96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
SB2968

 

Introduced 2/3/2010, by Sen. Carole Pankau

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/367   from Ch. 73, par. 979

    Amends the Illinois Insurance Code in the provision concerning group accident and health insurance to provide that no group policy may be issued or delivered without a provision that any employee may decline coverage by opting out of the group coverage and that the amount, if any, that would be charged to the employee if the employee were to participate in the group coverage shall be deducted from the premium for group coverage. Effective immediately.


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A BILL FOR

 

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1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by
5 changing Section 367 as follows:
 
6     (215 ILCS 5/367)  (from Ch. 73, par. 979)
7     Sec. 367. Group accident and health insurance.
8     (1) Group accident and health insurance is hereby declared
9 to be that form of accident and health insurance covering not
10 less than 2 employees, members, or employees of members,
11 written under a master policy issued to any governmental
12 corporation, unit, agency or department thereof, or to any
13 corporation, copartnership, individual employer, or to any
14 association upon application of an executive officer or trustee
15 of such association having a constitution or bylaws and formed
16 in good faith for purposes other than that of obtaining
17 insurance, where officers, members, employees, employees of
18 members or classes or department thereof, may be insured for
19 their individual benefit. In addition a group accident and
20 health policy may be written to insure any group which may be
21 insured under a group life insurance policy. The term
22 "employees" shall include the officers, managers and employees
23 of subsidiary or affiliated corporations, and the individual

 

 

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1 proprietors, partners and employees of affiliated individuals
2 and firms, when the business of such subsidiary or affiliated
3 corporations, firms or individuals, is controlled by a common
4 employer through stock ownership, contract or otherwise.
5     (2) Any insurance company authorized to write accident and
6 health insurance in this State shall have power to issue group
7 accident and health policies. No policy of group accident and
8 health insurance may be issued or delivered in this State
9 unless a copy of the form thereof shall have been filed with
10 the department and approved by it in accordance with Section
11 355, and it contains in substance those provisions contained in
12 Sections 357.1 through 357.30 as may be applicable to group
13 accident and health insurance and the following provisions:
14         (a) A provision that the policy, the application of the
15     employer, or executive officer or trustee of any
16     association, and the individual applications, if any, of
17     the employees, members or employees of members insured
18     shall constitute the entire contract between the parties,
19     and that all statements made by the employer, or the
20     executive officer or trustee, or by the individual
21     employees, members or employees of members shall (in the
22     absence of fraud) be deemed representations and not
23     warranties, and that no such statement shall be used in
24     defense to a claim under the policy, unless it is contained
25     in a written application.
26         (b) A provision that the insurer will issue to the

 

 

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1     employer, or to the executive officer or trustee of the
2     association, for delivery to the employee, member or
3     employee of a member, who is insured under such policy, an
4     individual certificate setting forth a statement as to the
5     insurance protection to which he is entitled and to whom
6     payable.
7         (c) A provision that to the group or class thereof
8     originally insured shall be added from time to time all new
9     employees of the employer, members of the association or
10     employees of members eligible to and applying for insurance
11     in such group or class.
12         (d) A provision that any employee may decline coverage
13     by opting out of the group coverage and that the amount, if
14     any, that would be charged to the employee if the employee
15     were to participate in the group coverage shall be deducted
16     from the premium for group coverage.
17     (3) Anything in this code to the contrary notwithstanding,
18 any group accident and health policy may provide that all or
19 any portion of any indemnities provided by any such policy on
20 account of hospital, nursing, medical or surgical services,
21 may, at the insurer's option, be paid directly to the hospital
22 or person rendering such services; but the policy may not
23 require that the service be rendered by a particular hospital
24 or person. Payment so made shall discharge the insurer's
25 obligation with respect to the amount of insurance so paid.
26 Nothing in this subsection (3) shall prohibit an insurer from

 

 

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1 providing incentives for insureds to utilize the services of a
2 particular hospital or person.
3     (4) Special group policies may be issued to school
4 districts providing medical or hospital service, or both, for
5 pupils of the district injured while participating in any
6 athletic activity under the jurisdiction of or sponsored or
7 controlled by the district or the authorities of any school
8 thereof. The provisions of this Section governing the issuance
9 of group accident and health insurance shall, insofar as
10 applicable, control the issuance of such policies issued to
11 schools.
12     (5) No policy of group accident and health insurance may be
13 issued or delivered in this State unless it provides that upon
14 the death of the insured employee or group member the
15 dependents' coverage, if any, continues for a period of at
16 least 90 days subject to any other policy provisions relating
17 to termination of dependents' coverage.
18     (6) No group hospital policy covering miscellaneous
19 hospital expenses issued or delivered in this State shall
20 contain any exception or exclusion from coverage which would
21 preclude the payment of expenses incurred for the processing
22 and administration of blood and its components.
23     (7) No policy of group accident and health insurance,
24 delivered in this State more than 120 days after the effective
25 day of the Section, which provides inpatient hospital coverage
26 for sicknesses shall exclude from such coverage the treatment

 

 

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1 of alcoholism. This subsection shall not apply to a policy
2 which covers only specified sicknesses.
3     (8) No policy of group accident and health insurance, which
4 provides benefits for hospital or medical expenses based upon
5 the actual expenses incurred, issued or delivered in this State
6 shall contain any specific exception to coverage which would
7 preclude the payment of actual expenses incurred in the
8 examination and testing of a victim of an offense defined in
9 Sections 12-13 through 12-16 of the Criminal Code of 1961, or
10 an attempt to commit such offense, to establish that sexual
11 contact did occur or did not occur, and to establish the
12 presence or absence of sexually transmitted disease or
13 infection, and examination and treatment of injuries and trauma
14 sustained by the victim of such offense, arising out of the
15 offense. Every group policy of accident and health insurance
16 which specifically provides benefits for routine physical
17 examinations shall provide full coverage for expenses incurred
18 in the examination and testing of a victim of an offense
19 defined in Sections 12-13 through 12-16 of the Criminal Code of
20 1961, or an attempt to commit such offense, as set forth in
21 this Section. This subsection shall not apply to a policy which
22 covers hospital and medical expenses for specified illnesses
23 and injuries only.
24     (9) For purposes of enabling the recovery of State funds,
25 any insurance carrier subject to this Section shall upon
26 reasonable demand by the Department of Public Health disclose

 

 

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1 the names and identities of its insureds entitled to benefits
2 under this provision to the Department of Public Health
3 whenever the Department of Public Health has determined that it
4 has paid, or is about to pay, hospital or medical expenses for
5 which an insurance carrier is liable under this Section. All
6 information received by the Department of Public Health under
7 this provision shall be held on a confidential basis and shall
8 not be subject to subpoena and shall not be made public by the
9 Department of Public Health or used for any purpose other than
10 that authorized by this Section.
11     (10) Whenever the Department of Public Health finds that it
12 has paid all or part of any hospital or medical expenses which
13 an insurance carrier is obligated to pay under this Section,
14 the Department of Public Health shall be entitled to receive
15 reimbursement for its payments from such insurance carrier
16 provided that the Department of Public Health has notified the
17 insurance carrier of its claim before the carrier has paid the
18 benefits to its insureds or the insureds' assignees.
19     (11) (a) No group hospital, medical or surgical expense
20     policy shall contain any provision whereby benefits
21     otherwise payable thereunder are subject to reduction
22     solely on account of the existence of similar benefits
23     provided under other group or group-type accident and
24     sickness insurance policies where such reduction would
25     operate to reduce total benefits payable under these
26     policies below an amount equal to 100% of total allowable

 

 

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1     expenses provided under these policies.
2         (b) When dependents of insureds are covered under 2
3     policies, both of which contain coordination of benefits
4     provisions, benefits of the policy of the insured whose
5     birthday falls earlier in the year are determined before
6     those of the policy of the insured whose birthday falls
7     later in the year. Birthday, as used herein, refers only to
8     the month and day in a calendar year, not the year in which
9     the person was born. The Department of Insurance shall
10     promulgate rules defining the order of benefit
11     determination pursuant to this paragraph (b).
12     (12) Every group policy under this Section shall be subject
13 to the provisions of Sections 356g and 356n of this Code.
14     (13) No accident and health insurer providing coverage for
15 hospital or medical expenses on an expense incurred basis shall
16 deny reimbursement for an otherwise covered expense incurred
17 for any organ transplantation procedure solely on the basis
18 that such procedure is deemed experimental or investigational
19 unless supported by the determination of the Office of Health
20 Care Technology Assessment within the Agency for Health Care
21 Policy and Research within the federal Department of Health and
22 Human Services that such procedure is either experimental or
23 investigational or that there is insufficient data or
24 experience to determine whether an organ transplantation
25 procedure is clinically acceptable. If an accident and health
26 insurer has made written request, or had one made on its behalf

 

 

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1 by a national organization, for determination by the Office of
2 Health Care Technology Assessment within the Agency for Health
3 Care Policy and Research within the federal Department of
4 Health and Human Services as to whether a specific organ
5 transplantation procedure is clinically acceptable and said
6 organization fails to respond to such a request within a period
7 of 90 days, the failure to act may be deemed a determination
8 that the procedure is deemed to be experimental or
9 investigational.
10     (14) Whenever a claim for benefits by an insured under a
11 dental prepayment program is denied or reduced, based on the
12 review of x-ray films, such review must be performed by a
13 dentist.
14 (Source: P.A. 91-549, eff. 8-14-99.)
 
15     Section 99. Effective date. This Act takes effect upon
16 becoming law.