§ 58-67-65. Prohibited practices. - North Carolina Statutes

§ 58‑67‑65. Prohibited practices.

(a)        No healthmaintenance organization, or representative thereof, may cause or knowinglypermit the use of advertising which is untrue or misleading, solicitation whichis untrue or misleading, or any form of evidence of coverage which isdeceptive. For purposes of this Article:

(1)        A statement or itemof information shall be deemed to be untrue if it does not conform to fact inany respect which is or may be significant to an enrollee of, or personconsidering enrollment in, a health care plan.

(2)        A statement or itemof information shall be deemed to be misleading, whether or not it may beliterally untrue, if, in the total context in which such statement is made orsuch item of information is communicated, such statement or item of informationmay be reasonably understood by a reasonable person, not possessing specialknowledge regarding health care coverage, as indicating any benefit oradvantage or the absence of any exclusion, limitation, or disadvantage ofpossible significance to an enrollee of, or person considering enrollment in ahealth care plan, if such benefit or advantage or absence of limitation,exclusion or disadvantage does not in fact exist.

(3)        An evidence ofcoverage shall be deemed to be deceptive if the evidence of coverage taken as awhole, and with consideration given to typography and format, as well aslanguage, shall be such as to cause a reasonable person, not possessing specialknowledge regarding health care plans and evidences of coverage therefor, toexpect benefits, services, premiums, or other advantages which the evidence ofcoverage does not provide or which the health care plan issuing such evidenceof coverage does not regularly make available for enrollees covered under suchevidence of coverage.

(b)        Article 63 of thisChapter applies to health maintenance organizations and their agents andrepresentatives.

(c)        An enrollee may notbe cancelled or not renewed because of any deterioration in the health of theenrollee.

(d)        No health maintenanceorganization, unless licensed as an insurer, may use in its name, contracts, orliterature any of the words "insurance", "casualty","surety", "mutual", or any other words descriptive of theinsurance, casualty, or surety business or deceptively similar to the name ordescription of any insurance or surety corporation doing business in thisState.

(e)        The HMO shall notrefuse to enroll employees except when they can demonstrate they are unable toarrange adequate services.

(f)         No healthmaintenance organization shall refuse to enroll an individual or refuse tocontinue enrollment of an individual in a health care plan; limit the amount,extent, or kinds of health care plans available to an individual; or charge anindividual a different rate for the same health plan, because of the race,color, or national or ethnic origin of that individual. (1977,c. 580, s. 1; 1979, c. 876, s. 1; 1989, c. 485, s. 24; 1999‑244, s. 14.)