurance coverage may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual:
(1) Health status.
(2) Medical condition (including both physical and mental illnesses).
(3) Claims experience.
(4) Receipt of health care.
(5) Medical history.
(6) Genetic information.
(7) Evidence of insurability (including conditions arising out of acts of domestic violence).
(8) Disability.
(9) Any other health status-related factor determined appropriate by the Commissioner.
79 Del. Laws, c. 99, §  13;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS › § 3612. Insurance offered through the state health insurance exchange [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3612. Insurance offered through the state health insurance exchange [For application of this section, see 79 Del. Laws, c. 99, § 19].
(a) A health insurer that offers health insurance coverage in the individual market through the state health insurance exchange program established pursuant to the Patient Protection and Affordable Care Act [P.L. 111-148] shall first satisfy all certification standards required by federal and state law, and the health insurer shall offer only those policies that are “qualified health plans” as required by federal and state law.
(b) The Commissioner shall adopt regulations, in accordance with the Administrative Procedures Act [Chapter 101 of Title 29], that set forth the certification and compliance standards and requirements for health insurers operating within the state health exchange.
79 Del. Laws, c. 99, §  13;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 37. DELAWARE CONSUMER CREDIT INSURANCE MODEL ACT › § 3701. Purpose.

§ 3701. Purpose.
The purpose of this chapter is to promote the public welfare by regulating consumer credit insurance. Nothing in this chapter is intended to prohibit or discourage reasonable competition. The provisions of this chapter shall be liberally construed.
70 Del. Laws, c. 576, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 37. DELAWARE CONSUMER CREDIT INSURANCE MODEL ACT › § 3703. Types of consumer credit insurance.

§ 3703. Types of consumer credit insurance.
The types of consumer credit insurance defined in § 3702 of this title may be written separately or in combination with other types of consumer credit insurance on an individual policy or group policy basis.
70 Del. Laws, c. 576, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 37. DELAWARE CONSUMER CREDIT INSURANCE MODEL ACT › § 3704. Amount of consumer credit insurance.

§ 3704. Amount of consumer credit insurance.
(a) Credit life insurance. — (1) The initial amount of credit life insurance shall not exceed the total amount repayable under the credit transaction, which is the gross debt.
(2) In cases where an indebtedness is repayable in substantially equal installments, the amount of insurance shall at no time exceed the scheduled or actual amount of unpaid indebtedness, whichever is greater.
(3) Notwithstanding paragraph (a)(1) or (2) of this section, insurance on agricultural credit transactions not exceeding 2 years in duration may be written up to the amount of the loan commitment on a nondecreasing or level term plan.
(4) Notwithstanding paragraphs (a)(1) and (2) of this section, or any other subsection, insurance on educational credit transaction commitments may be written for the amount of the portion of such commitment that has not been advanced by the creditor.
(b) Credit accident and health insurance. — (1) The total amount of periodic indemnity payable by credit accident and health insurance in the event of disability as defined in the policy shall not exceed the aggregate of the periodic scheduled unpaid installments of the gross debt and the amount of each periodic indemnity payment shall not exceed the original gross debt divided by the number of periodic installments.
(2) Notwithstanding paragraph (b)(1) of this section, for credit accident and health insurance written in connection with an open-end credit agreement, the amount of insurance shall not exceed the gross debt which would accrue on that amount using the periodic indemnity. Subject to any policy maximums, the periodic indemnity must not be less than the creditor's minimum repayment schedule.
70 Del. Laws, c. 576, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 37. DELAWARE CONSUMER CREDIT INSURANCE MODEL ACT › § 3708. Premiums and refunds.

§ 3708. Premiums and refunds.
(a) Any insurer may revise its schedules of premium rates from time to time and shall file the revised schedules with the Commissioner. No insurer shall issue any consumer credit insurance policy for which the premium rate exceeds that determined by the schedules of the insurer as then on file with the Commissioner. The Commissioner shall have the authority to promulgate regulations to assure that the premium rates are reasonable in relation to the benefits provided. In determining whether the premium rates are reasonable in relation to the benefits provided, the Commissioner shall consider and provide for:
actual and expected loss experience, general and administrative expenses, loss settlement and adjustment expenses, reasonable creditor compensation, investment income, the manner in which premiums are charged and other acquisition costs, reserves, taxes, regulatory license fees and fund assessments, reasonable insurer profit and other relevant data, consistent with generally accepted actuarial standards.
(b) Each individual policy or group certificate shall provide for a refund in the event of termination of the insurance prior to the scheduled maturity date of the insurance and upon notice to the insurer. The refund of an amount paid by the debtor for insurance shall be paid or credited promptly to the person entitled thereto; provided however, that the Commissioner shall prescribe a minimum refund and no refund which would be less than such minimum need be made. The formula to be used in computing such refund shall be filed with and approved by the Commissioner.
(c) If a creditor requires a debtor to make any payment for consumer credit insurance and an individual policy or group certificate of insurance is not issued, the creditor shall immediately give written notice to the debtor and shall promptly make an appropriate credit to the account or issue a refund.
(d) The amount charged to a debtor for any consumer credit insurance shall not exceed the premiums charged by the insurer, as computed at the time the charge to the debtor is determined.
(e) The insurance premium or other identifiable charge for credit life or credit accident and health insurance may be collected from the insured or included in the principal of any loan or other transaction at the time such transaction is completed.
(f) The premium or cost of credit life or credit accident and health insurance when issued through any creditor shall not be deemed interest or charges, consideration or an amount in excess of permitted charges in connection with the loan or other credit transaction, and any gain or advantage to the creditor arising out of the premium or commission or dividend from the issuance of such insurance shall not be deemed a violation of any other law, general or special, civil or criminal, of the State.
70 Del. Laws, c. 576, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 37. DELAWARE CONSUMER CREDIT INSURANCE MODEL ACT › § 3709. Issuance of policies.

§ 3709. Issuance of policies.
All policies of consumer credit insurance shall be delivered or issued for delivery in this State only by an insurer authorized to engage in the business of insurance therein and shall be issued only through holders of licenses or authorizations issued by the Commissioner.
70 Del. Laws, c. 576, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 37. DELAWARE CONSUMER CREDIT INSURANCE MODEL ACT › § 3710. Claims.

§ 3710. Claims.
(a) All claims shall be promptly reported to the insurer or its designated claim representative and the insurer shall maintain adequate claim files. All claims shall be settled as soon as possible and in accordance with the terms of the insurance contract.
(b) All claims shall be paid either by draft drawn upon the insurer, by electronic funds transfer or by check of the insurer to the order of the claimant to whom payment of the claim is due pursuant to the policy provisions or upon direction of such claimant to one specified.
(c) No plan or arrangement shall be used whereby any person, firm or corporation other than the insurer or its designated claim representative shall be authorized to settle or adjust claims. The creditor shall not be designated as claim representative for the insurer in adjusting claims; provided, that a group policyholder may, by arrangement with the group insurer, draw drafts, checks or electronic transfers in payment of claims due to the group policyholder subject to audit and review by the insurer.
70 Del. Laws, c. 576, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 37. DELAWARE CONSUMER CREDIT INSURANCE MODEL ACT › § 3711. Existing insurance — Choice of insurer.

§ 3711. Existing insurance — Choice of insurer.
When consumer credit insurance is required as additional security for any debt, the debtor shall, upon request to the creditor, have the option of furnishing the required amount of insurance through existing policies of insurance owned or controlled by the debtor or of procuring and furnishing the required coverage through any insurer authorized to transact any insurance business within this State.
70 Del. Laws, c. 576, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 37. DELAWARE CONSUMER CREDIT INSURANCE MODEL ACT › § 3712. Duties of an insurer.

§ 3712. Duties of an insurer.
Except as otherwise prohibited by law, duties imposed upon an insurer within this chapter may be carried out by a creditor if the creditor is acting as a common law or statutory agent on behalf of the insurer.
70 Del. Laws, c. 576, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 37. DELAWARE CONSUMER CREDIT INSURANCE MODEL ACT › § 3713. Enforcement; penalties.

§ 3713. Enforcement; penalties.
(a) The Commissioner may, after notice and hearing, issue such rules and regulations as the Commissioner deems appropriate for the supervision of this chapter.
(b) Whenever the Commissioner finds that there has been a violation of this chapter or any rules or regulations issued pursuant thereto, and after written notice thereof and hearing given to the insurer or other person authorized or licensed by the Commissioner, the Commissioner may impose an administrative penalty in accordance with § 329 of this title. The Commissioner, in his or her discretion, may revoke or suspend the license or certificate of authority of the person, firm or corporation guilty of repeated wilful violations.
(c) Before the Commissioner may impose or order a penalty pursuant to this section, the violator shall be given notice of the violation and an opportunity to be heard at a public hearing. The procedures for such notice and hearing, and any appeal from the Commissioner's decision shall be the same as set forth in the Delaware Administrative Procedures Act, Chapter 101 of Title 29.
(d) The Commissioner may set forth by regulation prima facie reasonable premium rates, together with corresponding safe-harbor benefit provisions, which premium rates shall be conclusively presumed reasonable in relation to the benefits provided when used for policies containing such benefit provisions.
70 Del. Laws, c. 576, §  1;  70 Del. Laws, c. 186, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3802. Definitions.

§ 3802. Definitions.
Definitions as used in this chapter:
(1) “Child with a severe disability” means a person under the age of 21 who, due to a significant mental or physical condition, illness, or disease, is likely to require specialized treatment or supports to secure effective access to dental care.
(2) “Dental plan” means any contractual arrangement for dental services provided directly or arranged for or administered directly on a prepaid or postpaid individual or group capitation basis.
(3) “Dental plan organization” means any person who undertakes to provide directly or to arrange for or administer 1 or more dental plans providing dental services.
(4) “Dental services” means services included in the practice of dentistry as defined in § 1121 of Title 24.
(5) “Enrollee” means an individual and that individual's dependents who are enrolled in a dental plan organization.
(6) “Evidence of coverage” means any certificate, agreement or contract issued to an enrollee setting out the dental services to which the enrollee is entitled.
63 Del. Laws, c. 49, §  1;  70 Del. Laws, c. 186, §  1;  77 Del. Laws, c. 54, §  3;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3805. General surplus; special contingent surplus.

§ 3805. General surplus; special contingent surplus.
(a) The Commissioner may determine, at his or her discretion, the amount of a general surplus, if any, that the dental plan organization shall be required to maintain.
(b) A dental plan organization utilizing in the aggregate the services of more than 10 full-time equivalent dentists shall accumulate and maintain a special contingent surplus in excess of its assets over liabilities the rate of 2 percent annually of its net contract and certificate income until the surplus totals $50,000.
63 Del. Laws, c. 49, §  1;  70 Del. Laws, c. 186, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3806. Bonding requirement.

§ 3806. Bonding requirement.
Any director, officer, employee or partner of a dental plan organization who receives, collects, reimburses or invests moneys in connection with the activities of the organization shall be bonded for his or her fidelity in an amount which shall be determined by the Commission.
63 Del. Laws, c. 49, §  1;  70 Del. Laws, c. 186, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3807. Medical negligence insurance.

§ 3807. Medical negligence insurance.
Each dentist employed by a dental plan organization shall be insured against professional liability or medical negligence by an insurer licensed to conduct business in this State for such minimum amounts as shall be determined by the Commissioner.
63 Del. Laws, c. 49, §  1;  71 Del. Laws, c. 373, §  3;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3808. Evidence of coverage.

§ 3808. Evidence of coverage.
(a) An enrollee shall be entitled to receive evidence of coverage or a certificate indicating specifically the nature and extent of coverage, and evidence of the total amount or percentage of payment, if any, which the enrollee is obligated to pay for dental services. If an individual enrollee obtains coverage through an insurance policy or through a contract issued by a medical or dental service corporation, whether by option or otherwise, the insurer or medical or dental service corporation shall issue the evidence of coverage. Otherwise, the dental plan organization shall issue the evidence of coverage.
(b) No evidence of coverage or amendment thereto shall be issued or delivered to any person until a copy of the form of evidence of coverage or amendment thereto has been filed with the Commissioner.
(c) Evidence of coverage shall contain a clear and complete statement if a contract, or a reasonably complete summary if a certificate, of:
(1) The dental services and the insurance and other benefits, if any, to which enrollees are entitled;
(2) Any limitations on the services, kind of services, benefits, or kind of benefits to be provided including any charge, deductible or co-payment features;
(3) Where and in what manner information is available as to how services may be obtained; and
(4) A clear and understandable description of the dental plan organization's method for resolving enrollees' complaints.
(d) Any subsequent change in the evidence of coverage, or the amount or percentage of payment which the enrollee is obligated to pay, shall be evidenced in a separate document issued to the enrollee.
63 Del. Laws, c. 49, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3809. Schedule of charges.

§ 3809. Schedule of charges.
(a) No schedule of charges for enrollee coverage for dental services, or amendment thereto, may be used by a dental plan organization until a copy of such schedule, or amendment thereto, has been filed with the Commissioner. The Commissioner may disapprove the schedule of charges at any time if he or she finds that the charges are excessive, inadequate or unfairly discriminatory. If the Commissioner disapproves the schedule of charges he or she shall notify the dental plan organization within 5 days of the day of disapproval and specify in the notice the reason for his or her disapproval. A hearing shall be granted within 20 days after a request in writing by the filer. It shall be unlawful for any dental plan organization whose schedule of charges has been disapproved to effect any contract or issue any subscription certificate which uses the disapproved schedule of charges until a revised schedule of charges has been filed.
(b) Charges shall be established in accordance with actuarial principles, but charges applicable to an enrollee shall not be individually determined based on the status of his or her health.
63 Del. Laws, c. 49, §  1;  70 Del. Laws, c. 186, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3810. Examination of records.

§ 3810. Examination of records.
(a) The Commissioner or his or her designee may, as often as he or she may reasonably determine, investigate the business and examine the books, accounts, records and files of every dental plan organization. For that purpose the Commissioner or his or her designee shall have reasonably free access to the offices and places of business, books, accounts, papers, records and files of all dental plan organizations. A dental plan organization shall keep and use in its business such books, accounts and records as will enable the Commissioner to determine whether the dental plan organization is complying with this chapter and with the rules and regulations promulgated pursuant to it. A dental plan organization shall preserve its books, accounts and records for at least 3 years; except that preservation by photographic reproduction or records in photographic form shall constitute compliance with this chapter.
(b) For the purpose of the examination, the Commissioner may, within the limits of funds appropriated for such purpose, contract with such persons as he or she may deem advisable to conduct the same or assist therein.
(c) The expenses incurred in making any examination pursuant to this section, up to $1,000 annually, shall be assessed against and paid by the dental plan organization so examined. Upon written notice by the Commissioner of the total amount of an assessment, a dental plan organization shall become liable for and shall pay the assessment to the Commissioner.
63 Del. Laws, c. 49, §  1;  70 Del. Laws, c. 186, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3811. Complaint system.

§ 3811. Complaint system.
(a) A dental plan organization shall establish and maintain a complaint system to provide reasonable procedures for the resolution of written complaints initiated by enrollees concerning dental plan services. The dental plan organization shall maintain records of all written complaints initiated by enrollees.
(b) The Commissioner may examine the complaint system and if he or she determines that the system is not adequate he or she may require a revision of the complaint system.
63 Del. Laws, c. 49, §  1;  70 Del. Laws, c. 186, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3812. Annual report.

§ 3812. Annual report.
(a) Every dental plan organization annually on or before March 1 shall file with the Commissioner a report covering its activities for the preceding calendar year.
(b) The reports shall be on forms prescribed by the Commissioner and shall include:
(1) A financial statement of the dental plan organization, including its balance sheet, receipts and disbursements for the preceding year certified by a certified public accountant;
(2) Any significant modification of information submitted with the application for a certificate of authority;
(3) The number of persons who became enrollees during the year, the number of enrollees as of the end of the year and the number of enrollments terminated during the year;
(4) A description of the enrollee complaint system including the procedures of the complaint system, the total number of written complaints handled through the system, a summary of causes underlying the complaints filed, and the number, amount and disposition of medical negligence claims settled during the year by the dental plan organization and any of the dentists used by it; and
(5) Any other information relating to the performance of the dental plan organization as required by the Commissioner.
63 Del. Laws, c. 49, §  1;  71 Del. Laws, c. 373, §  3;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3813. Maximum portion of income used for expenses.

§ 3813. Maximum portion of income used for expenses.
A dental plan organization shall not use more than 30 percent of its gross contract and certificate income in the first year of operation, 25 percent in the second year of operation and 20 percent in any subsequent year for general expenses, acquisition expenses and miscellaneous taxes, licenses and fees.
63 Del. Laws, c. 49, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3814. Advertising.

§ 3814. Advertising.
(a) No dental plan organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this subsection:
(1) A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a dental plan;
(2) A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information may be reasonably understood by a person who does not possess special knowledge regarding dental plan coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee of, or person considering enrollment in a dental plan, if the benefit or advantage or absence of exclusion, limitation or disadvantage does not in fact exist; and
(3) Evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography, format and language, may cause a person who does not possess special knowledge regarding dental plans and evidences of coverage therefor, to expect benefits, services, charges or other advantages which the evidence of coverage does not provide or which the dental plan organization issuing the evidence of coverage does not regularly make available for enrollees covered under such evidence of coverage.
(b) No dental plan organization, unless licensed as an insurer, may use in its name, evidence of coverage or literature any of the words “insurance,” “assurance,” “casualty,” “surety,” “mutual” or any other words descriptive of the insurance, casualty or surety business or deceptively similar to the name or description of any insurer licensed to do business in this State.
(c) This section shall be enforced by the Division of Consumer Protection and, where applicable, the Commissioner. Nothing in this chapter shall limit the powers of the Attorney General and the procedures with respect to consumer fraud.
63 Del. Laws, c. 49, §  1;  69 Del. Laws, c. 291, §  98(c);
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3815. Suspension or revocation of certificate of authority.

§ 3815. Suspension or revocation of certificate of authority.
(a) The Commissioner may suspend or revoke any certificate of authority issued to a dental plan organization pursuant to this chapter if he or she finds that any of the following conditions exists:
(1) The dental plan organization is operating in a manner significantly contrary to that described in § 3803 of this title;
(2) The dental plan organization issues an evidence of coverage which does not comply with the requirements of § 3808 of this title;
(3) The dental plan organization does not provide or arrange for an effective dental plan as determined by the Commissioner;
(4) The dental plan organization can no longer be expected to meet its obligations to enrollees;
(5) The dental plan organization, or any authorized person on its behalf, has advertised or merchandised its services in an untrue or misleading manner;
(6) The dental plan organization has failed to comply with this chapter or any rules and regulations promulgated thereunder.
(b) When the Commissioner has cause to believe that grounds for the suspension or revocation of a certificate of authority exist, he or she shall notify the dental plan organization in writing, specifically stating the grounds for suspension or revocation. A hearing on the matter shall be granted by the Commissioner within 20 days after a request in writing by the dental plan organization. After the hearing, or upon failure of the dental plan organization to appear at the hearing, the Commissioner shall take action on his or her findings.
(c) If the Commissioner suspends the certificate of authority, the dental plan organization shall not accept any additional enrollees or engage in any advertising or solicitation during the period of the suspension.
(d) If the Commissioner revokes the certificate of authority, the dental plan organization shall proceed to dissolve its structure immediately following the effective date of the order of revocation, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the dental plan organization. The Commissioner by written order, however, may permit such further operation of the dental plan organization as he or she finds to be in the best interest of enrollees to the end that enrollees shall be afforded the greatest practical opportunity to obtain continuing dental plan coverage.
(e) Notwithstanding subsections (c) and (d) of this section, a dental plan organization which has had its certificate of authority suspended or revoked, or has suffered an adverse decision by the Commissioner, shall be entitled to appeal this decision. The appeal shall be granted as a matter of right and shall be taken to the Court of Chancery in any county in this State.
63 Del. Laws, c. 49, §  1;  70 Del. Laws, c. 186, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3816. Cease and desist order.

§ 3816. Cease and desist order.
(a) The Commissioner may issue an order directing a dental plan organization or a representative of a dental plan organization to cease and desist from engaging in any act or practice in violation of this chapter.
(b) Within 20 days after service of the order of cease and desist, the respondent may request a hearing on a question of whether acts or practices in violation of this chapter have occurred.
63 Del. Laws, c. 49, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3817. Civil penalty; exceptions.

§ 3817. Civil penalty; exceptions.
Any dental plan organization which violates any provisions of this chapter, or neglects, fails or refuses to comply with any of the requirements of this chapter, except the failure to file an annual report and the failure to reply in writing to inquiries of the Commissioner, shall be liable for a civil penalty of no more than $1,000 for each violation.
63 Del. Laws, c. 49, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3818. Injunctive power.

§ 3818. Injunctive power.
Whenever any dental plan organization shall become insolvent or shall suspend its ordinary business for want of funds to carry on the same, or whenever the Commissioner shall ascertain, as a result of examination as authorized by this chapter, or in any other manner, that the dental plan organization is exceeding its powers or violating the law or that its condition or methods of business may render the continuance of its operations hazardous to its enrollees or the public, or that its assets are less than its liabilities, the Commissioner may institute an action in the Court of Chancery to enjoin it from the transaction of any further business, or from the transfer or disposal of its property in any manner whatsoever. The Court may proceed in the action in a summary manner or otherwise. It may grant injunctive relief and appoint a receiver, with power to sue for, collect, receive and take into his or her possession all the goods and chattels, rights and credits, moneys and effects, lands and tenement, books, papers, choses in action, bills, notes and property of every description belonging to the dental plan organization and sell and convey and assign the same, and authorize the purchase of continuing coverage for enrollees utilizing the remaining assets, and hold and dispose of the proceeds thereof. The Court may cause the receiver to continue the existing operation of the organization, under Court supervision, until the next anniversary of the subscription certificates and contracts then in force. The dental plan organization may be deemed insolvent whenever it is presently or prospectively unable to fulfill its outstanding contracts and to maintain the surpluses required pursuant to this chapter.
63 Del. Laws, c. 49, §  1;  70 Del. Laws, c. 186, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 38. DENTAL PLAN ORGANIZATION ACT › § 3819. Confidentiality of documents.

§ 3819. Confidentiality of documents.
Applications, filings and reports required under this chapter, except contracts referred to in § 3803(c)(4) and (5) of this title, shall be treated as public documents and shall not be considered confidential.
63 Del. Laws, c. 49, §  1;  80 Del. Laws, c. 376, § 5;