2023 New York Laws › ISC - Insurance › Article 42 - Life Insurance Companies and Accident and Health Insurance Companies and Legal Services Insurance Companies › 4235 - Group Accident and Health Insurance.

§  4235.  Group  accident  and health insurance. (a) (1) Any policy of
insurance against death or  injury  resulting  from  an  accident  which
covers  more than one person, except blanket accident insurance policies
as defined in section four thousand two  hundred  thirty-seven  of  this
article  and  accident  and  health  insurance  policies  conforming  to
subsections (a), (b) and (c)  of  section  three  thousand  two  hundred
sixteen  of  this  chapter,  shall  be deemed a group accident insurance
policy.
(2) Any policy which insures against disablement, disease or  sickness
(excluding  disablement  which  results from accident), and which covers
more than one  person,  except  blanket  health  insurance  policies  as
defined  in  section  four  thousand  two  hundred  thirty-seven of this
article  and  accident  and  health  insurance  policies  conforming  to
subsections  (a),  (b)  and  (c)  of  section three thousand two hundred
sixteen of this chapter,  shall  be  deemed  a  group  health  insurance
policy.
(3)  Any  policy  of  insurance  which  combines the coverage of group
accident insurance and of group health insurance shall be deemed a group
accident and health insurance policy.
(b) No policy of group accident, group health or  group  accident  and
health  insurance,  and no certificate thereunder, shall be delivered or
issued for delivery in this state unless it conforms to the requirements
of section three thousand two hundred twenty-one  of  this  chapter  and
with  the  exception  of  a group policy or contract of insurance issued
pursuant to article nine of the workers'  compensation  law,  unless  it
conforms to the requirements of subsection (c) of this section.
(c)  (1)  No  policy of group accident, group health or group accident
and health insurance shall be delivered or issued for delivery  in  this
state unless it conforms to one of the following descriptions:
(A)  A  policy  issued to an employer or to a trustee or trustees of a
fund established by an employer, which employer or trustee  or  trustees
shall  be  deemed the policyholder, insuring with or without evidence of
insurability satisfactory to the insurer, employees  of  such  employer,
and  insuring,  except as hereinafter provided, all of such employees or
all of any class or classes thereof determined by conditions  pertaining
to  the  employment  or  a combination of such conditions and conditions
pertaining to the family status of the employee, for insurance  coverage
on  each  person  insured  based  upon  some  plan  which  will preclude
individual selection. However, such a plan may permit a  limited  number
of  selections by employees if the selections offered utilize consistent
plans of coverage for individual group members  so  that  the  resulting
plans  of  coverage  are reasonable. The premium for the policy shall be
paid by the policyholder, either from  the  employer's  funds,  or  from
funds  contributed  by  the insured employees, or from funds contributed
jointly by the employer and employees. If all or part of the premium  is
to be derived from funds contributed by the insured employees, then such
policy  must  insure  not  less  than  fifty  percent  of  such eligible
employees or, if less, fifty or more of such employees when such  policy
is  providing  coverage  for  group  hospital, medical, major medical or
similar comprehensive types of expense reimbursed insurance and, for all
other types of group  accident  and  health  insurance,  must  insure  a
minimum  of  fifty percent or five of such eligible employees, whichever
is fewer.
(B) A policy issued to a trustee or trustees of a fund established by,
or participated in, by the employer  members  of  a  trade  association,
which trustees shall be deemed the policyholder, for the sole benefit of
the  employees of such employers, the policy must conform subject to the
following requirements:
(i) The policy may be issued only if:
(I)  the  association has been in existence for at least two years and
was formed for purposes principally other than obtaining insurance, and
(II) the participating employers, meaning such employer members  whose
employees  are to be insured, constitute at date of issue at least fifty
percent of the total employers eligible to participate, unless the total
number of persons covered at date of issue exceeds six hundred, in which
event such participating employers must constitute at least  twenty-five
percent   of   such  total  employers,  in  either  case  omitting  from
consideration any employer whose employees are already insured  under  a
similar group accident and health insurance policy.
(ii)  The persons eligible for insurance under the policy shall be all
of the employees of the participating employers, or all of any class  or
classes thereof determined by conditions pertaining to their employment.
(iii)  The  premium  for  the  policy  shall be paid by the trustee or
trustees either from funds  contributed  by  the  employers  or  by  the
employees;  or  funds  contributed  jointly  by  the  employers  and the
employees. A policy on which no part of the premium so payable is to  be
derived  from funds contributed by the insured employees must insure all
eligible employees.
(iv) The policy must cover at least fifty employees at date of issue.
(v) The insurance coverage under the policy must be  based  upon  some
plan  precluding  individual selection either by the employees or by the
policyholder or the employer. However, such a plan may permit  a  number
of  selections  by  the  employer  if  the  selections  offered  utilize
consistent plans of coverage so the  resulting  plans  of  coverage  are
reasonable.  Furthermore,  such  a  plan  may permit a limited number of
selections by employees if the  selections  offered  utilize  consistent
plans  of  coverage  for  individual group members so that the resulting
plans of coverage are reasonable.
(C) A policy issued to a  labor  union,  which  shall  be  deemed  the
policyholder,   insuring,  with  or  without  evidence  of  insurability
satisfactory to the insurer, members of such union and insuring,  except
as  hereinafter  provided all of such members or of any class or classes
thereof determined by  conditions  pertaining  to  their  employment  or
membership  in the union or both for amounts of insurance on each person
insured based  on  a  plan  precluding  individual  selection,  provided
however,  such  a  plan  may  permit  a  limited number of selections by
members if the selections offered utilize consistent plans  of  coverage
for individual group members so that the resulting plans of coverage are
reasonable, and not less than fifty percent of all eligible union or, if
less, fifty or more of such eligible members are insured.
(D) A policy issued to a trustee or trustees of a fund established, or
participated  in,  by  two  or  more  employers  or by one or more labor
unions, or by one or more employers and one or more labor unions,  which
trustee  or  trustees  shall  be  deemed  the  policyholder,  to  insure
employees of the employers or members of the unions for the  benefit  of
persons other than the employers or the unions, subject to the following
requirements:
(i)  The  persons eligible for insurance shall be all of the employees
of the employers or all of the members of the  unions,  or  all  of  any
class  or  classes  thereof determined by conditions pertaining to their
employment, or to membership in the unions, or to both.
(ii) The premium for the policy  shall  be  paid  by  the  trustee  or
trustees  either  wholly  from  funds  contributed  by  the  employer or
employers of the insured person or by the union or unions, or  by  both,
or  jointly from such funds and funds contributed by the insured persons
specifically for their insurance or from contributions  by  the  insured

persons.  A  policy on which all or part of the premium is to be derived
from funds contributed by the insured  persons  specifically  for  their
insurance  may be placed in force only if it insures not less than fifty
percent of the then eligible persons, or, if less, fifty or more of such
eligible  persons  excluding  any  as  to  whom  evidence  of individual
insurability is not satisfactory to the insurer. A policy  on  which  no
part  of  the  premium  is  to  be derived from funds contributed by the
insured  persons  specifically  for  their  insurance  must  insure  all
eligible  persons,  excluding  any  as  to  whom  evidence of individual
insurability is not satisfactory to the insurer.
(iii) The policy shall insure at least fifty persons at date of issue,
except that if part of the premium is to be derived  from  funds  to  be
contributed  by the insured persons specifically for their insurance the
policy shall insure at least one hundred employees or members at date of
issue.
(iv) The insurance coverage under the policy shall be based upon  some
plan precluding individual selection either by the insured persons or by
the  policyholders,  employers,  or  unions.  However, with respect to a
policyholder, employer or union,  such  plan  may  permit  a  number  of
selections  by  the  policyholder,  employer or union, if the selections
offered utilize consistent plans of coverage so that the resulting plans
of coverage are reasonable.  Furthermore,  such  a  plan  may  permit  a
limited  number  of  selections  by  insured  persons  if the selections
offered utilize  consistent  plans  of  coverage  for  individual  group
members so that the resulting plans of coverage are reasonable.
(v) With respect to a policy issued to a trustee or trustees of a fund
established by one or more labor unions, or by one or more employers and
one  or  more  labor  unions  the  proposed insured must submit, and the
insurer must obtain, a written certification that a reasonable number of
comparative bids have been obtained from  different  insurers  and  that
such  bids have been considered by the trustees before making a decision
concerning which bid  to  accept.  Such  decision  must  be  made  at  a
trustees'  meeting  held on a date certain, and a copy of the minutes of
such meeting must be attached to such certification.
(E) A policy issued to  a  creditor,  vendor,  (including  the  parent
holding  company of such creditor or vendor), trustee, trustees or agent
insuring a group of debtors  or  vendees,  (including  coverage  on  the
spouse of a debtor or vendee), all as defined and set forth in paragraph
three  of subsection (b) of section four thousand two hundred sixteen of
this article and under the same conditions and limitations  and  subject
to  the  definitions  as  specified therein; provided, however, that the
amount  of  indemnity  payable  with  respect  to  any  person   insured
thereunder shall not at any time exceed:
(i)  in  all cases except as hereinafter provided the lesser of thirty
thousand dollars and the amount of unpaid indebtedness due from  or  the
amount of the purchase price unpaid by such person;
(ii)  in  the  case  of  a  loan  commitment pursuant to a program for
defraying the cost of attendance of a student at a college or university
or at an elementary or secondary school providing education required for
minors as described in said paragraph, the  lesser  of  thirty  thousand
dollars  and  the  total of the unpaid balance of the scheduled periodic
payments whether due or not due and the amount of any  outstanding  loan
commitment pursuant to such a program; or
(iii)  in the case of a transaction secured by a real estate mortgage,
the lesser of the sum of seventy-five thousand dollars and the amount of
the indebtedness so secured.
(F) A policy issued to a social services district pursuant to  section
three hundred sixty-seven-a of the social services law.
(G) A policy issued to the state of New York insuring, with or without
evidence of individual insurability satisfactory to the insurer, persons
who  are  managerial or confidential employees, or retired managerial or
confidential employees, of  governments  or  public  employers  for  the
purposes  of  article fourteen of the civil service law. The state shall
be deemed to be the policyholder. With respect  to  its  employees,  the
state  and  each other participating government or public employer shall
be deemed to be the employer. The premiums on such policy may be paid by
the employer, by  the  employees,  or  by  the  employer  and  employees
jointly.  If  the  premiums are derived from funds contributed wholly by
the employer, the policy must insure all eligible employees. If  all  or
part  of  the premium is to be derived from funds contributed by insured
employees, then such policy must insure not less than forty  percent  of
such  employees,  the  calculation  being  with respect to each employer
individually. The insurance coverage may be  based  upon  a  plan  which
permits  a limited number of selections by the employees. The provisions
of subsections (d), (h), (i) and (j) hereof shall not apply to a  policy
issued pursuant to this subparagraph.
(H)  A policy issued to an association, or to a trustee or trustees of
a fund established, created or maintained for the benefit of members  of
one  or  more  associations, all of whose eligible members have the same
profession, trade or occupation, which association or associations  have
been  organized  and  maintained  in good faith for purposes principally
other than that of obtaining insurance and have been in active existence
for at least two years. The policy shall insure members, or employees of
members, of such association or associations for the benefit of  persons
other  than  employers  and  the  association  or  associations,  or any
officials, representatives, trustees or agents thereof and shall provide
for the issuance of  a  certificate  to  the  persons  insured  or  such
beneficiary  as  evidence  of  such  insurance. The members or employees
eligible for the insurance under the policy shall be all the members, or
all the members and their employees, or all  of  any  class  or  classes
thereof  determined  by  conditions pertaining to their employment or to
association membership or both. The premiums for  the  policy  shall  be
paid  from  association or members' funds, or partly from such funds and
partly from funds contributed by the insured individuals, or from  funds
wholly  contributed by the insured individuals. A policy on which all or
part of the premium is to be  derived  from  funds  contributed  by  the
insured  individuals  specifically  for  their  insurance must insure at
least fifty percent of the then eligible individuals or a minimum of two
hundred individuals,  whichever  is  less,  excluding  any  as  to  whom
evidence  of individual insurability is not satisfactory to the insurer.
A policy on which no part of the premium is to  be  derived  from  funds
contributed  by the insured individuals specifically for their insurance
must cover all eligible individuals, excluding any as to  whom  evidence
of  individual insurability is not satisfactory to the insurer. In every
case the policy must cover at least one hundred individuals at  date  of
issue.  The  insurance  coverage  on  employees insured under the policy
shall be based upon some plan precluding individual selection.  However,
with  respect  to such fund, or association or associations, such a plan
may  permit  a  number  of  selections  by  the  fund,  association   or
associations  if  the  selections  offered  utilize  consistent plans of
coverage so  that  the  resulting  plans  of  coverage  are  reasonable.
Furthermore,  such  a  plan  may  permit  a limited number of selections
offered by employees  or  members  if  the  selections  offered  utilize
consistent  plans  of  coverage for individual group members so that the
resulting plans of coverage are reasonable.  If  a  policy  dividend  is
declared or a reduction in rate is made under such a policy, the excess,

if  any,  of the aggregate dividends or rate reductions under the policy
over the aggregate expenditure for insurance under such policy made from
association or employer funds, including expenditures made in connection
with administration of such policy, shall be applied by the policyholder
for  the  sole  benefit  of  the  insured  individuals.  A policy issued
pursuant to this subparagraph shall provide a  conversion  privilege  no
less favorable than that provided for in subsection (e) of section three
thousand two hundred twenty-one of this chapter.
(I)  A policy insuring persons employed under 32 U.S.C. § 709, members
of the national guard on full-time training duty under title 32  of  the
United  States Code, or on active duty or active duty for training under
title 10 of the United States Code, under the full-time manning program,
issued to the adjutant general, who shall be deemed the policyholder, or
to a trustee or trustees of a fund established, created,  or  maintained
for  the  benefit of such individuals insured, which trustee or trustees
shall be deemed the policyholder, the premium of which is to be paid  by
the  individuals  insured  either directly or by deduction from wages or
salary. The policy must insure at least fifty percent or four hundred of
the individuals eligible for such insurance,  whichever  is  less.  Such
policy  shall  provide  for  the  payment of benefits, to the individual
insured or to some  beneficiary  or  beneficiaries  other  than  to  the
aforesaid  trustees  or  the  adjutant  general.  The  policy shall also
provide for the issuance of a certificate of insurance to the individual
insured or to such beneficiary,  as  evidence  of  such  insurance.  The
insurance  coverage  may  be  based  upon a plan which permits a limited
number of selections by the insured member, if  the  selections  offered
utilize  consistent  plans  of  coverage  so that the resulting plans of
coverage are reasonable.
(J) Under a policy issued by  an  insurer  to  a  trustee  or  to  the
trustees  of  a trust, established or adopted by two or more individuals
who are entitled to a right of conversion, pursuant to subsection (e) of
section three thousand two hundred twenty-one of this chapter  or  under
the terms of a contract covering residents of New York, which trustee or
trustees  shall  be  deemed  to  be  the  policyholder,  to  insure such
individuals, subject to the following requirements:
(i) The policy must cover at least twenty-five individuals during  the
first policy year.
(ii) The benefits provided under the policy shall be those required by
subsection  (f),  (g)  or  (h)  of  section  three  thousand two hundred
twenty-one of this chapter.
(iii) In lieu of the coverage requirements of subsections (k) and  (l)
of  section  three  thousand  two hundred twenty-one of this chapter and
subparagraphs (B), (C), (D), (E) and (F) of paragraph four of subsection
(f) of this section, the coverage requirements of paragraphs one through
ten of subsection (i) and the requirements of subsection (j) of  section
three  thousand  two hundred sixteen of this chapter shall be applicable
to such policy.
(iv) If a policy dividend is declared or a reduction in rate  is  made
under  such  a  policy,  it shall be applied by the policyholder for the
sole benefit of the insured individuals.
(K) A policy issued to an association or the trustee or trustees of  a
trust  established,  or participated in, by one or more associations, to
insure association members, subject to the following:
(i) Each association shall have:
(I) A minimum of two hundred insured members at the policy's  date  of
issue;
(II)  Been  organized  and  maintained  in  good  faith  for  purposes
principally other than that of obtaining insurance;
(III) Been in active existence for at least two years; and
(IV) A constitution and by-laws which provide that:
(aa)  The  association hold regular meetings not less than annually to
further the purposes of the association;
(bb) The  association  collect  dues  or  solicit  contributions  from
members; and
(cc)  The  members  have  voting  privileges and representation on the
governing board and committees.
(ii) The premium for the policy shall be paid by  the  association  or
the  trustees either wholly from funds contributed by the association or
by the insured individuals, or from funds  contributed  jointly  by  the
association  and  insured  individuals. A policy on which no part of the
premium  is  to  be  derived  from  funds  contributed  by  the  insured
individuals  specifically  for  their insurance must insure all eligible
individuals excluding any as to whom evidence of individual insurability
is not satisfactory to the insurer.
(iii) The amount of insurance under the policy  shall  be  based  upon
some  plan precluding individual selection either by the insured members
or by the association. However, with respect to an association,  such  a
plan  may  permit  a  number  of  selections  by  the association if the
selections offered utilize consistent plans of  insurance  so  that  the
resulting plans of coverage are reasonable. Furthermore, such a plan may
permit  a  limited  number  of  selections  by  insured  members  if the
selections offered utilize consistent plans of insurance for  individual
group members so that the resulting plans of coverage are reasonable.
(iv) Except as provided in subsection (e) of this section, such policy
shall  provide  for  the payment of benefits to the person insured or to
some beneficiary or beneficiaries other  than  the  association  or  any
officials, representatives, trustees or agents thereof and shall provide
for the issuance of a certificate to the association for delivery to the
member or such beneficiary, as evidence of such insurance.
(v)  The  premiums  charged  must  be  reasonable  in  relation to the
benefits provided.
(L) A policy issued to any organization, or the trustee or trustees of
a trust established,  or  participated  in,  by  one  or  more  of  such
organizations, to insure certain persons subject to the following:
(i) The organization must be:
(I)  A bank, retailer or other issuer of a credit card, charge card or
payment card which can be used to buy goods or services, and the  policy
must insure holders of that card;
(II)  A bank, savings and loan association, credit union, mutual fund,
money market fund, stockbroker or other  similar  financial  institution
regulated  by  state  or  federal  law,  and  the policy must insure the
depositors, account holders or members of that institution.
(ii) Except for a  credit  union  where  the  premium  shall  be  paid
entirely from funds contributed by the credit union, the organization or
organizations shall have a minimum of two hundred insured persons at the
policy's date of issue.
(iii)  The premium for the policy shall be paid by the organization or
trustees either wholly from funds contributed by the organization or  by
the  insured  individuals,  or  from  funds  contributed  jointly by the
organization and insured individuals. A policy on which no part  of  the
premium  is  to  be  derived  from  funds  contributed  by  the  insured
individuals specifically for their insurance  must  cover  all  eligible
individuals excluding any as to whom evidence of individual insurability
is not satisfactory to the insurer.
(iv)  The  amounts  of  insurance under the policy shall be based upon
some plan precluding individual selection either by the insured  persons

or by the organization. However, with respect to an organization, such a
plan  may  permit  a  number  of  selections  by the organization if the
selections offered utilize consistent plans of  insurance  so  that  the
resulting plans of coverage are reasonable. Furthermore, such a plan may
permit  a  limited  number  of  selections  by members if the selections
offered utilize consistent plans of grading the amounts of insurance for
individual group members so that the resulting  plans  of  coverage  are
reasonable.
(v)  Except as provided in subsection (e) of this section, such policy
shall provide for the payment of benefits to the person  insured  or  to
some  beneficiary  or  beneficiaries other than the organization, or any
officials,  representatives,  trustees  or  agents  thereof,  and  shall
provide for the issuance of a certificate to the persons insured or such
beneficiary, as evidence of such insurance.
(vi)  The  premium  charged  must  be  reasonable  in  relation to the
benefits provided.
(M) A policy  issued  to  insure  any  other  group  approved  by  the
superintendent  upon a finding that: (i) there is a common enterprise or
economic or social affinity or relationship; (ii) the  premiums  charged
are  reasonable  in  relation  to  the  benefits provided; and (iii) the
issuance of the policy would  result  in  economies  of  acquisition  or
administration, would be actuarially sound, and would not be contrary to
the  best  interest  of  the public. The superintendent shall promulgate
regulations setting forth any such groups that  have  been  accepted  as
qualifying pursuant to this subparagraph.
(N) A policy issued to a continuing care retirement community covering
at least fifty percent of the residents of the community, in conjunction
with  a  continuing  care  retirement contract described in section four
thousand six hundred one of the public health law.
(2) For the purpose of complying with the  participation  requirements
prescribed  in subparagraphs (A), (B), (C), (D) and (G) of paragraph one
of this  subsection,  the  provisions  of  this  subsection  are  to  be
construed as permitting the issuance of more than one policy or contract
when offered as alternatives to the eligible employees or members.
(3)  (A) Any dividend hereafter apportioned on any participating group
insurance policy, or any rate reduction hereafter made or  continued  on
any  non-participating group policy for the first or any subsequent year
of insurance under any such policy heretofore or hereafter issued  under
subparagraph (K), (L) or (M) of paragraph one of this subsection, may be
applied  to  reduce  the policyholder's part of the cost of such policy,
except that the excess, if any, of the insured's aggregate  contribution
under the policy over the net cost (gross premium less dividends or rate
reductions)  of  the insurance shall be applied at the discretion of the
insurer either as a cash  payment  to  the  insured  or  to  reduce  the
insured's  premium,  unless  the  insured  assigns  the dividend or rate
reduction to the policyholder.  If  a  dividend  or  rate  reduction  is
payable  upon  termination  of  the policy the insurer shall either make
payment to the  insured  or  to  the  policyholder  upon  receipt  of  a
certification  from the policyholder that the dividend or rate reduction
will be distributed by the policyholder to the insureds  or  applied  to
reduce the insured's premium.
(B)  The  provisions of subparagraph (A) of this paragraph shall apply
to New York residents  insured  under  a  policy  issued  in  any  other
jurisdiction  to  a  group  which  is  not  of  the  type  described  in
subparagraphs (A) through (J) of paragraph one of this subsection.
(d) (1) In this section, for the purpose of insurance other  than  for
group hospital, medical, major medical or similar comprehensive-types of
expense   reimbursed   insurance  hereunder:  "employees"  includes  the

officers, managers, employees and retired employees of the employer  and
of  subsidiary  or  affiliated corporations of a corporate employer, and
the individual proprietors, partners, employees and retired employees of
affiliated  individuals  and  firms  controlled  by the insured employer
through stock ownership,  contract  or  otherwise;  "employees"  may  be
deemed  to include the individual proprietor or partners if the employer
is an individual proprietor or a partnership; and "employees" as used in
subparagraph (A) of paragraph one of  subsection  (c)  hereof  may  also
include  the  directors  of the employer and of subsidiary or affiliated
corporations of a corporate employer.
(2) In this section "employer" may include any municipal  corporation,
or  the proper officers, as such, of any unincorporated municipality, or
any  department  of  such  corporation  or  municipality  determined  by
conditions pertaining to the employment.
(3) In this section, for the purpose of group hospital, medical, major
medical  or  similar comprehensive-types of expense reimbursed insurance
hereunder:
(A) "employee" shall have  the  meaning  set  forth  in  the  Employee
Retirement Income Security Act of 1974, 29 U.S.C. § 1002(6); and
(B)  "full-time employee" means with respect to any month, an employee
who is employed on average for at least thirty hours of service per week
as set forth in section 4980H(c)(4) of the  internal  revenue  code,  26
U.S.C. § 4980H(c)(4), or any regulations promulgated thereunder.
(e)  The  benefits  payable  under  the policy shall be payable to the
employee or other insured member of the group or to some beneficiary  or
beneficiaries  designated  by  him,  other  than  the  employer  or  the
association or  any  officer  thereof  as  such;  but  if  there  is  no
designated  beneficiary  as to all or any part of the insurance benefits
at the death of the employee or member, then the  benefits  payable  for
which  there is no designated beneficiary shall be payable to the estate
of the employee or member, except that the insurer may in such case,  at
its  option,  pay  such  insurance  to  any one or more of the following
surviving relatives of the employee or member:  wife,  husband,  mother,
father,  child or children, brothers or sisters; and except that payment
of benefits for expenses  incurred  on  account  of  hospitalization  or
medical  or  surgical aid, may be made by the insurer to the hospital or
other person or persons furnishing such aid, and the payment of benefits
for expenses incurred  on  account  of  hospitalization  or  medical  or
surgical  aid  after  the  death  of  an employee or other member of the
insured group for such person's spouse,  child  or  children,  or  other
person  chiefly  dependent  upon  him for support or maintenance, may be
made by the insurer to the surviving spouse or otherwise as  the  policy
may  provide.  Payment  so made shall discharge the insurer's obligation
with respect to the amount of insurance so paid.
(f) (1) (A) Any policy  of  group  accident,  group  health  or  group
accident  and health insurance may include provisions for the payment by
the insurer of benefits for expenses incurred on  account  of  hospital,
medical  or  surgical  care  or  physical  and  occupational  therapy by
licensed physical and occupational therapists upon the  prescription  or
referral  of a physician for the employee or other member of the insured
group, the employee's or member's spouse,  the  employee's  or  member's
child  or children, or other persons chiefly dependent upon the employee
or member for support and maintenance; provided that:
(i) a policy of hospital,  medical,  surgical,  or  prescription  drug
expense insurance that provides coverage for children shall provide such
coverage  to  a  married  or  unmarried  child  until  attainment of age
twenty-six, without regard to financial dependence, residency  with  the
employee  or member, student status, or employment, except a policy that

is a grandfathered health plan may,  for  plan  years  beginning  before
January first, two thousand fourteen, exclude coverage of an adult child
under  age twenty-six who is eligible to enroll in an employer-sponsored
health  plan other than a group health plan of a parent. For purposes of
this item, "grandfathered health plan" means  coverage  provided  by  an
insurer  in  which an individual was enrolled on March twenty-third, two
thousand ten for as long as the coverage maintains grandfathered  status
in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
§ 18011(e); and
(ii) a policy under which coverage terminates at a specified age shall
not  so terminate with respect to an unmarried child who is incapable of
self-sustaining employment by reason of  mental  illness,  developmental
disability,  as  defined in the mental hygiene law, or physical handicap
and who became so incapable prior to attainment  of  the  age  at  which
coverage  would  otherwise  terminate  and who is chiefly dependent upon
such employee or member for support and maintenance, while the insurance
of the employee or member remains in force and the child remains in such
condition, if the insured employee or member has within thirty-one  days
of  such  child's  attainment  of the termination age submitted proof of
such child's incapacity as described herein.
(B) In addition to  the  requirements  of  subparagraph  (A)  of  this
paragraph,  every insurer issuing a group policy of hospital, medical or
surgical expense  insurance  pursuant  to  this  section  that  provides
coverage  for  children,  must  make  available  and if requested by the
policyholder, extend coverage under the policy  to  an  unmarried  child
through  age  twenty-nine, without regard to financial dependence who is
not insured by or  eligible  for  coverage  under  any  employer  health
benefit  plan as an employee or member, whether insured or self-insured,
and who lives, works or resides in New York state or the service area of
the insurer. Such coverage shall be made available at the  inception  of
all  new  policies  and  with  respect  to  all  other  policies  at any
anniversary date. Written notice of the availability  of  such  coverage
shall  be  delivered  to the policyholder prior to the inception of such
group policy and annually thereafter.
(2) Notwithstanding any rule, regulation or law to the  contrary,  any
family coverage available under this article shall provide that coverage
of  newborn infants, including newly born infants adopted by the insured
or subscriber if such insured or subscriber takes  physical  custody  of
the  infant  upon  such  infant's  release from the hospital and files a
petition pursuant to section  one  hundred  fifteen-c  of  the  domestic
relations  law within thirty days of birth; and provided further that no
notice of revocation to the adoption has been filed pursuant to  section
one  hundred  fifteen-b of the domestic relations law and consent to the
adoption has not been revoked, shall be effective  from  the  moment  of
birth  for injury or sickness including the necessary care and treatment
of  medically  diagnosed  congenital  defects  and  birth  abnormalities
including premature birth, except that in cases of adoption, coverage of
the initial hospital stay shall not be required where a birth parent has
insurance  coverage  available  for  the  infant's  care. In the case of
individual coverage the insurer must also permit the person to whom  the
certificate is issued to elect such coverage of newborn infants from the
moment of birth. If notification and/or payment of an additional premium
or  contribution  is  required  to make coverage effective for a newborn
infant, the coverage may provide that such notice and/or payment be made
within no less than thirty days of the day of  birth  to  make  coverage
effective  from the moment of birth. This election shall not be required
in the case of student insurance or where  the  group's  plan  does  not
provide coverage for children.
(3)  A  policy  under  which  coverage  of a dependent spouse or named
insured would terminate upon such spouse or named insured attaining  the
age  prescribed  in subchapter XVIII of the federal Social Security Act,
42 U.S.C. §§ 1395 et seq. ("Medicare"), as the age of first  eligibility
for  the  benefits  provided by such law shall not so terminate, if such
dependent spouse is not then eligible for all of such  benefits  for  as
long  as  the  policy remains in force and such dependent spouse remains
ineligible to receive any of such "Medicare" benefits, provided proof of
such ineligibility is submitted to the insurer within thirty-one days of
the date notice of termination of coverage be sent by first  class  mail
by  the  insurer to the last known address of the policyholder. Any such
policy may provide for the continuation of such benefit  provisions,  or
any  part  or  parts thereof, after the exhaustion of the benefit rights
with respect to the employee or other member of the  insured  group,  or
after  the death of an active or retired employee or other member of the
insured group.
(4) Notwithstanding any provisions of  a  policy  of  group  accident,
group  health  or  group  accident  and  health insurance, whenever such
policy provides for reimbursement for:
(A) any physical and occupational therapy service which is within  the
lawful  scope  of  practice  of  a  licensed  physical  and occupational
therapist,  a  subscriber  to  such  policy   shall   be   entitled   to
reimbursement for such service, whether the said service is performed by
a  physician or licensed physical and occupational therapist pursuant to
prescription or referral by a physician;
(B) any podiatrical service  which  is  within  the  lawful  scope  of
practice  of a licensed podiatrist, a subscriber to such policy shall be
entitled to reimbursement for such service, whether the said service  is
performed  by a physician or licensed podiatrist and when such policy or
any certificate issued thereunder is delivered or  issued  for  delivery
without this state by an authorized insurer, covered persons residing in
this  state shall be entitled to reimbursement for podiatric services as
herein provided;
(C) any optometric  service  which  is  within  the  lawful  scope  of
practice of a licensed optometrist, a subscriber to such policy shall be
entitled  to reimbursement for such service, whether the said service is
performed by a physician or licensed optometrist and when such policy or
any certificate issued thereunder or delivered or  issued  for  delivery
without  the state by an authorized insurer so provides, covered persons
residing in this state shall  be  entitled  to  reimbursement  for  that
service  which  may  be  rendered  by an optometrist as herein provided.
Unless  such  policy  shall  otherwise  provide,  there  shall   be   no
reimbursement  for ophthalmic materials, lenses, spectacles, eyeglasses,
and/or appurtenances thereto;
(D) any dental service which is within the lawful scope of practice of
a licensed dentist, a subscriber to such policy  shall  be  entitled  to
reimbursement  for such service whether the said service is performed by
a physician or licensed dentist and when such policy or any  certificate
issued  thereunder or delivered or issued for delivery without the state
by an authorized insurer so provides, covered persons residing  in  this
state  shall  be entitled to reimbursement for dental services as herein
provided;
(E) The services of licensed health professionals  who  can  bill  for
services, a subscriber to such policy shall be entitled to reimbursement
for   such  service  provided  pursuant  to  a  clinical  practice  plan
established pursuant to subdivision fourteen of section two hundred  six
of the public health law;
(F) any speech-language pathology or audiology service which is within
the  lawful  scope  of  practice  of  a  duly  licensed  speech-language
pathologist or  audiologist,  a  subscriber  to  such  policy  shall  be
entitled  to  reimbursement for such service whether the said service is
performed by a physician or duly licensed speech-language pathologist or
audiologist,  provided  however,  that nothing contained herein shall be
construed to impair any terms of such  policy  which  may  require  said
service  to  be  performed  pursuant to a medical order, or a similar or
related service of a physician, in  which  case  coverage  need  not  be
provided  for  any  tests,  evaluations  or  diagnoses  if  such  tests,
evaluations or diagnoses have already been  provided  by  or  through  a
physician  within  twelve  months  of  the  referral  or  order from the
physician. However, nothing herein shall be construed as  preventing  an
insurer  from  covering  more  than one test or evaluation provided by a
speech-language pathologist or audiologist within a twelve-month  period
where  such  test  or  evaluation is ordered by a physician as medically
necessary. Nor shall anything herein be  construed  as  prohibiting  the
limitation  of such services, where covered, to specified settings other
than offices,  such  as  hospitals  or  to  services  provided  by  such
professionals  as  part  of a home care agency's services; and when such
policy or any certificate issued thereunder is delivered or  issued  for
delivery  without  the  state  by an authorized insurer, covered persons
residing  in  this  state  shall  be  entitled  to   reimbursement   for
speech-language pathology or audiology service as herein provided.
(G)  psychiatric  or  psychological  services or for the diagnosis and
treatment of  mental,  nervous,  or  emotional  disorders  or  ailments,
however  defined  in  such  policy, a subscriber to such policy shall be
entitled to reimbursement for such psychiatric or psychological services
or diagnosis or treatment whether performed by a physician, psychiatrist
or a certified and registered psychologist when  the  services  rendered
are  within  the lawful scope of their practice, and when such policy or
any certificate issued thereunder is delivered or  issued  for  delivery
without this state by an authorized insurer, covered persons residing in
this  state  shall  be  entitled to reimbursement for such diagnosis and
treatment by a physician, psychiatrist or  a  certified  and  registered
psychologist as hereinabove provided; and
(H)  any  service  which  is  within the lawful scope of practice of a
licensed chiropractor, a subscriber to such policy shall be entitled  to
reimbursement  for  such  service  when  such  service is performed by a
licensed chiropractor.
(g) (1) No domestic insurer and no  foreign  or  alien  insurer  doing
business  in  this  state  shall hereafter issue, within or without this
state, any policy of group accident, group health or group accident  and
health  insurance,  other  than a policy issued pursuant to subparagraph
(J) of paragraph one of subsection (c) hereof, which shall not appear to
be self-supporting on reasonable assumptions as to  morbidity  or  other
appropriate claim rate, interest and expense.
(2) The superintendent may require all such insurers to file with him,
either  directly or through such agency as he may approve, at such times
and in such manner and for such forms of  insurance  as  he  prescribes,
their  experience  under  such  forms  and such other information as the
superintendent may deem necessary or expedient for the administration of
this section and such experience and other information shall be compiled
and analyzed as the superintendent prescribes.
(h) (1) Each domestic insurer and each foreign or alien insurer  doing
business  in this state shall file with the superintendent its schedules
of  premium  rates,  rules  and  classification  of  risks  for  use  in
connection  with  the  issuance of its policies of group accident, group

health or group accident and health  insurance,  and  of  its  rates  of
commissions,  compensation  or  other  fees  or allowances to agents and
brokers pertaining to the solicitation or sale of such insurance and  of
such fees or allowances, exclusive of amounts payable to persons who are
in  the  regular employ of the insurer, other than as agent or broker to
any individuals, firms or  corporations  pertaining  to  such  class  of
business,  whether  transacted  within  or  without  the  state. A group
accident and health insurance policy  providing  disability  and  family
leave benefits pursuant to article nine of the workers' compensation law
shall be subject to the requirements of subsection (n) of this section.
(2)  An insurer may revise such schedules from time to time, and shall
file such revised schedules with the superintendent.
(3) No insurer shall issue any policy of group accident, group  health
or  group accident and health insurance the premium rate under which for
the first policy year is less than that determined by the  schedules  of
such  insurer  as then on file with the superintendent; nor shall it pay
to the agent or agents or to a broker or brokers for the solicitation or
sale of such policy or for any other purpose related to such policy  any
commission,  compensation  or other fees or allowances in excess of that
determined on the basis of the schedules of such insurer as then on file
with the  superintendent;  nor  shall  such  insurer  pay  for  services
pertaining  to  the service or administration thereof to any individual,
firm or corporation any fees, commissions or  allowances  in  excess  of
that determined on the basis of the schedules of such insurer as then on
file with the superintendent or for such services not rendered in behalf
of  such insurer; provided, however, that nothing contained herein shall
apply to or affect the computation of  dividends  or  experience  rating
credits.
(4) Nothing herein shall prohibit the state insurance fund from taking
into account peculiar hazards of individual risks in establishing higher
premium  rates  to be charged for insurance providing for the payment of
disability and family leave benefits in accordance with article nine  of
the workers' compensation law.
(i)  (1)  Whenever  the superintendent determines, after notice to all
insurers doing the business of group accident,  group  health  or  group
accident  and health insurance in this state and a hearing at which such
insurers may present pertinent statistics and other available data, that
it is advisable in  the  administration  of  this  section  to  adopt  a
schedule of minimum premium rates for any type of benefit provided under
policies  of  group  accident, group health or group accident and health
insurance, the superintendent shall thereupon file in his office such  a
schedule  which  shall  include a description of the benefit or benefits
for which minimum premium rates are being prescribed and of the  minimum
premium rates applicable thereto.
(2)  Such  schedule  may be revised by the superintendent from time to
time or withdrawn, after a similar notice and hearing.
(3) The effective date of such schedule, or of any  such  revision  or
withdrawal  thereof, shall be specified by the superintendent. After the
effective date of the first schedule no domestic insurer and no  foreign
or  alien  insurer  doing  business in this state shall issue, within or
without this state, any policy of group accident, group health or  group
accident  and  health  insurance  providing  any  benefit  to  which the
schedule of minimum premium rates then in  effect  applies,  unless  the
premium  for  such  benefit  for the first policy year shall be at least
equal to that determined on the basis of such schedule.
(4) If an insurer desires to provide a benefit  of  the  same  general
type  as,  but  not  identical  with, one described in said schedule, it
shall before issuing any policy providing  for  such  different  benefit

obtain  the  superintendent's  approval  of  the  premium proposed to be
charged therefor. The superintendent shall grant such approval if he  is
satisfied  that  the  proposed premium is not less than that which would
have to be charged consistent with the schedule of minimum premium rates
then in effect.
(j)  (1) Anything in this chapter to the contrary notwithstanding, any
policy of group accident, group health  or  group  accident  and  health
insurance  may  provide for readjustment of the rate of premium based on
the experience thereunder at the  end  of  the  first  year  or  of  any
subsequent  year  of  insurance thereunder, and such readjustment may be
made retroactive only for such policy year.
(2) Any such rate readjustment shall be computed on a basis  which  is
equitable  to  all  group  accident,  group health or group accident and
health insurance policies.
(3) Any refund under any plan for readjustment of the rate of  premium
based on the experience under group policies and any dividend paid under
such policies may be used to reduce the employer's contribution to group
insurance  for  the  employees of the employer, and the excess over such
contribution by the employer shall be applied by the  employer  for  the
sole benefit of the employees.
(k) Whenever an insurer elects to terminate any policy as described in
this  section,  such insurer shall include in his notification of intent
to   terminate   such   policy   reference   to    the    policyholder's
responsibilities  under  section two hundred seventeen of the labor law.
Whenever any policy as described in this section terminates as a  result
of  a  default  in  payment  of  premiums,  the insurer shall notify the
policyholder that termination has  occurred  or  will  occur  and  shall
include   in   his   notification   reference   to   the  policyholder's
responsibilities under section two hundred seventeen of the labor law.
(l)  The  superintendent  shall  promulgate  rules   and   regulations
concerning  the  method,  manner  and time for a policyholder to provide
written notice of termination to the certificate holders as required  by
subdivision three of section two hundred seventeen of the labor law.
(m) This section shall not apply to any contract issued by any article
forty-three  corporation  except  as  provided  in section four thousand
three hundred five of this chapter.
(n)(1)  On  or  before  June  first,  two  thousand   seventeen,   the
superintendent of financial services by regulation, in consultation with
the  chair  of  the  workers'  compensation  board  of this state, shall
determine whether the family leave benefit coverage of a group  accident
and  health  insurance  policy  providing  disability  and  family leave
benefits pursuant to article nine  of  the  workers'  compensation  law,
including  policies  issued  by  the  state  insurance  fund,  shall  be
experience rated or community rated, which may  include  subjecting  the
family  leave  benefit  coverage  of  the  policy  to  a risk adjustment
mechanism. Notwithstanding any law to the contrary,  the  superintendent
shall  establish  the rates for any community rated family leave benefit
coverage and shall  apply  commonly  accepted  actuarial  principles  to
establish  community  rated family leave benefit coverage rates that are
not excessive, inadequate or unfairly discriminatory. On June first, two
thousand seventeen and on September first of each  year  thereafter  the
superintendent  shall  publish  all community rated family leave benefit
rates for the policy period beginning on the following January first.
(2) If the policy is subjected to a  risk  adjustment  mechanism,  the
superintendent   of  financial  services  shall  promulgate  regulations
necessary for the implementation of this subsection in consultation with
the chair of the workers' compensation board of  this  state.  Any  such
risk   adjustment  mechanism  shall  be  administered  directly  by  the

superintendent of financial services of this state, in consultation with
the chair of the workers' compensation board of  this  state,  or  by  a
third  party vendor selected by the superintendent of financial services
in consultation with the chair of the workers' compensation board.
(3)  "Risk  adjustment mechanism" as used in this subsection means the
process used to equalize the per member per month  claim  amounts  among
insurers  in  order  to  protect  insurers from disproportionate adverse
risks.
(o) (1) No contract or agreement between a health plan subject to this
article and a health care provider, other than a residential health care
facility as defined by section twenty-eight hundred one  of  the  public
health law, shall include a provision that:
(A) contains a most-favored-nation provision; or
(B)  restricts  the ability of a corporation, an entity that contracts
with a corporation for a provider network, or a health care provider  to
disclose:  (i) actual claims costs; or (ii) price or quality information
required to be  disclosed  under  federal  law,  including  the  allowed
amount,  negotiated  rates  or  discounts,  or  any  other claim-related
financial  obligations,  including,  but   not   limited   to,   patient
cost-sharing  covered  by  the  provider  contract  to  any  subscriber,
enrollee, group, or other entity receiving health care services pursuant
to the contract, or to any public compilation of reimbursement data such
as the New York all  payer  database  required  by  law  or  regulation,
provided  that  no disclosure shall include protected health information
or other information covered by statutory or other privilege.
(2) For purposes of this subsection,  the  term  "health  plan"  shall
include:  (A)  an  insurer licensed pursuant to this chapter or a health
maintenance organization certified pursuant to article forty-four of the
public health law; and
(B) a third-party administrator, affiliated with an insurer or  health
maintenance organization, who administers a health benefit plan.