§ 756.2. Group accident and sickness insurance
Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 40 P.S. InsuranceEffective: July 9, 2010
Effective: July 9, 2010
40 P.S. § 756.2
§ 756.2. Group accident and sickness insurance
(a) Group accident and sickness insurance is hereby declared to be that form of accident and sickness insurance covering groups of persons defined in this section with or without one or more members of their families or one or more of their dependents, or covering one or more members of the families or one or more dependents of such groups or persons and issued upon the following basis:
(1) Under a policy issued to an employer or trustees of a fund established by an employer, who shall be deemed the policyholder insuring at least two employes of such employer for the benefit of persons other than the employer. The term “employes,” as used herein, shall be deemed to include the officers, managers and employes of the employer, the individual proprietor or partner, if the employer is an individual proprietor or partnership, the officers, managers and employes of subsidiary or affiliated corporations, the individual proprietors, partners and employes of individuals and firms, if the business of the employer and such individual or firm is under common control through stock ownership, contract or otherwise. The term “employes,” as used herein, may include retired employes. A policy issued to insure employes of a public body may provide that the term “employes” shall include elected or appointed officials.
(2) Under a policy issued to an association, including a labor union, which shall have a constitution and by-laws and which has been organized by other than an insurer and is maintained in good faith for purposes other than that of obtaining insurance insuring at least twenty-five members, employes or employes of members of the association for the benefit of persons other than the association or its officers or trustees, which has been in active existence for at least two years, operates from offices other than the insurer's, and is controlled by principals other than the insurer's. The term “employes,” as used herein, may include retired employes.
(3) Under a policy issued to the trustees of a fund established by an insurer for two or more employers or by two or more employers or by an insurer for one or more labor unions or by one or more labor unions or by an insurer for one or more employers and one or more labor unions or by one or more employers and one or more labor unions or by an insurer for one or more associations meeting the qualifications as defined in clause (2) of this subsection or by one or more associations meeting the qualifications as defined in clause (2) of this subsection, which trustees shall be deemed the policyholder to insure employes of the employers or members of the unions or members, employes thereof and employes of the associations for the benefit of persons other than the employers or the unions or the associations. The term “employes,” as used herein, may include the officers, managers and employes of the employer and the individual proprietor or partners, if the employer is an individual proprietor or partnership. The term “employes,” as used herein, may include retired employes. The policy may provide that the term “employes” shall include the trustees or their employes, or both, if their duties are principally connected with such trusteeship.
(5.1) Under a policy issued to a group, other than one described in clauses (1) through (5) and under which the Insurance Commissioner finds that the issuance is not contrary to the best interest of the public, the issuance would result in economies of acquisition or administration; and the benefits are reasonable in relation to the premiums charged.
(6) A policy delivered or issued for delivery on or after January 1, 1968 under which coverage of a dependent of an employe1 or other member of the insured group terminates at a specified age shall, with respect to an unmarried child covered by the policy prior to the attainment of the age of nineteen who is incapable of self-sustaining employment by reason of mental retardation or physical handicap and who became so incapable prior to attainment of age nineteen and who is chiefly dependent upon such employe or member for support and maintenance, not so terminate while the insurance of the employe or member remains in force and the dependent remains in such condition, if the insured employe or member has within thirty-one days of such dependent's attainment of the termination age submitted proof of such dependent's incapacity as described herein. The foregoing provisions of this paragraph shall not require an insurer to insure a dependent who is a mentally retarded or physically handicapped child of an employe or other member of the insured group where such dependent does not satisfy the conditions of the group policy as to any requirements for evidence of insurability or other provisions as may be stated in the group policy required for coverage thereunder to take effect. In any such case the terms of the policy shall apply with regard to the coverage or exclusion from coverage of such dependent.
(1) A provision that in the absence of fraud, all statements made by any applicant or applicants or the policyholder or by an insured person shall be deemed representations and not warranties and that no statement made for the purpose of effecting insurance shall avoid such insurance or reduce benefits, unless contained in a written instrument signed by the policyholder or the insured person a copy of which has been furnished to such policyholder or to such person or his beneficiary.
(2) A provision that the insurer will furnish to the policyholder, for delivery to each employe or member of the insured group, an individual certificate setting forth, in summary form, a statement of the essential features of the insurance coverage of such employe or member and to whom benefits thereunder are payable. If dependents are included in the coverage, only one certificate need be issued for each family unit.
(c) Any group accident and health policy may provide that all or any portion of any indemnities provided by any such policy, 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. Except as provided in section 630,2 the policy may not require that the service be rendered by a particular hospital or person. Payment so made shall discharge the insurer's obligation with respect to the amount of insurance so paid.
(d) A group policy delivered or issued for delivery in this state which provides hospital, surgical or major medical expense insurance, or any combination of these coverages, on an expense incurred basis, but not a policy which provides indemnity benefits or benefits for specific diseases or for accidental injuries only, shall provide that an employe or member whose insurance under the group policy has been terminated for any reason, including discontinuance of the group policy in its entirety or with respect to an insured class, and who has been continuously insured under the group policy (and under any group policy providing similar benefits which it replaces) for at least three months immediately prior to termination, shall be entitled to have issued to him by the insurer a policy of health insurance (hereafter referred to as the converted policy). An employe or member shall not be entitled to have a converted policy issued to him if termination of his insurance under the group policy occurred because he failed to pay any required contribution, or any discontinued group coverage was replaced by similar group coverage within thirty-one days. Issuance of a converted policy shall be subject to the following conditions:
(6) The insurer shall not be required to issue a converted policy covering any person if such person is or could be covered by medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded). Furthermore, the insurer shall not be required to issue a converted policy covering any person if:
(ii) the benefits provided under the sources referred to in subclause (i)(I) for such person or benefits provided or available under the sources referred to in subclauses (i)(II) and (III) for such person together with the benefits provided by the converted policy, would result in overinsurance according to the insurer's standards. The insurer's standards must bear some reasonable relationship to actual health care costs in the area in which the insured lives at the time of conversion and must be filed with the commissioner prior to their use in denying coverage.
(iii) similar benefits are provided for or are available to such person, pursuant to or in accordance with the requirements of any state or Federal law. The converted policy may provide that the insurer may refuse to renew the policy or the coverage of any person insured thereunder for the following reasons only:
(I) Either the benefits provided under the sources referred to in clause (7)(i) and (ii) for such person or benefits provided or available under the sources referred to in clause (7)(iii) for such person, together with the benefits provided by the converted policy, would result in overinsurance according to the insurer standards on file with the commissioner, or the converted policyholder fails to provide the requested information.
(III) Eligibility of the insured person for coverage under Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded) or under any other state or Federal law providing for benefits similar to those provided by the converted policy.
(9) The converted policy shall not exclude a pre-existing condition not excluded by the group policy. However, the converted policy may provide that any hospital, surgical or medical benefits payable thereunder may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance thereunder. The converted policy may also include provisions so that during the first policy year the benefits payable under the converted policy, together with the benefits payable under the group policy shall not exceed those that would have been payable had the individual insurance under the group policy remained in force and effect.
(10) Subject to the provisions and conditions of this act, if the group insurance policy from which conversion is made insures the employe or member for basic hospital or surgical expense insurance, the employe or member shall be entitled to obtain a converted policy providing, at his option, coverage on an expense incurred basis under any one of the plans meeting the following requirements:
The maximum dollar amounts in Plan A shall be determined by the commissioner and may be redetermined by him from time to time as to converted policies issued subsequent to such redetermination. Such redetermination shall not be made more often than once in three years. The maximum dollar amounts in Plans A, B and C shall be rounded to the nearest multiple of ten dollars ($10).
(11) Subject to the provisions and conditions of this act, if the group insurance policy from which conversion is made insures the employe or member for major medical expense insurance, the employe or member shall be entitled to obtain a converted policy providing catastrophic or major medical coverage under a plan meeting the following requirements:
(ii) Payment of benefits at the rate of eighty per centum (80%) of covered medical expenses which are in excess of the deductible, until twenty per centum (20%) of such expenses in a benefit period reaches one thousand dollars ($1,000), after which benefits will be paid at the rate of one hundred per centum (100%) during the remainder of such benefit period. Payment of benefits for outpatient treatment of mental illness, if provided in the converted policy, may be at a lesser rate but not less than fifty per centum (50%).
(IV) the corresponding deductible in the group policy. The term “benefits deductible,” as used herein, means the value of any benefits provided on an expense incurred basis which are provided with respect to covered medical expenses by any other hospital, surgical, or medical insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan, or any other plan or program whether on an insured or uninsured basis, or in accordance with the requirements of any state or Federal law and, if pursuant to clause (12), the converted policy provides both basic hospital or surgical coverage and major medical coverage, the value of such basic benefits.
If the maximum benefit is determined by subclause (i)(II), the insurer may require that the deductible be satisfied during a period of not less than three months if the deductible is one hundred dollars ($100) or less, and not less than six months if the deductible exceeds one hundred dollars ($100).
(v) The term “covered medical expenses,” as used above, shall include at least, in the case of hospital room and board charges, the lesser of the dollar amount in Plan A and the average semi-private room and board rate for the hospital in which the individual is confined and twice such amount for charges in an intensive care unit. Any surgical schedule shall be consistent with those customarily offered by the insurer under group or individual health insurance policies and must provide at least a one thousand two hundred dollars ($1,200) maximum benefit.
(12) The conversion privilege required by this act shall, if the group insurance policy insures the employe or member for basic hospital or surgical expense insurance as well as major medical expense insurance make available the plans of benefits set forth in clauses (10) and (11). At the option of the insurer, such plans of benefits may be provided under one policy.
The insurer may also, in lieu of the plans of benefits set forth in clauses (10) and (11), provide a policy of comprehensive medical expense benefits without first dollar coverage. Said policy shall conform to the requirements of clause (11): Provided, however, That an insurer electing to provide such a policy shall make available a low deductible option, not to exceed one hundred dollars ($100), a high deductible option between five hundred dollars ($500), and one thousand dollars ($1,000), and a third deductible option midway between the high and low deductible options.
(14) In the event coverage would be continued under the group policy on an employe following his retirement prior to the time he is or could be covered by Medicare, he may elect, in lieu of such continuation of group insurance, to have the same conversion rights as would apply had his insurance terminated at retirement by reason of termination of employment or membership.
(15) The converted policy may provide for reduction of coverage on any person upon his eligibility for coverage under Medicare (Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded) or under any other state or Federal law providing for benefits similar to those provided by the converted policy.
(i) to the surviving spouse, if any, at the death of the employe or member, with respect to the spouse and such children whose coverage under the group policy terminates by reason of such death, otherwise to each surviving child whose coverage under the group policy terminates by reason of such death, or, if the group policy provides for continuation of dependents coverage following the employe's or member's death, at the end of such continuation;
(ii) to the spouse of the employe or member upon termination of coverage of the spouse, while the employe or member remains insured under the group policy, by reason of ceasing to be a qualified family member under the group policy, with respect to the spouse and such children whose coverage under the group policy terminates at the same time; or
Each certificate holder in the insured group shall be given written notice of such conversion privilege and its duration within fifteen days before or after the date of termination of group coverage, provided that if such notice be given more than fifteen days but less than ninety days after the date of termination of group coverage, the time allowed for the exercise of such privilege of conversion shall be extended for fifteen days after the giving of such notice. If such notice be not given within ninety days after the date of termination of group coverage, the time allowed for the exercise of such conversion privilege shall expire at the end of such ninety days. Written notice by the contract holder given to the certificate holder or mailed to the certificate holder at his last known address, or written notice by the insurer mailed to the certificate holder at the last address furnished to the insurer by the contract holder, shall be deemed full compliance with the provisions of this clause for the giving of notice. A group contract issued by an insurer may contain a provision to the effect that notice of such conversion privilege and its duration shall be given by the contract holder to each certificate holder upon termination of his group coverage.
(20) Where the contract holder is the employer of the certificate holder, the insurer shall also give written notice of termination of the group contract to any organization or organizations representing such certificate holder for the purpose of collective bargaining, and the employer shall provide to the insurer a written list of such organizations within ten days after the date the policy is issued and thereafter within ten days of the beginning or termination of representation by any such organization of any certificate holder or holders, which list shall identify the collective bargaining unit and the group insurance contract to which the request relates. There shall be no liability on the part of, and no cause of action of any nature shall arise, against any labor organization representing the employes of a contract holder for the purposes of collective bargaining due to any action it takes or fails to take as to the written notice required to be given by the insurer under this clause unless shown to have been done in bad faith with malice in fact by any such organization.
Compliance or non-compliance with the provisions of this clause shall in no way affect the rights, duties or obligations of the contract holder, insurer or certificate holder as otherwise set forth in this act.
(e) No insurer shall issue in this Commonwealth group accident and health insurance coverage provided under a group policy issued in another state or deliver or issue for delivery in this Commonwealth a certificate of group accident and health insurance evidencing coverage under a group policy issued in another state unless:
(2) For coverage under a group policy or a certificate evidencing coverage under a group policy issued to an out-of-State trustee of a fund, such coverage is issued in another state wherein the insurance supervisory official or agency of that state has determined that the issuance of the group policy or certificate is not contrary to the best interests of the general public, the issuance of the group policy or certificate would result in economies of acquisition or administration, the benefits are reasonable in relation to the premium charged and such coverage is in compliance with any mandated benefit act specifically providing for coverage on residents of this Commonwealth regardless of whether the group policy is used within or outside this Commonwealth. If coverage or a certificate is issued in this Commonwealth pursuant to this clause, an insurer shall file with the Insurance Department a copy of the group policy and certificate, a copy of the statute from the state in which the group policy or certificate is issued authorizing the issuance of the group policy or certificate, evidence of approval in the state where the policy or certificate is issued and copies of all supportive material used by the company to secure approval of the group policy or certificate in that state, including all the documentation required in this clause. The Insurance Commissioner, at any time subsequent to receipt of such information, after finding that the standards of this clause have not been met, may order the insurer to stop marketing such coverage in this Commonwealth.
(i) This clause shall apply to any group policy or certificate evidencing coverage under a group policy issued to any organization, or to any trust or trustee of a trust established or participated in by one or more organizations, to insure certain persons: Provided, however, That the organization must be:
(ii) This clause shall not apply to any group policy or certificate providing credit accident and health insurance as defined in the act of September 2, 1961 (P.L. 1232, No. 540),3 known as the “Model Act for the Regulation of Credit Life Insurance and Credit Accident and Health Insurance.”
(3) An association, or a trust or trustee of a trust established or participated in by one or more associations, to insure association members or spouses or dependents of members: Provided, however, That the association must be organized or domiciled in a state other than this Commonwealth, have a constitution and bylaws, be organized by other than an insurer, be maintained in good faith for purposes other than those of obtaining insurance, have been in active existence for at least two years, operate from offices other than the insurer's and be controlled by principals other than the insurer's.
(g)(1) For group accident and health insurance coverage provided in this Commonwealth under a policy issued in another State and except as provided in clause (2) of subsection (e) and subsection (f), all group policies, certificates, amendments, endorsements and enrollment forms shall be filed with the Commissioner for approval. The insurer shall also file with the Commissioner evidence of approval in the State where the group policy is issued.
(2) Forms so filed for approval shall be subject to the provisions of section 354.4
(h)(1) In the case of a policy issued to a group described in clause (2) or (5.1) of subsection (a) on a group basis, if compensation of any kind will or may be paid to a policyholder or sponsoring or endorsing entity, the insurer shall cause to be distributed to prospective insureds in a written notice that compensation will or may be paid.
(ii) whether such compensation is paid to or retained by the policyholder or sponsoring or endorsing entity, or paid to or retained by a third party at the direction of the policyholder or sponsoring or endorsing entity, or any entity affiliated therewith by way of ownership, contract, or employment.
(4) As used in this subsection, a “sponsoring or endorsing entity” means an organization which has arranged for the offering of a program of insurance in a manner which communicates that eligibility for participation in the program is dependent upon affiliation with such organization or that it encourages participation in the program.
(i) The provisions of this amendatory act shall not invalidate or otherwise affect either group policies legally issued prior to the effective date of this section or certificates in effect prior to the effective date of this section. All such group policies or certificates may remain in full force and effect until three years after the effective date of this section, notwithstanding the fact they do not comply with the provisions of this act.
(k) Certificates issued on or after the effective date of this subsection under a group policy legally issued prior to the effective date of this subsection shall comply with the provisions of this act no later than three years after the effective date of this subsection if issued to: an employer or trustees of a fund established by an employer or trustees of a fund established by two or more employers none of whom has joined after the effective date of this subsection, labor union, police fraternity, firemen's fraternity, teacher's association or federation and a unit of the National Guard or Naval Militia. Any other certificates issued on or after the effective date of this subsection under a group policy issued prior to the effective date of this subsection shall comply with the provisions of this act.
(m) As used in this section, the term “out-of-State single employer” means any person acting directly as an employer and has its principal office located in a state other than this Commonwealth. An “out-of-State trustee” of a fund means a trustee of a fund established by an insurer for two or more employers or established by two or more persons acting directly as employers and the trustee has its principal office located in a state other than this Commonwealth. “Out-of-State coverage” means insurance coverage issued in this Commonwealth and provided under a group policy issued in a state other than this Commonwealth. A “union-negotiated out-of-State trust” means a trust established under a collective bargaining agreement and which is located in a state other than this Commonwealth.
Credits
1921, May 17, P.L. 682, art. VI, § 621.2, added 1955, Dec. 9, P.L. 807, No. 233, § 2. Amended 1968, Jan. 18, P.L. (1967) 969, No. 433, § 2; 1976, July 9, P.L. 952, No. 185, § 1, effective in 180 days; 1986, June 11, P.L. 226, No. 64, § 11, imd. effective; 1994, Feb. 17, P.L. 92, No. 9, § 8, effective in 90 days. Affected 1996, Dec. 18, P.L. 1066, No. 159, § 14(b). Amended 2010, July 9, P.L. 362, No. 51, § 4, imd. effective.
40 P.S. § 756.2, PA ST 40 P.S. § 756.2
Current through Act 10 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
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