reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26-47 - Injunction

17B:26-47. Injunction
The commissioner may, through the Attorney General of this State, institute an action in the Superior Court to enjoin and restrain any insurer who has entered into a policy which does not conform to the regulations promulgated pursuant to this act or an insurer or any other person who has attempted to induce entry into any such policy or whose method of sale is in violation of the regulations promulgated pursuant to this act. The court may proceed in the action in a summary manner.
L.1979, c. 78, s. 3, eff. April 15, 1979.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-1 - Definitions

17B:26A-1. Definitions
1. For the purposes of this act:
a. "Applicant" means:
(1) In the case of an individual medicare supplement policy, the person who seeks to contract for insurance benefits, and
(2) In the case of a group medicare supplement policy, the proposed certificate holder.
b. "Certificate" means any certificate issued under a group medicare supplement policy, which certificate has been delivered or issued for delivery in this State.
c. "Commissioner" means the Commissioner of Insurance.
d. "Medicare" means the program established by the "Health Insurance for the Aged Act," Title XVIII of the "Social Security Act," Pub.L. 89-97, as then constituted or later amended (42 U.S.C. s.1395 et seq.).
e. "Medicare supplement policy" means a group or individual insurance policy or certificate which is advertised, marketed, designed primarily as, or is otherwise held out to be, a supplement to reimbursements under medicare for the hospital, medical or surgical expenses of persons eligible for medicare, other than a policy issued pursuant to a contract under 42 U.S.C. s.1395l or 42 U.S.C. s.1395mm or a policy issued under a demonstration project authorized pursuant to the "Health Insurance for the Aged Act," 42 U.S.C. s.1395 et seq. The term does not include a policy issued to one or more employers or labor organizations, or to the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees, or combination thereof, or for members or former members, or combination thereof, of the labor organizations.
L.1982,c.94,s.1; amended 1992,c.163,s.2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-2 - Regulations; medicare supplement policies

17B:26A-2. Regulations; medicare supplement policies
The commissioner shall issue regulations to establish specific standards for policy provisions of medicare supplement policies, which shall be in addition to and in accordance with applicable laws of this State, and may cover, but shall not be limited to:
a. Terms of renewability;
b. Initial and subsequent conditions of eligibility;
c. Nonduplication of coverage;
d. Probationary periods;
e. Benefit limitations, exceptions and reductions;
f. Elimination periods;
g. Requirements for replacement;
h. Recurrent conditions; and
i. Definition of terms.
L.1982, c. 94, s. 2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-3 - Prohibited provisions

17B:26A-3. Prohibited provisions
3. a. No medicare supplement policy shall contain benefits which duplicate any benefits provided by medicare.
b. The commissioner may issue regulations that specify prohibited policy provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person insured or proposed for coverage under a medicare supplement policy.
L.1982,c.94,s.3; amended 1992,c.163,s.3.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-4 - Preexisting condition; denial of claim for losses

17B:26A-4. Preexisting condition; denial of claim for losses
Notwithstanding any other provision of law of this State to the contrary, a medicare supplement policy may not deny a claim for losses incurred more than 6 months from the effective date of coverage for a preexisting condition. The policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage.
L.1982, c. 94, s. 4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-5 - Regulations

17B:26A-5. Regulations
5. The commissioner shall promulgate regulations to effectuate and enforce the provisions of P.L.1982, c.94 (C. 17B:26A-1 et seq.) and any regulations which are necessary to conform medicare supplement policies and certificates with federal law. These regulations shall include, but not be limited to:
a. Establishment of minimum standards for benefits, claim payments, marketing and reporting practices and compensation arrangements;
b. Establishment of a uniform methodology for calculating and reporting loss ratios, and requiring refunds or credits if the policies or certificates do not meet loss ratio requirements;
c. Establishment of a process for filing of all requests for premium increases and rate changes, which may include public hearings as determined appropriate by the commissioner prior to approval of any premium increases;
d. Assurance of access by the public to policy, premium and loss ratio information; and
e. Establishment of standards for Medicare Select policies and certificates at such time as this State is authorized under federal law to authorize Medicare Select policies and certificates.
L.1982,c.94,s.5; amended 1992,c.163,s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-7 - Outline of coverage, regulations

17B:26A-7. Outline of coverage, regulations
7. a. In order to provide for full and fair disclosure in the sale of medicare supplement policies, no medicare supplement policy or certificate shall be delivered or issued for delivery in this State unless an outline of coverage is delivered to the applicant at the time application is made.
b. The commissioner shall prescribe the format and content of the outline of coverage required by subsection a. of this section. For the purposes of this section, "format" means style, arrangement and overall appearance, including such items as the size, color and prominence of the font used, paper size and weight and the arrangement of text and captions. The outline of coverage shall include:
(1) A description of the principal benefits and coverage provided in the policy;
(2) (Deleted by amendment, P.L.1992, c.163).
(3) A statement of the renewal provisions, including any reservation by the insurer of a right to change premiums, and disclosure of the existence of any automatic renewal premium increases based on the policyholder's age; and
(4) A statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.
c. The commissioner may require by regulation the publication of forms and an informational brochure with a standardized format and content, to serve as an aid in the selection of appropriate coverage, if any, by those eligible for medicare, and to aid the consumer in improving his understanding of medicare benefits. Except in the case of direct response solicitation insurance policies, the commissioner may require by regulation that the informational brochure be provided, concurrently with delivery of the outline of coverage, to all prospective insureds eligible for medicare. With respect to direct response solicitation insurance policies, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective insureds eligible for medicare, but in no event later than the time of policy delivery.
d. The commissioner may promulgate regulations for captions or notice requirements for all accident and sickness insurance policies sold to persons eligible for medicare, other than for medicare supplement policies, to inform those prospective insureds that the particular insurance coverage is not a medicare supplement policy.
e. The commissioner may further promulgate regulations to govern the full and fair disclosure of the information in connection with the replacement of insurance policies or certificates by persons eligible for medicare.
L.1982,c.94,s.7; amended 1992,c.163,s.6.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-8 - 30-day examination period, refunds

17B:26A-8. 30-day examination period, refunds
8. Medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Refunds made pursuant to this section shall be made in a timely manner and shall be paid directly to the applicant.
L.1982,c.94,s.8; amended 1992,c.163,s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-9 - Applicability

17B:26A-9. Applicability
1. Except as otherwise specifically provided:
a. The provisions of P.L.1982, c.94 (C.17B:26A-1 et seq.) shall apply to all medicare supplement policies delivered or issued for delivery in this State and all certificates issued under group medicare supplement policies, which certificates are delivered or issued for delivery in this State.
b. The provisions of P.L.1982, c.94 (C.17B:26A-1 et seq.) shall not apply to health insurance policies, including group conversion policies, provided to medicare eligible persons that are not advertised, marketed, designed primarily as or otherwise held out to be medicare supplement policies.
L.1992,c.163,s.1.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-10 - Filing of copies of advertising materials, regulations

17B:26A-10. Filing of copies of advertising materials, regulations
8. a. Every insurer shall file with the Department of Insurance a copy of all advertising materials to be used in promoting medicare supplement policies to which residents of this State will have access, and through which the insurer intends, or by implication purports to the reasonable, targeted consumer its intent, to make such policies available for purchase or enrollment in this State. The requirements of this section shall apply to all advertisements in any medium, whether in print or by means of television or radio broadcast. Filings shall be made at least 30 days prior to the date on which the advertisement is to be used in this State, or made accessible to residents of this State.
b. The commissioner may, in the public interest, promulgate regulations governing medicare supplement policy advertising including, but not limited to, specific filing procedures, standards upon which review may be based, celebrity endorsements, unfair practices and review and disapproval procedures.
c. Notwithstanding the provisions of subsection b. of this section, the commissioner may disapprove any advertisement for use in this State at any time if he determines that the advertisement misrepresents the product, misleads the targeted consumer, uses a strategy which involves scare tactics, unnecessarily confusing data or representation, false or fraudulent statements or otherwise violates any applicable laws of this State or regulations promulgated thereunder.
L.1992,c.163,s.8.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-11 - Additional remedies

17B:26A-11. Additional remedies
9. In addition to any other applicable penalties for violation of the provisions of Title 17B of the New Jersey Statutes, the commissioner may require any health insurer violating the provisions of P.L.1982, c.94 (C.17B:26A-1 et seq.) to cease marketing any medicare supplement policy or certificate in this State which is related directly or indirectly to the violation, require that insurer to take such action as is necessary to comply with the provisions of that act, or both.
L.1992,c.163,s.9.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-16 - Audit required, conditions

17B:26A-16. Audit required, conditions
5. a. Whenever the contracting carrier reports a net loss to the commissioner pursuant to paragraph (2) of subsection a. of section 4 of this act, the related operations of the contracting carrier and any losses incurred by the contracting carrier regarding Medicare supplement insurance policies or contracts issued pursuant to subsection a. of section 3 of this act shall be subject to an audit conducted by a qualified independent certified public accountant prior to the imposition of any assessment pursuant to subsection b. of section 4 of this act.
b. The auditor shall be selected and approved by the governing board of the plan through a competitive bidding process of certified public accountants qualified in New Jersey to perform such audits. The audit shall include:
(1) a review of the handling and accounting of assets and monies of the contracting carrier;
(2) a determination that administrative expenses have been properly allocated and are reasonable;
(3) a review of the internal financial controls of the contracting carrier;
(4) a review of the annual financial report of the contracting carrier; and
(5) a review of the calculation by the commissioner of any assessments for net losses.
c. A copy of the audit and related management letters shall be delivered to the governing board of the plan, to the commissioner and to each carrier and health maintenance organization to which the provisions of this act apply. The audit report shall be reviewed by the governing board of the plan. Upon recommendation of the governing board, the contracting carrier shall implement any recommendations made by the auditor.
L.1995,c.229,s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:26A-17 - Definitions.

17B:26A-17 Definitions.
6. As used in this act:
"Carrier" means an insurance company or service corporation authorized to issue health benefits plans in this State.
"Financially impaired" means a carrier or health maintenance organization which, after the effective date of P.L.1995, c.229 (C.17B:26A-12 et seq.), is not insolvent, but is deemed by the commissioner to be potentially unable to fulfill its contractual obligations, or a carrier or health maintenance organization which is under an order of rehabilitation or conservation by a court of competent jurisdiction.
"Health benefits plan" means a hospital and medical expense insurance policy; hospital service corporation contract, medical service corporation contract or health service corporation contract delivered or issued for delivery in this State.
"Newly eligible" means first eligible for Medicare benefits by reason of age or disability on or after January 1, 2020, in accordance with 42 U.S.C. s.426 or 426-1.
L.1995, c.229, s.6; amended 2019, c.139, s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-26 - Definitions and requirements

17B:27-26. Definitions and requirements
Any policy or contract of health insurance which covers more than one person, other than a blanket insurance policy, or a policy issued pursuant to section 17B:26-2a(3), shall be deemed a group health insurance policy. No group health insurance policy may be delivered or issued for delivery in this State unless it conforms to one of the descriptions set forth in sections 17B:27-27 to 17B:27-29, inclusive.
L.1971, c. 144, s. 17B:27-26.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-27 - Employer, trustee, labor union, association groups

17B:27-27. Employer, trustee, labor union, association groups
A policy issued to an employer or to the trustees of a fund established by one or more employers, or issued to a labor union, or issued to an association formed for purposes other than obtaining such insurance, or issued to the trustees of a fund established by one or more labor unions or by one or more employers and one or more labor unions, insuring employees and members of associations or labor unions.
L.1971, c. 144, s. 17B:27-27.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-30.1 - Benefits provided by group policy to subscriber's child.

17B:27-30.1 Benefits provided by group policy to subscriber's child.
11. a. A policy which provides hospital or medical expense benefits under which dependent coverage is available shall continue to make that coverage available for an adult child until the child turns 26 years of age. A policy shall not deny coverage for an insured's child on the grounds that:
(1) The child was born out of wedlock;
(2) The child is not claimed as a dependent on the insured's federal tax return;
(3) The child does not reside with the insured or in the insurer's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the policy with respect to the use of specified providers;
(4) The child is married;
(5) The child has or adopts a child; or
(6) The child starts or leaves school.
b. If a child has coverage through a health insurance policy of a noncustodial parent, the insurer shall:
(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through the child's noncustodial parent's coverage;
(2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent; and
(3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate.
c. When a parent who is the insured is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the insurer shall:
(1) Permit the parent to enroll his child as a dependent, without regard to any open enrollment restrictions;
(2) Permit the child's other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child under the health insurance policy if the parent who is the insured fails to enroll the child; and
(3) Not terminate coverage of the child unless the parent who is the insured provides the insurer with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage.
L.1995, c.288, s.11; amended 2019, c.356 s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-30.2 - Requirements applicable to State Medicaid

17B:27-30.2. Requirements applicable to State Medicaid
12. An insurer shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other insured.
L.1995,c.288,s.12.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-30.3 - Coverage provided by group health plan to subscriber's child.

17B:27-30.3 Coverage provided by group health plan to subscriber's child.
15. a. A group health plan as defined in section 607(1) of the "Employee Retirement Income Security Act of 1974," 29 U.S.C.1167(1) which provides hospital or medical expense benefits under which dependent coverage is available shall continue to make that coverage available for an adult child until the child turns 26 years of age. A plan shall not deny coverage for a covered employee's child on the grounds that:
(1) The child was born out of wedlock;
(2) The child is not claimed as a dependent on the covered employee's federal tax return;
(3) The child does not reside with the covered employee or in the group health plan's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the plan with respect to the use of specified providers;
(4) The child is married;
(5) The child has or adopts a child; or
(6) The child starts or leaves school.
b. If a child has coverage through a group health plan of a noncustodial parent, the plan shall:
(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through the child's noncustodial parent's coverage;
(2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent; and
(3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate.
c. When a parent who is the covered employee is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the group health plan shall:
(1) Permit the parent to enroll his child as a dependent, without regard to any open enrollment restrictions;
(2) Permit the child's other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child under the group health plan if the parent who is the covered employee fails to enroll the child; and
(3) Not terminate coverage of the child unless the parent who is the covered employee provides the group health plan with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage.
L.1995, c.288, s.15; amended 2019, c.356 s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-30.4 - Requirements applicable to State Medicaid

17B:27-30.4. Requirements applicable to State Medicaid
16. A group health plan as defined in section 607(1) of the "Employee Retirement Income Security Act of 1974," 29 U.S.C.1167(1) shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other covered employee.
L.1995,c.288,s.16.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-31 - "Employees" defined

17B:27-31. "Employees" defined
The policy may provide that the term "employees" shall include as employees of a single employer the employees of one or more subsidiary corporations and the employees, individual proprietors and partners of affiliated corporations, proprietorships and partnerships if the business of the employer and such corporations, proprietorships or partnerships is under common control through stock ownership, contract or otherwise. The policy may provide that the term "employees" shall include the individual proprietor or partners of an individual proprietorship or a partnership. The policy may provide that the term "employees" shall include retired employees. A policy issued to trustees may provide that the term "employees" shall include the trustees or their employees, or both, if their duties are principally connected with such trusteeship. A policy issued to the trustees of a fund established by the members of an association of employers may provide that the term "employees" shall include the employees of the association.
L.1971, c. 144, s. 17B:27-31.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-33 - Standard provisions

17B:27-33. Standard provisions
No policy of group health or blanket insurance and no certificate thereunder shall be delivered or issued for delivery in this State unless the policy contains in substance all the provisions specified in sections 17B:27-34 to 17B:27-46 following.
L.1971, c. 144, s. 17B:27-33.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-34 - Application; statements

17B:27-34. Application; statements
There shall be a provision that a copy of the application, if any, of the policyholder shall be attached to the policy when issued, that all statements made by the policyholder or by the persons insured shall be deemed representations and not warranties, and that no statement made by any person insured shall avoid the insurance or reduce benefits thereunder unless contained in a written instrument signed by the person insured.
L.1971, c. 144, s. 17B:27-34.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-35 - Policy changes

17B:27-35. Policy changes
There shall be a provision that no agent has authority to change the policy or to waive any of its provisions and that no change in the policy shall be valid unless approved by an officer of the insurer and evidenced by endorsement on the policy, or by amendment to the policy signed by the policyholder and the insurer.
L.1971, c. 144, s. 17B:27-35.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-36 - New entrants

17B:27-36. New entrants
There shall be a provision that all new employees or new members, as the case may be, in the groups or classes eligible for such insurance must be added to such eligible groups or classes.
L.1971, c. 144, s. 17B:27-36.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-36.1 - Eligibility for enrollment under policy providing hospital, medical expense benefits.

17B:27-36.1. Eligibility for enrollment under policy providing hospital, medical expense benefits.
6. Notwithstanding any other provision of law to the contrary, an insurer shall not consider a person's eligibility for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or the equivalent statute in another state, when determining the person's eligibility for enrollment in, or the provision of benefits under, a policy providing hospital or medical expense benefits delivered, issued or executed in this State, or approved for issuance in this State by the Commissioner of Insurance.
L.1995,c.291,s.6.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-36.2 - Group health insurance, policy, exclusion, rates, terms based on genetic information prohibited

17B:27-36.2. Group health insurance, policy, exclusion, rates, terms based on genetic information prohibited
15. Every group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall not exclude any person or eligible dependent and shall not establish any rates or terms therefor on the basis of an actual or expected health condition or on the basis of any genetic characteristic. For the purposes of this section, "genetic characteristic" means any inherited gene or chromosome, or alteration thereof, that is scientifically or medically believed to predispose an individual to a disease, disorder or syndrome, or to be associated with statistically increased risk of development of a disease, disorder or syndrome.
L.1996,c.126,s.14.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-37 - Payment of premiums

17B:27-37. Payment of premiums
There shall be a provision that all premiums due under the policy shall be remitted by the employer or employers of the persons insured, by the policyholder, or by some other designated person acting on behalf of the association or group insured, to the insurer on or before the due date thereof with such period of grace as may be specified therein.
L.1971, c. 144, s. 17B:27-37.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-38 - Certificate

17B:27-38. Certificate
There shall be a provision that the insurer shall issue to the employer, the policyholder, or other person or association in whose name such policy is issued, for delivery to each employee or member, a certificate setting forth in summary form a statement of the essential features of the insurance coverage, to whom the benefits thereunder are payable, and in substance the provisions of sections 17B:27-39 to 17B:27-46, inclusive of this chapter. This section shall not apply to blanket policies issued pursuant to section 17B:27-32a(1) and 17B:27-32a(3) of this act, nor to group health policies insuring a private plan under the Temporary Disability Benefits Law, if reasonable notice of the benefits provided thereby is furnished to the covered employees by direct notification or by conspicuous posting at the place of employment. If family members or dependents are included in the coverage, only one certificate need be issued for each family unit.
L.1971, c. 144, s. 17B:27-38.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-39 - Age limits

17B:27-39. Age limits
There shall be a provision specifying the ages, if any there be, to which the insurance provided therein shall be limited; and the ages, if any there be, for which additional restrictions are placed on benefits, and the additional restrictions placed on the benefits at such ages.
L.1971, c. 144, s. 17B:27-39.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-40 - Notice of loss

17B:27-40. Notice of loss
There shall be a provision that written notice of sickness or of injury must be given to the insurer within 20 days after the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.
L.1971, c. 144, s. 17B:27-40.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-41 - Proof of loss

17B:27-41. Proof of loss
There shall be a provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within 30 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within 90 days after the date of such loss. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible.
L.1971, c. 144, s. 17B:27-41.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-42 - Forms for proof

17B:27-42. Forms for proof
There shall be a provision that the insurer will furnish to the person making claim, or to the policyholder for delivery to such person, such forms as are usually furnished by it for filing proof of loss. If the person making claim does not receive such forms before the expiration of 15 days after the insurer receives notice of any claim under the policy, the person making such claim shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, character and extent of the loss for which claim is made.
L.1971, c. 144, s. 17B:27-42.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-43 - Examination, autopsy

17B:27-43. Examination, autopsy
There shall be a provision that the insurer shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law.
L.1971, c. 144, s. 17B:27-43.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-44 - Time of benefit payment

17B:27-44. Time of benefit payment
There shall be a provision that all benefits payable under the policy other than benefits for loss of time will be payable not more than 60 days after receipt of proof, and that, subject to due proof of loss, all accrued benefits payable under the policy for loss of time will be paid not later than at the expiration of each period of 30 days during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of such proof.
L.1971, c. 144, s. 17B:27-44.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-45 - Beneficiary; direct payment to hospitals and other purveyors of services

17B:27-45. Beneficiary; direct payment to hospitals and other purveyors of services
There shall be a provision that indemnity for loss of life of the insured shall be payable to the beneficiary or beneficiaries designated by the insured, other than the policyholder or an officer thereof as such, or if no beneficiary is designated, to such other person or persons as shall be specified in the policy; and that all other indemnities of the policy are payable to the employee or member, except that, at the request of the employee or member or in the event of his death, payment of benefits to the extent of expenses incurred on account of hospitalization may be made by the insurer to the hospital and except that the group policy may provide that all or any portion of any benefits 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 provided, further, that authorization for any such payments has been obtained from the insured. If a beneficiary is designated, the consent of the beneficiary shall not be requisite to change of beneficiary or to any other changes in the policy or certificate except as may be specifically provided by the policy.
This section shall not apply to a blanket insurance policy issued to an airline under which the benefits are payable to the airline or a trust established by the airline and the premiums are paid from its funds.
L.1971, c. 144, s. 17B:27-45.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-46 - Time limits, suits

17B:27-46. Time limits, suits
There shall be a provision that no action at law or in equity shall be brought to recover on the policy prior to the expiration of 60 days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought at all unless brought within 3 years from the expiration of the time within which proof of loss is required by the policy.
L.1971, c. 144, s. 17B:27-46.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-46.1a - Reconstructive breast surgery; benefits

17B:27-46.1a. Reconstructive breast surgery; benefits
1. Every group health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses and, under any policy providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the policy.
L.1983,c.52,s.1; amended 1997, c.75, s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-46.1b - Group health insurance policies

17B:27-46.1b. Group health insurance policies
Every group health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this amendatory and supplementary act, shall offer coverage for maternity care without regard to marital status to subscribers or other persons covered thereunder for expenses incurred in pregnancy and childbirth. The benefits for the expenses of pregnancy and childbirth shall be provided to the same extent as the hospitalization benefit is provided in the policy for any other covered illness. If a fixed amount is specified in the policy for surgery, the fixed amount for a pregnancy-related surgical procedure shall be commensurate with the fixed amount payable for a surgical procedure of comparable difficulty and severity.
L. 1985, c. 277, s. 2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-46.1c - Benefits for purchase of blood products, infusion equipment

17B:27-46.1c. Benefits for purchase of blood products, infusion equipment
Every group health insurance policy providing hospital expense benefits to any policy holder or other person covered thereunder for expenses incurred in connection with the treatment of routine bleeding episodes associated with hemophilia shall provide benefits for expenses incurred in connection with the purchase of blood products and blood infusion equipment required for home treatment of routine bleeding episodes associated with hemophilia when the home treatment program is under the supervision of a State approved hemophilia treatment center. The benefits shall be provided to the same extent as for any sickness under the policy.
As used in this act, "blood product" includes, but is not limited to, Factor VIII, Factor IX and cryoprecipitate; and "blood infusion equipment" includes, but is not limited to, syringes and needles.
Participation in a home treatment program shall not preclude further or additional treatment or care at any eligible facility if the number of home treatments, in accordance with a ratio of home treatments to benefit days established by regulation by the Commissioner of Insurance, does not exceed the total number of benefit days provided for any other sickness under the policy.
L. 1987, c. 63, s. 1.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-46.1d - Commercial health insurer benefits for preexisting condition

17B:27-46.1d. Commercial health insurer benefits for preexisting condition
a. Notwithstanding any other provision of law to the contrary, no group health insurance policy issued by an insurer pursuant to the provisions of Chapter 27 of Title 17B of the New Jersey Statutes, shall contain any provision which denies benefits for a preexisting condition to any person becoming a member of that group if: (1) during the period immediately preceding the person's becoming a member of the group the person was enrolled as a member under another group policy issued by the insurer; and (2) the insurer paid benefits for the condition under the group policy in which the person was previously insured.
b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any group policy.
c. This section shall apply to every group contract or policy in which the corporation or insurer has the right to change the premium.
L.1989, c.63, s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-46.1e - Group health insurance policy to pay benefits for treatment of Wilm's tumor

17B:27-46.1e. Group health insurance policy to pay benefits for treatment of Wilm's tumor
Every group health insurance policy providing hospital or medical expense benefits shall provide benefits to any named insured or other person covered thereunder for expenses incurred in the treatment of Wilm's tumor, including autologous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such treatment may be deemed experimental or investigational. These benefits shall be provided to the same extent as for any other sickness under the policy.
L.1990,c.71,s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-46.1f - Group health insurance policy, mammogram examination benefits.

17B:27-46.1f Group health insurance policy, mammogram examination benefits.
5. a. No group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the insurer of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the policy.
c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
L.1991, c.279, s.5; amended 1999, c.341, s.5; 2004, c.86, s.5; 2013, c.196, s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-46.1g - .Group health insurance policy, benefits for "off-label" drugs required

17B:27-46.1g .Group health insurance policy, benefits for "off-label" drugs required
6. a. Except as otherwise provided in P.L.1992, c.162 (C.17B:27A-17 et seq.), no group health insurance policy which provides benefits for expenses incurred in prescribing drugs approved by the federal Food and Drug Administration shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State, on or after the effective date of this act unless the policy provides benefits to any policyholder or other person covered thereunder for expenses incurred in prescribing a drug for a treatment for which it has not been approved by the Food and Drug Administration if the drug is recognized as being medically appropriate for the specific treatment for which the drug has been prescribed in one of the following established reference compendia:
(1) the American Medical Association Drug Evaluations;
(2) the American Hospital Formulary Service Drug Information;
(3) the United States Pharmacopoeia Drug Information;
or, it is recommended by a clinical study or review article in a major-peer reviewed professional journal.
b. Notwithstanding the provisions of this section, coverage shall not be required for any experimental or investigational drug or any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed. The benefits provided pursuant to this section shall be provided to the same extent as other benefits under the policy for drugs prescribed for treatments approved by the Food and Drug Administration.
c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.
d. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug.
L.1993,c.321,s.6.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27-46.1j - Benefits for certain cancer treatments

17B:27-46.1j. Benefits for certain cancer treatments
5. In addition to benefits provided under regulations adopted pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), an insurer shall offer under every group policy providing health insurance coverage delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act to provide benefits for the treatment of cancer by dose-intensive chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants when performed by institutions approved by the National Cancer Institute or pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. Benefits for such treatment shall be provided to the same extent as for any other illness under the policy.
The offer required pursuant to this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium. Nothing in this section shall be construed to limit an insurer in adjusting premium amounts, or providing for reasonable deductibles or copayments, with respect to benefits provided pursuant to this section.
L.1995,c.100,s.5.