(215 ILCS 125/4-13) (from Ch. 111 1/2, par. 1409.6)
Sec. 4-13.
Prior approval of policy forms.
No health maintenance
organization shall issue or deliver in this State a group contract or
evidence of coverage, attach an endorsement or rider thereto, incorporate
by reference bylaws or other matter therein, or use an application blank in
this State until the form and content of the group contract or evidence of
coverage, endorsement, rider, bylaw, or other matter incorporated by
reference or application blank has been filed with and approved by the
Director, except that any such endorsement or rider that is to be attached
to a group contract or evidence of coverage after the date the group contract
or evidence of coverage is issued must be filed with, reviewed, and approved by
the Director before the date it is attached to a group contract or evidence of
coverage issued or delivered in this State. The Director shall withhold
approval of any such group contract, evidence of coverage, endorsement, rider,
bylaw, or other matter incorporated by reference or application blank if it
contains provisions that may encourage misrepresentation or that are unjust,
unfair, inequitable, ambiguous, misleading, inconsistent, deceptive, or
contrary to the law or public policy of this State or contains exceptions and
conditions that unreasonably or deceptively affect the risk purported to be
assumed in the general coverage of the group contract or evidence of coverage.
The Director shall not withhold approval of a form under this Section solely
because of the absence of coverage for mental health services if the Department
of Children and Family Services presents evidence that coverage of mental
health services for clients of that Department will be provided by another
entity. In all cases the Director shall approve or disapprove any such form
within 60 days after submission unless the Director extends by not more than an
additional 30 days the period within which he shall approve or disapprove any
such form by giving written notice to the organization of the extension before
expiration of the initial 60-day period.
The Director shall withdraw his approval of a group contract or evidence of
coverage, endorsement, rider, bylaw, or other matter incorporated by reference
or application blank if he subsequently determines that the group contract or
evidence of coverage, endorsement, rider, bylaw, other matter, or application
blank is misrepresentative, unjust, unfair, inequitable, ambiguous, misleading,
inconsistent, deceptive, or contrary to the law or public policy of this State,
or contains exceptions or conditions that unreasonably or deceptively affect
the risk purported to be assumed in the general coverage of the group contract
or evidence of coverage. The Director shall not withdraw approval of a form
under this Section solely because of the absence of coverage for mental health
services if the Department of Children and Family Services presents evidence
that coverage of mental health services for clients of that Department is being
or will be provided by another entity.
If a previously approved group contract or evidence of coverage,
endorsement, rider, bylaw, or other matter incorporated by reference or
application blank is withdrawn for use, the Director shall serve upon the
company an order of withdrawal of use, either personally or by mail. If the
service is by mail, the service shall be completed if the notice is deposited
in the post office, postage prepaid, addressed to the health maintenance
organization's last known address specified in the records of the Department of
Insurance. The order of withdrawal of use shall take effect 30 days from the
date of mailing but shall be stayed if within the 30-day period a written
request for hearing is filed with the Director. The hearing shall be held at
the time and place designated in the order given by the Director. The hearing
may be held either in the City of Springfield, the City of Chicago, or in the
county where the principal business address of the health maintenance
organization is located.
The action of the Director in disapproving or withdrawing the form shall be
subject to judicial review under the Administrative Review Law.
(Source: P.A. 88-487.)
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