California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2a - Group Disability Policies › Subarticle 3 - Optional Uniform Provisions › Section 2232.34 - Insurance with Other Insurers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Form A.
Reduced Hospital Benefits in Case of Coverage Under the
						California Unemployment Insurance Code. The hospital benefits otherwise payable
						to insured employees hereunder shall be reduced by the amounts of additional
						benefits during hospital confinement to which such employees shall become
						entitled pursuant to the California Unemployment Insurance Code or any
						voluntary plan approved thereunder which is specifically identified in this
						policy or in the application therefor or in a rider attached to this policy
						specifically referring to this provision, as such plan is constituted on the
						effective date of this policy or such rider, as the case may be.
Instructions for Use of Form A
1. The insurer may use this provision only in
					 a policy providing hospital benefits.
2. In lieu of incorporating this uniform
					 provision in the policy, the insurer may, at its option, incorporate the
					 substance or effect thereof, or a provision more favorable to insured
					 employees, in the statement of hospital benefits of the policy by way of an
					 affirmative statement of the benefits applicable to those employees who are
					 also entitled to additional benefits during hospital confinement under the
					 California Unemployment Insurance Code or an existing voluntary plan proved
					 pursuant thereto, or applicable to a period of time for which such additional
					 benefits are payable, or to both. Such affirmative statement of benefits may
					 specifically eliminate or reduce hospital benefits because, or by the amount of
					 the benefits on account of hospitalization to which the employee is entitled as
					 state plan benefits under the California Unemployment Insurance Code to make
					 such equitable adjustment of premium and premium rate for the policy as will
					 after giving effect to the changes in the benefits of the policy resulting from
					 the amendments of the California Unemployment Insurance Code, make such premium
					 and premium rate thereafter commensurate with the premium and premium rate for
					 the benefits theretofore provided by the policy.
Form B. Insurance With Other Insurers, Expense Incurred
						Basis.
If there be other valid coverage, not with this insurer,
						on any individual with respect to whom coverage is provided by this policy,
						providing benefits for the same loss on a provision of service basis or an
						expense incurred basis and of which this insurer has not been given written
						notice prior to the occurrence or commencement of the loss, then the only
						liability under an expense incurred coverage of this policy shall be for such
						proportion of the loss as the amount which would otherwise have been payable
						hereunder plus the total like amount under all such other valid coverages for
						the same loss of which this insurer had notice bears to the total like amounts
						under all valid coverages for such loss, and for the return of each portion of
						the premium paid as shall exceed the prorated portion of the amount of benefits
						so determined. For the purpose of applying this provision when other coverage
						is on a provision of service basis, the "like amount" of such other coverage
						shall be taken as the amount which the services rendered would have cost in the
						absence of such coverage.
Instructions for Use of Form B
(1) The insurer may include Form B in any
					 policy providing benefits upon an expense incurred basis. The insurer may, at
					 its option, include in this provision a definition of "other valid coverage"
					 approved as to form by the commissioner, which definition shall be limited in
					 subject matter to coverage provided by organizations subject to regulation by
					 insurance law or by insurance authorities of this or any other state of the
					 United States or any province of Canada, or by hospital or medical service
					 organizations, and to any other coverage, the inclusion of which may be
					 approved by the commissioner. In the absence of such definition, such term
					 shall not include individual insurance, automobile medical payment insurance or
					 coverage provided by hospital or medical service organizations, or by union
					 welfare plans or employer or employee benefit organizations. For the purpose of
					 applying this provision with respect to any person with respect to whom
					 insurance coverage is provided, any amount of benefit provided for such person
					 pursuant to any compulsory benefit statute (including any workmen's
					 compensation, or employers' liability statute) whether provided by a government
					 agency or otherwise shall in all cases be deemed to be "other valid coverage"
					 of which the insurer has had notice. In applying this provision no third party
					 liability coverage shall be included as "other valid coverage." The insurer may
					 restrict the applicability of this provision by the definition of "other valid
					 coverage" to other group insurance benefits.
Instructions Applicable to Form A and Form
						B
Except as may be herein otherwise provided, the proration
						of benefits of a group disability policy because of other insurance covering
						the same loss is not appropriate to or applicable for use in group disability
						policies providing benefits other than benefits upon an expense incurred basis,
						except to the extent that Form A above is used in accordance with the
						instructions for its use, and no other such provision may be used. (Ins. C.
						10369.5 and 10369.6.)