Chapter 10. Required Standard Provisions

“Blanket health insurance” has the meaning stated in Insurance Article, §15-305, Annotated Code of Maryland.

“Carrier” means an insurer or nonprofit health service plan.

“Coverage period” means the interval of time the blanket health insurance contract or group health insurance contract provides protection, in exchange for the payment of a particular premium.

Group Health Insurance.

“Group policyholder” means the entity to whom the group health insurance contract or blanket health insurance contract is issued.

“Insured” means an individual covered under a group health insurance contract or blanket health insurance contract.

“Preferred provider” means a provider that has entered into a provider service contract.

“Preferred provider benefit” means a benefit that appears in a group health insurance contract or blanket health insurance contract under which health care services are to be provided to the insured by a preferred provider.

“Provider service contract” means a contract between a provider and a carrier or other entity, under which the provider agrees to provide health care services on a preferential basis under contracts containing preferred provider benefits.

Listed in Regulation .04 of this chapter; or

Which in the opinion of the Commissioner, as compared to the provisions in Regulation .04 of this chapter, are:

Listed in Regulation .05 of this chapter; or

Which in the opinion of the Commissioner, as compared to the provisions in Regulation .05 of this chapter, are:

Omit from the contract the inapplicable provision or part of the provision; or

Modify the inconsistent provision or part of the provision to make it consistent with the coverage provided by the contract.

Which documents constitute the entire contract of insurance; and

That a change in the policy may not be valid:

Each group health insurance contract shall contain a provision that:

The provision required by §B(1) of this regulation does not preclude the assertion at any time of defenses based upon the person's ineligibility for coverage under the contract or upon other provisions in the contract.

Each group contract shall contain a provision describing how and when a claim form can be requested from a carrier.

If the carrier requires written notice of claim for the carrier to send a claim form to the claimant, the provision shall indicate that:

The carrier shall provide claim forms for filing proof of loss to each claimant or to the group policyholder for delivery to the claimant; and

If the carrier does not provide the claim forms within 15 days after notice of claim is received, the claimant is considered to have complied with the requirements of the policy as to proof of loss if the claimant submits, within the time fixed in the policy for filing proof of loss, written proof of the occurrence, character, and extent of the loss for which the claim is made.

Written proof of loss shall be furnished to the carrier:

Failure to furnish the proof of loss within the time required does not invalidate or reduce a claim if it was not reasonably possible to submit the proof within the required time, if the proof is furnished as soon as reasonably possible and, except in the absence of legal capacity of the claimant, not later than 1 year from the time proof is otherwise required.

Each group health insurance contract shall contain a provision that:

A policy is considered to provide for periodic payment for loss under §F(1)(b) of this regulation only if the policy contains a specific statement to that effect.

Each group health insurance contract shall contain a provision that all benefits, other than those described in §G(2) and (3) of this regulation, will be payable to the insured.

Loss of Life Benefits.

If a group health insurance policy contains a preferred provider benefit, the policy may indicate that benefits for services rendered by a preferred provider will be paid directly to the preferred provider rendering the services.

At the option of the carrier, the contract may provide that if any benefit of the contract is payable to the estate of an individual, or to an individual who is a minor or otherwise not competent to give a valid release, the carrier may pay the benefit, up to an amount not exceeding $5,000, to any relative by blood or connection by marriage of the individual who is considered by the carrier to be equitably entitled to the benefit.

To recover on the policy before the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the policy; and

After the expiration of 3 years after the written proof of loss is required to be furnished.

Each group health insurance contract shall contain in substance the following provision: “Grace Period: A grace period of 30 days will be granted for payment of each premium due after the first premium, unless the carrier does not intend to renew the policy beyond the period for which premium has been accepted and notice of the intention not to renew is delivered to the group policyholder at least 45 days before the premium is due. During the grace period the policy shall continue in force.”

Any additional provisions related to the grace period shall be expressly stated in the policy subject to the following limitations:

Unless the carrier makes delivery directly to the employee or member, the carrier will provide to the group policyholder, for delivery to each employee or member of the insured group, a statement that summarizes the essential features of the insurance coverage of the employee or member and that indicates to whom benefits under the policy are payable; and

If dependents are included in the coverage, only one statement need be issued for each family unit.

A provision specifying an equitable adjustment of premiums or of benefits, or both, to be made in the event the age of an insured has been misstated; and

A clear statement of the method of adjustment to be used.

Each group health insurance contract shall specify the premium due date.

The premium due date shall be the date the coverage period begins.

A carrier may offer each group policyholder the option to pay the premium through an electronic payment.

If the group policyholder elects an electronic payment, the carrier may not debit or charge the amount of the premium due prior to the premium due date, except as authorized by the group policyholder.

Absent fraud, each statement made by the group policyholder is considered to be a representation and not a warranty; and

A statement made by the group policyholder may not be used in defense to a claim under the policy unless the statement is contained in a written application.

If a claim is for loss of time because of disability, written proof of loss shall be submitted to the insurer within 30 days after the beginning of the period for which the insurer is liable, and subsequent written proofs that the disability continues shall be submitted to the insurer at the intervals that the insurer reasonably requires;

If a claim is for a loss other than loss of time because of disability, written proof of loss shall be submitted to the insurer within 90 days after the date of the loss; and

Failure to submit proof of loss within the time required does not invalidate or reduce a claim if it is shown that it was not reasonably possible to submit the proof of loss within the time required, and that proof of loss was submitted as soon as was reasonably possible.

Benefits payable under the policy, other than benefits for loss of time, are payable immediately on the insurer's receipt of written proof of loss; and

Subject to proof of loss:

Except as described in §A(3) of this regulation, a group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's commission of or attempt to commit a crime.

A group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss for which a contributing cause was the commission of or the attempt to commit a crime by an individual other than the insured.

A group disability benefit or a group accidental death and dismemberment benefit:

Except as described in §B(2) of this regulation, a group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's being engaged in an illegal occupation.

A group disability benefit or a group accidental death and dismemberment benefit:

Except as described in §C(2) of this regulation, a group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss:

A group disability benefit or a group accidental death and dismemberment benefit:

Each group health insurance contract or blanket health insurance contract shall contain a provision specifying the additional exclusions or limitations, if any, applicable under the contract with respect to a disease or physical condition of an individual, not otherwise excluded from the individual's coverage by name or specific description effective on the date of the individual's loss, that existed before the effective date of the individual's coverage under the contract.

The exclusion described in §D(1) of this regulation may apply only to a disease or physical condition for which medical advice or treatment was received by the individual during the 12 months before the effective date of the individual's coverage.

The exclusion described in §D(1) of this regulation does not apply to loss incurred or disability beginning after the earlier of:

If a group health insurance contract or blanket health insurance contract contains a preexisting condition limitation or exclusion, the limitation or exclusion may not apply to a condition that the applicant revealed in the application for the contract, unless the condition is excluded by means of a signed waiver rider attached to the contract.

A carrier may include a provision in a group health insurance contract or blanket health insurance contract giving the carrier the right to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim under the contract.

If the carrier includes the provision described in §A(1) of this regulation, the provision shall indicate that any physical examination required by the carrier will be performed at the expense of the carrier.

A carrier may include a provision in a group health insurance contract or blanket health insurance contract giving the carrier the right to make an autopsy in case of death when an autopsy is not forbidden by law.

A carrier may include a provision in a group health insurance contract or blanket health insurance contract that any autopsy required by the carrier will be performed at the expense of the carrier.

A carrier may include a provision in a group health insurance contract or blanket health insurance contract giving the insured or the group policyholder the option of entering binding arbitration to settle a dispute with the carrier.

If the carrier includes the provision described in §C(1) of this regulation, the provision may not require the insured or the group policyholder to enter binding arbitration.