2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 19 - Health Services Organizations (§§ 1901 — 1928) › § 1908 - Evidence of coverage and health services fees

(1)
(a) Each subscriber is entitled to an evidence of coverage. If the subscriber obtains coverage through an insurance policy, the insurer shall issue the evidence of coverage. Otherwise, the health services organization shall issue the evidence of coverage.
(b) No form of evidence of coverage or any amendment thereto shall be issued or delivered to any person in Puerto Rico unless it has first been presented to the Commissioner and approved by him. Each such presentation shall be made at least sixty (60) days prior to the issuance, delivery or use. Upon expiration of said sixty (60) days, counting from the date such presentations are received in the Commissioner’s Office, the form presented shall be deemed approved unless previously approved affirmatively or disapproved by order of the Commissioner. The approval of a form by the Commissioner shall constitute a waiver of the remaining term of the waiting period. The Commissioner may extend the period within which he may affirmatively approve or disapprove said form for not more than sixty (60) days notifying said extension before the expiration of the initial sixty (60) day period; Provided, That in case the Commissioner determines that the information furnished in the presentation is insufficient, or the forms presented do not meet any of the provisions of this title or its regulations, and therefore, requests additional information for the pertinent amendments, the term that elapses from the time the Commissioner advises of said requirement until the information or amendments requested are received by the Commissioner shall not be counted in the computation of the above terms.
(c) The coverage evidence shall contain:
(i) Provisions which are not uncertain, unjust, discriminatory, deceptive, disloyal, or which lead to misrepresentations, as defined in § 1915(1) of this title.
(ii) A complete statement of the contract, or a summary, if it concerns a certificate of:
(A) Health care services, insurance and other benefits, if any, to which the subscriber is entitled under a health care plan.
(B) Any limitation on the services, kinds of services, benefits or kinds of benefits, to be offered, including any deductible or co-payments.
(C) Where and in what form the information is available on how to obtain the services.
(D) With relation to individual contracts, the cost, if any, that the subscriber is bound to pay for the health care services and the benefits for compensation or services. With relation to the group plans certificates, an indication of whether it is a contributing or noncontributing plan; and
(E) a clear and simple description of the method used by the health services organization for the complaints of the subscribers.
Any subsequent change may be evidenced in a separate document which shall be sent to the subscribers.
(d) A copy of the coverage evidence form to be used in Puerto Rico, and any amendment thereto, shall be filed and approved as required in clause (b) of this subsection unless they are subject to the approval of the Commissioner under the laws regulating the health insurance, in which case the provisions for the filing and approval of said legislation shall be applicable. Insofar as said provisions do not apply to the requirements of clause (c), said requirements shall apply.
(2)
(a) Every health services organization shall register the rates to be used in any health care plan with the Commissioner before applying them in Puerto Rico. No registration shall be effective until sixty (60) days after the date of its presentation in the Commissioner’s office, unless they are affirmatively approved by him. Said period may be extended by the Commissioner for an additional term which shall not exceed sixty (60) days, if the Commissioner advises the presenter thereof within said waiting period. Provided, That in case the Commissioner determines that the information that was furnished in the presentation is insufficient and therefore, would require additional information, the period of time from the moment the Commissioner informs of such requirement until the information requested is received by him shall not count in the computation of the indicated terms.
(b) Said rates shall be established in accordance with the actuarial principles for several categories of subscribers; Provided, That the fees applicable to a subscriber shall not be determined individually on the basis of health condition. The rates shall not be excessive, inadequate or discriminatory. A certificate by a qualified actuary on the adequacy of the rates, based on reasonable assumption, shall accompany the filing of the rates with the proper information in support of the petition.
(3) The Commissioner shall, within a reasonable time, approve any form if the requirements of subsection (1) are met; and any rate, if the requirements of subsection (2) are met. If the Commissioner disapproves the filing, he shall so notify the applicant, specifying the grounds for his disapproval. Within thirty (30) days from the date of disapproval, the person affected may request a hearing as provided in § 222 of this title. After the lapse of sixty (60) days from the filing of the form or the rate, they shall be considered approved unless the Commissioner has approved or disapproved them affirmatively through order to that effect.
(4) At any time after the applicable review period provided in subsections (1)(b) and (2)(a) of this section, the Commissioner may call a hearing to determine whether the registration meets the established requirements. It shall give notice, in writing, to the presenting health services organization, at least ten (10) days prior to the hearing. If after said hearing the Commissioner determines that the registration does not meet the requirements in this section, he shall issue an order specifying the reasons on which he grounds his decision and indicating the date, within a subsequent reasonable period, on which the registration shall be deemed to be ineffective. Said order shall not affect any contract granted or ratified prior to the expiration of the period stipulated in the order.
(5) In order to determine whether to approve or disapprove a form or rate filed as provided in this section, the Commissioner may request that there be submitted any relevant information he may deem pertinent.
History —Ins. Code, added as § 19.080 on June 2, 1976, No. 113, p. 313, § 1; July 2, 1987, No. 88, p. 337, § 6.