SECTIONS 10600-10609 - California Statutes

INSURANCE CODE

SECTION 10600-10609

10600. This part shall be known and may be referred to as the
"Health Insurance Disclosure Act of 1974."

10601. As used in this chapter:
(a) "Benefits and coverage" means the accident, sickness or
disability indemnity available under a policy of disability
insurance.
(b) "Exception" means any provision in a policy whereby coverage
for a specified hazard or condition is entirely eliminated.
(c) "Reduction" means any provision in a policy which reduces the
amount of a policy benefit to some amount or period less than would
be otherwise payable for medically authorized expenses or services
had such a reduction not been used.
(d) "Limitation" means any provision other than an exception or a
reduction which restricts coverage under the policy.
(e) "Presenting for examination or sale" means either (1)
publication and dissemination of any brochure, mailer, advertisement,
or form which constitutes a presentation of the provisions of the
policy and which provides a policy enrollment or application form, or
(2) consultations or discussions between prospective beneficiaries
or their contract agents and employees or agents of disability
insurers, when such consultations or discussions include presentation
of formal, organized information about the policy which is intended
to influence or inform the prospective insured or beneficiary, such
as brochures, summaries, charts, slides, or other modes of
information in lieu of or in addition to the policy itself.
(f) "Disability insurance" means every policy of disability
insurance, self-insured employee welfare benefit plan, and nonprofit
hospital service plan issued, delivered, or entered into pursuant to
or described in Chapter 1 (commencing with Section 10110), Chapter 4
(commencing with Section 10270), or Chapter 11A (commencing with
Section 11491) of this part.
(g) "Insurer" means every insurer transacting disability
insurance, every self-insured employee welfare plan, and every
nonprofit hospital service plan specified in subdivision (e).
(h) "Disclosure form" means the standard supplemental disclosure
form required pursuant to Section 10603.

10602. For the purposes of this chapter, where the definition of
the term "hospital" in the policy omits care in any "health facility"
defined pursuant to subdivision (a) or (b) of Section 1250 of the
Health and Safety Code, the omitted coverage shall constitute a
limitation. Further, where the definition of the term "nursing home"
in the policy omits care in any "health facility" defined pursuant to
subdivision (c) or (d) of Section 1250 of the Health and Safety
Code, the omitted coverage shall constitute a limitation.

10602.1. Nothing in this chapter shall prevent an insurer which
makes contracts with hospitals from distinguishing between
contracting hospitals and noncontracting hospitals.

10603. (a) On or before April 1, 1975, the commissioner shall
promulgate a standard supplemental disclosure form for all disability
insurance policies. Upon the appropriate disclosure form as
prescribed by the commissioner, each insurer shall provide, in easily
understood language and in a uniform, clearly organized manner, as
prescribed and required by the commissioner, such summary information
about each disability insurance policy offered by the insurer as the
commissioner finds is necessary to provide for full and fair
disclosure of the provisions of the policy.
(b) Nothing in this section shall preclude the disclosure form
from being included with the evidence of coverage or certificate of
coverage or policy.

10604. The disclosure form shall include the following information,
in concise and specific terms, relative to the disability insurance
policy:
(a) The applicable category or categories of coverage provided by
the policy, from among the following:
(1) Basic hospital expense coverage.
(2) Basic medical-surgical expense coverage.
(3) Hospital confinement indemnity coverage.
(4) Major medical expense coverage.
(5) Disability income protection coverage.
(6) Accident only coverage.
(7) Specified disease or specified accident coverage.
(8) Such other categories as the commissioner may prescribe.
(b) The principal benefits and coverage of the disability
insurance policy.
(c) The exceptions, reductions, and limitations that apply to such
policy.
(d) A summary, including a citation of the relevant contractual
provisions, of the process used to authorize or deny payments for
services under the coverage provided by the policy including coverage
for subacute care, transitional inpatient care, or care provided in
skilled nursing facilities. This subdivision shall only apply to
policies of disability insurance that cover hospital, medical, or
surgical expenses.
(e) The full premium cost of such policy.
(f) Any copayment, coinsurance, or deductible requirements that
may be incurred by the insured or his family in obtaining coverage
under the policy.
(g) The terms under which the policy may be renewed by the
insured, including any reservation by the insurer of any right to
change premiums.
(h) A statement that the disclosure form is a summary only, and
that the policy itself should be consulted to determine governing
contractual provisions.

10604.1. (a) The Legislature finds and declares that the right of
every patient to receive basic information necessary to give full and
informed consent is a fundamental tenet of good public health policy
and has long been the established law of this state. Some hospitals
and other providers do not provide a full range of reproductive
health services and may prohibit or otherwise not provide
sterilization, infertility treatments, abortion, or contraceptive
services, including emergency contraception. It is the intent of the
Legislature that every patient be given full and complete information
about the health care services available to allow patients to make
well informed health care decisions.
(b) On or before July 1, 2001, every disability insurer that
provides coverage for hospital, medical, or surgical benefits, and
which provides a list of network providers to prospective insureds
and insureds, shall do both of the following:
(1) Include the following statement, in at least 12-point boldface
type, at the beginning of each provider directory:

"Some hospitals and other providers do not provide one or more of
the following services that may be covered under your policy and that
you or your family member might need: family planning; contraceptive
services, including emergency contraception; sterilization,
including tubal ligation at the time of labor and delivery;
infertility treatments; or abortion. You should obtain more
information before you become a policyholder or select a network
provider. Call your prospective doctor or clinic, or call the insurer
at (insert the insurer's membership services number or other
appropriate number that individuals can call for assistance) to
ensure that you can obtain the health care services that you need."

(2) Place the statement described in paragraph (1) in a prominent
location on any provider directory posted on the insurer's website,
if any, and include this statement in a conspicuous place in the
insurer's evidence of coverage and disclosure forms.
(c) A disability insurer shall not be required to provide the
statement described in paragraph (1) of subdivision (b) in a service
area in which none of the hospitals, health facilities, clinics,
medical groups, or independent practice associations with which it
contracts limit or restrict any of the reproductive services
described in the statement.
(d) This section shall not apply to vision-only, dental-only,
accident-only, specified disease, hospital indemnity, Medicare
supplement, long-term care, or disability income insurance.

10604.5. An insurer shall annually disclose to the governing board
of a public agency that is the policyholder of a group health
insurance policy, the name and address of, and amount paid to, any
agent, broker, or individual to whom the insurer paid fees or
commissions related to the public agency's group health insurance
policy. As part of this disclosure, the insurer shall include the
name, address, and amounts paid to the specific agents, brokers, or
individuals involved in transactions with the public agency. The
compensation disclosure required by this section is in addition to
any other compensation disclosure requirements that exist under law.

10605. (a) Effective July 1, 1976, all insurers, and their
employees and agents, shall, when presenting any disability insurance
policy for examination or sale to an individual prospective insured
or individual prospective subscriber, provide such individual with a
properly completed disclosure form, as prescribed by the commissioner
pursuant to Sections 10603 and 10604, for each disability insurance
policy so examined or sold.
(b) In the case of group disability insurance contracts, the
completed disclosure form shall be presented to the contract holder
upon delivery of the group policy or contract.
(c) Group insurance contract holders shall disseminate copies of
the completed disclosure form to all persons or family units eligible
under the group contract. Where the individual members of the group
are offered a choice of policies, separate disclosure forms shall be
supplied for each policy available.
(d) Disability insurance issued in connection with an employees'
welfare plan subject to the Federal Employee Retirement Income
Security Act of 1974 (P.L. 93-406) is exempt from the provisions of
this chapter.

10606. Effective July 1, 1976, where the commissioner finds it
necessary in the interest of full and fair disclosure, all
advertising and other consumer information, including brochures,
disseminated by insurers for the purpose of influencing persons to
purchase health insurance shall contain such supplemental disclosure
information as the commissioner may require.

10607. In addition to the other disclosures required by this
chapter, every insurer and their employees or agents shall, when
presenting a plan for examination or sale to any individual or the
representative of a group consisting of 25 or fewer individuals,
disclose in writing the ratio of incurred claims to earned premiums
(loss-ratio) for the insurer's preceding calendar year. This section
shall become operative on March 1, 1991, in order to allow insurers
time to comply with its provisions.

10608. The commissioner shall, from time to time as conditions
warrant, after notice and public hearing, promulgate such reasonable
rules and regulations, and amendments and additions thereto, as are
necessary to administer this chapter.

10609. Beginning on or before January 1, 1976, each insurer shall,
to the extent required by the commissioner, file with the
commissioner copies of all printed advertising which the insurer
proposes to disseminate in the state.