Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 1 - Minimum Standards for Health Benefit Plans (230-RICR-20-30-1) › Section 230-RICR-20-30-1.8 - Group and Blanket Health Benefit Contract Standard Provisions

Current through June 14, 2024
1.8.1
General Provisions
A. No group or blanket health benefit
				  contract shall be delivered or issued for delivery in the state unless it
				  contains in substance the following provisions, or provisions which in the
				  opinion of the Director are more favorable to the persons covered; or at least
				  as favorable to the persons covered and more favorable to the master
				  contractholder. PROVIDED; HOWEVER, that:
1.
				  the standard provisions required for individual health benefit contracts shall
				  not apply to group health benefit contracts;
2. if any provision of this section is in
				  whole or in part inapplicable to or inconsistent with the coverage provided by
				  a particular form of contract, the insurer, with the approval of the Director,
				  shall omit from such contract any inapplicable provision or part of a
				  provision, and shall modify any inconsistent provision or part of a provision
				  in such a manner as to make the provision as contained in the contract
				  consistent with the coverage provided by the contract;
3.
												§
												1.8.1(A)(6)(g)   of this Part, below,
				  shall be optional with respect to blanket contracts;
4. if the group contract (but not a blanket
				  contract) provides hospital, surgical, or major medical benefits or any
				  combination of these coverages for other than specified diseases or accidental
				  injuries only, it shall also contain a conversion privilege conforming to the
				  requirements of §
												1.8.2   of this Part;
5. if a contract subject to this section
				  shall contain other benefits in addition to health benefits, some or all of the
				  provisions required in this section may be restricted so as to apply to health
				  benefits only, and other appropriate provisions may be included which apply to
				  non-health benefit portions of the contract.
6. The text of all master contract,
				  certificate and subscriber contract forms, including any riders or endorsements
				  to be attached to such forms shall be plainly printed in light-face type of a
				  style in general use, the size of which shall be uniform and not less than ten
				  (10) point with a lower-case unspaced alphabet length not less than one hundred
				  and twenty (120) point (the "text" shall include all printed matter except the
				  name and address of the insurer, any specific information required by law or
				  regulation to be in some other type, the name or title of the contract,
				  certificate, etc., and captions and subcaptions). The effective date of this
				  §
												1.8   of this Part shall be the same as that generally provided in
				  §
												1.11   of this Part for filing of forms.
a. A provision that the master contractholder
				  is entitled to a grace period of thirty-one (31) days or, at the option of the
				  insurer, one month for the payment of any premium due except the first, during
				  which grace period the contract shall continue in force, unless the master
				  contractholder shall have given the insurer written notice of discontinuance of
				  the coverage in advance of the date of discontinuance and in accordance with
				  the terms of the contract. The contract may provide that the master
				  contractholder shall be liable to the insurer for the payment of a pro rata
				  premium for the time the coverage was in force during such grace
				  period.
b. A provision that
				  validity of the contract shall not be contested, except for non-payment of
				  premiums, after it has been in force for two years from its date of issue; and
				  that no statement made for the purpose of effecting insurance coverage under
				  the contract with respect to a person shall be used to avoid the insurance with
				  respect to which such statement was made or to reduce benefits thereunder after
				  such insurance has been in force for a period of two (2) years during such
				  person's lifetime, nor unless such statement is contained in a written
				  instrument signed by the person making such statement and a copy of that
				  instrument is or has been furnished to him.
c. A provision that a copy of the
				  application, if any, of the master contractholder shall be attached to the
				  master contract when issued, and that all statements made by the master
				  contractholder or by the persons covered shall be deemed representations and
				  not warranties.
d. A provision that
				  no agent has authority to change the contract or waive any of its provisions
				  and that no change in the contract shall be valid unless approved by an officer
				  of the insurer and evidenced by an endorsement on the contract, or by rider or
				  amendment to the contract signed by the insurer, provided that any such
				  amendment which reduces or eliminates coverage was either requested in writing
				  by the master contractholder or signed by the master contractholder.
e. A provision specifying the additional
				  exclusions or limitations, if any, applicable under the contract with respect
				  to a disease or physical condition of a person, not otherwise excluded from the
				  person's coverage by name or specific description effective on the date of the
				  person's loss, which existed prior to the effective date of the person's
				  coverage under the contract. Any such exclusion or limitation may only apply to
				  a disease or physical condition for which medical advice or treatment was
				  received by the person during the twelve (12) months prior to the effective
				  date of his coverage. In no event shall such exclusion or limitation apply to
				  loss incurred after the earlier of (a) the end of a continuous period of twelve
				  (12) months commencing on or after the effective date of the person's coverage
				  during all of which the person has received no medical advice or treatment in
				  connection with such disease or physical condition and (b) the end of the two
				  (2) year period commencing on the effective date of the person's
				  coverage.
f. A provision specifying
				  the ages, if any, to which the insurance provided shall be limited; and the
				  ages, if any, for which additional restrictions are placed on benefits, and the
				  additional restrictions placed on the benefits at such ages. If the premiums or
				  benefits vary by age, there shall also be a provision specifying an equitable
				  adjustment of premiums or of benefits, or both, to be made in the event the age
				  of a covered person has been misstated, such provision to contain a clear
				  statement of the method of adjustment to be used. In no event, however, shall
				  coverage be required for any person during any period when, according to his
				  correct age, coverage would otherwise not be provided for him under the
				  contract.
g. (Optional with respect
				  to blanket contracts) A provision that the insurer will issue to the master
				  contractholder for delivery to each person insured, a certificate or subscriber
				  contract, which may be in summary form, setting forth the essential features of
				  the coverage and to whom the benefits are payable. If family members or
				  dependents are included in the coverage, only one certificate or subscriber
				  contract need be issued for each family unit.
h. A provision that written notice of claim
				  must be given to the insurer within twenty (20) days after the occurrence or
				  commencement of any loss covered by the contract. 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.
i.
				  A provision that the insurer will furnish to the person making the claim, or to
				  the master contractholder for delivery to such person, such forms as are
				  usually furnished by it for filing proof of loss. If such forms are not
				  furnished before the expiration of fifteen (15) days after the insurer received
				  notice of any claim under the contract, the person making such claim shall be
				  deemed to have complied with the requirements of the contract as to proof of
				  loss, upon submitting within the time fixed in the contract for filing proof of
				  loss, written proof covering the occurrence, character and extent of the loss
				  for which claim is made.
j. A
				  provision that, in the case of claim for loss, written proof of such loss must
				  be furnished to the insurer within ninety (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 was not reasonably possible to furnish such proof within
				  such time, provided such proof is furnished as soon as reasonably possible and
				  in no event, except in the absence of legal capacity of the claimant, later
				  than one (1) year from the time proof is otherwise required.
k. A provision that all benefits payable
				  under the contract will be payable not more than sixty (60) days after receipt
				  of such proof.
l. A provision that
				  all indemnities of the contract are payable to the insured, except that the
				  master contract may provide that all or any portion of any benefits on account
				  of hospital, medical, surgical or other services may, at the insurer's option,
				  be paid directly to the hospital or person rendering such services. Any payment
				  made by the insurer in good faith pursuant to the foregoing provisions shall
				  discharge an insurer's obligation with respect to the extent of such
				  payment.
m. A provision that the
				  insurer shall have the right and opportunity to examine the person of the
				  individual for whom claim is made when and so often as it may reasonably
				  require during the pendency of claim under the contract.
n. A provision that no action at law or in
				  equity shall be brought to recover on the contract prior to the expiration of
				  sixty (60) days after proof of loss has been filed in accordance with the
				  requirements of the contract and that no such action shall be brought at all
				  unless brought within three (3) years from the expiration of the time within
				  which proof of loss is required by the contract.