1399.60. The provisions of this article shall apply to all group
health care service contracts issued in this state pursuant to this
chapter.
1399.61. In this article, unless the context otherwise requires:
(a) "Carrier" shall mean the health care service plan or other
entity responsible for the payment of benefits or provision of
services under a group contract.
(b) "Dependent" shall have the meaning set forth in a contract.
(c) "Discontinuance" shall mean the termination of the contract
between the entire employer unit under a contract and the health care
service plan, and does not refer to the termination of any agreement
between any individual member under a contract and the health care
service plan.
(d) "Employee" shall mean all agents, employees, and members of
unions or associations to whom benefits are provided under a
contract.
(e) "Extension of benefits" shall mean the continuation of
coverage under a particular benefit provided under a contract
following discontinuance with respect to an employee or dependent who
is totally disabled on the date of discontinuance.
(f) "Contract" shall mean any group health care service plan or
contract subject to the provisions of this article.
(g) "Contractholder" shall mean the entity to which a contract is
issued.
(h) "Dues" shall mean the consideration payable to the carrier.
(i) "Replacement coverage" shall mean the benefits provided by a
succeeding carrier.
(j) "Totally disabled" shall have the meaning set forth in a
contract.
1399.62. (a) Every contract containing hospital, medical, or
surgical expense benefits or service benefits shall contain a
reasonable extension of such benefits upon discontinuance of the
contract with respect to employees or dependents who become totally
disabled while enrolled under the contract on or after the date this
article becomes applicable to such contract and who continue to be
totally disabled at the date of discontinuance of the contract.
(b) Every contract providing hospital, medical or surgical expense
benefits or service benefits shall be deemed to include a reasonable
extension of such benefits upon discontinuance of the contract if it
provides benefits for covered services directly relating to the
condition causing total disability existing at the time dues payments
cease for the employee or dependent and incurred during a period of
not less than 12 months thereafter, which period shall not be
interrupted by discontinuance of the contract.
That extension of benefits may be terminated at such time as the
employee or dependent is no longer totally disabled or at such time
as a succeeding carrier may elect to provide replacement coverage to
that employee or dependent without limitation as to the disabling
condition.
(c) The services provided during any extension of benefits may be
subject to all limitations or restrictions contained in the contract.
1399.63. (a) Any carrier providing replacement coverage with
respect to hospital, medical or surgical expense or service benefits
within a period of 60 days from the date of discontinuance of a prior
contract or policy providing such hospital, medical or surgical
expense or service benefits shall immediately cover all employees and
dependents who were validly covered under the previous contract or
policy at the date of discontinuance, including all former employees
entitled to continuation coverage under Section 1373.621, who are
within the definitions of eligibility under the succeeding carrier's
contract and who would otherwise be eligible for coverage under the
succeeding carrier's contract, regardless of any provisions of the
contract relating to active full-time employment or hospital
confinement or pregnancy. However, with respect to employees or
dependents who are totally disabled on the date of discontinuance of
the prior carrier's contract or policy and entitled to an extension
of benefits pursuant to subdivision (b) of Section 1399.62, or
pursuant to subdivision (d) of Section 10128.2 of the Insurance Code,
the succeeding carrier is not required to provide benefits for
services or expenses directly related to any conditions which caused
the total disability.
(b) Except as otherwise provided in subdivision (a), until an
employee or dependent entitled to coverage under a succeeding carrier'
s contract pursuant to subdivision (a) of this section qualifies for
full benefits by meeting all effective date requirements of the
succeeding carrier's contract, the level of benefits shall not be
lower than the benefits provided under the prior carrier's contract
or policy reduced by the amount of benefits paid by the prior
carrier. Such employee or dependent shall continue to be covered by
the succeeding carrier until the earlier of the following dates:
(1) The date coverage would terminate for an employee or dependent
in accordance with the provisions of the succeeding carrier's
contract, or
(2) In the case of an employee or dependent who was totally
disabled on the date of discontinuance of the prior carrier's
contract or policy and entitled to an extension of benefits pursuant
to subdivision (d) of Section 10128.2 of the Insurance Code or
subdivision (b) of Section 1399. 62, the date the period of extension
of benefits terminates or, if the prior carrier's contract or policy
is not subject to this article, the date to which benefits would
have been extended had the prior carrier's contract or policy been
subject to this article.
(c) Except as otherwise provided in this section, and except to
the extent that benefits for the condition would have been reduced or
excluded under the prior carrier's contract or policy, no provision
in a succeeding carrier's contract of replacement coverage which
would operate to reduce or exclude benefits on the basis that the
condition giving rise to benefits preexisted the effective date of
the succeeding carrier's contract shall be applied with respect to
those employees, former employees entitled to continuation coverage
under Section 1373.621, and dependents validly covered under the
prior carrier's contract or policy on the date of discontinuance.
(d) In a situation where a determination of the prior carrier's
benefit is required by the succeeding carrier, at the succeeding
carrier's request, the prior carrier shall furnish a statement of
benefits available or pertinent information, sufficient to permit
verification of the benefit determination by the succeeding carrier.
(e) For purposes of subdivision (a), a succeeding carrier's
coverage shall not exclude any dependent child who was covered by the
previous carrier solely because the plan member does not provide the
primary support for that dependent child.
(f) Except to the extent that benefits for the condition would
have been reduced or excluded under the prior carrier's contract or
policy, no provision in the succeeding carrier's contract, where an
employee changes carriers due to a change in employment or other
circumstances, that would operate to reduce or exclude benefits for
the following congenital craniofacial anomalies: cleft lip and palate
(as defined in ICD-9-CM Diagnosis Code 749, International
Classification of Diseases, 9th Revision, Clinical Modification,
Volume 1, Second Edition, September, 1980), acrocephalosyndactyly (as
defined in ICD-9-CM Diagnosis Code 755.55, cranio only), and other
congenital musculoskeletal anomalies (as defined in ICD-9-CM
Diagnosis Code 756.0), on the basis that the condition giving rise to
benefits preexisted the effective date of the succeeding carrier's
contract, shall be applied to those employees, former employees
entitled to continuation coverage under Section 1373.621, and
dependents validly covered under the prior carrier's contract or
policy on the date the prior contract or policy terminated when
payment or services had been commenced by the previous carrier. That
succeeding coverage shall otherwise be subject to all other
provisions of the contract between the insured and the succeeding
carrier. Nothing in this subdivision shall be construed to limit or
otherwise affect any obligation of a succeeding carrier to provide
benefits for a condition not specified in this subdivision, where
expressly or impliedly required by other provisions of this chapter;
this subdivision is not intended to affect the construction of the
language of any other provision of this chapter.
1399.64. This article shall apply to all contracts issued,
delivered, amended, or renewed in this state after January 1, 1977. A
policy subject to the provisions of this article which is issued,
delivered, amended as to benefits, or renewed in this state on or
after the effective date of amendments to this article made at the
1977-1978 Regular Session of the Legislature shall be construed to be
in compliance with the provisions of this article and such
amendments to this article.
1399.60. The provisions of this article shall apply to all group
health care service contracts issued in this state pursuant to this
chapter.
1399.61. In this article, unless the context otherwise requires:
(a) "Carrier" shall mean the health care service plan or other
entity responsible for the payment of benefits or provision of
services under a group contract.
(b) "Dependent" shall have the meaning set forth in a contract.
(c) "Discontinuance" shall mean the termination of the contract
between the entire employer unit under a contract and the health care
service plan, and does not refer to the termination of any agreement
between any individual member under a contract and the health care
service plan.
(d) "Employee" shall mean all agents, employees, and members of
unions or associations to whom benefits are provided under a
contract.
(e) "Extension of benefits" shall mean the continuation of
coverage under a particular benefit provided under a contract
following discontinuance with respect to an employee or dependent who
is totally disabled on the date of discontinuance.
(f) "Contract" shall mean any group health care service plan or
contract subject to the provisions of this article.
(g) "Contractholder" shall mean the entity to which a contract is
issued.
(h) "Dues" shall mean the consideration payable to the carrier.
(i) "Replacement coverage" shall mean the benefits provided by a
succeeding carrier.
(j) "Totally disabled" shall have the meaning set forth in a
contract.
1399.62. (a) Every contract containing hospital, medical, or
surgical expense benefits or service benefits shall contain a
reasonable extension of such benefits upon discontinuance of the
contract with respect to employees or dependents who become totally
disabled while enrolled under the contract on or after the date this
article becomes applicable to such contract and who continue to be
totally disabled at the date of discontinuance of the contract.
(b) Every contract providing hospital, medical or surgical expense
benefits or service benefits shall be deemed to include a reasonable
extension of such benefits upon discontinuance of the contract if it
provides benefits for covered services directly relating to the
condition causing total disability existing at the time dues payments
cease for the employee or dependent and incurred during a period of
not less than 12 months thereafter, which period shall not be
interrupted by discontinuance of the contract.
That extension of benefits may be terminated at such time as the
employee or dependent is no longer totally disabled or at such time
as a succeeding carrier may elect to provide replacement coverage to
that employee or dependent without limitation as to the disabling
condition.
(c) The services provided during any extension of benefits may be
subject to all limitations or restrictions contained in the contract.
1399.63. (a) Any carrier providing replacement coverage with
respect to hospital, medical or surgical expense or service benefits
within a period of 60 days from the date of discontinuance of a prior
contract or policy providing such hospital, medical or surgical
expense or service benefits shall immediately cover all employees and
dependents who were validly covered under the previous contract or
policy at the date of discontinuance, including all former employees
entitled to continuation coverage under Section 1373.621, who are
within the definitions of eligibility under the succeeding carrier's
contract and who would otherwise be eligible for coverage under the
succeeding carrier's contract, regardless of any provisions of the
contract relating to active full-time employment or hospital
confinement or pregnancy. However, with respect to employees or
dependents who are totally disabled on the date of discontinuance of
the prior carrier's contract or policy and entitled to an extension
of benefits pursuant to subdivision (b) of Section 1399.62, or
pursuant to subdivision (d) of Section 10128.2 of the Insurance Code,
the succeeding carrier is not required to provide benefits for
services or expenses directly related to any conditions which caused
the total disability.
(b) Except as otherwise provided in subdivision (a), until an
employee or dependent entitled to coverage under a succeeding carrier'
s contract pursuant to subdivision (a) of this section qualifies for
full benefits by meeting all effective date requirements of the
succeeding carrier's contract, the level of benefits shall not be
lower than the benefits provided under the prior carrier's contract
or policy reduced by the amount of benefits paid by the prior
carrier. Such employee or dependent shall continue to be covered by
the succeeding carrier until the earlier of the following dates:
(1) The date coverage would terminate for an employee or dependent
in accordance with the provisions of the succeeding carrier's
contract, or
(2) In the case of an employee or dependent who was totally
disabled on the date of discontinuance of the prior carrier's
contract or policy and entitled to an extension of benefits pursuant
to subdivision (d) of Section 10128.2 of the Insurance Code or
subdivision (b) of Section 1399. 62, the date the period of extension
of benefits terminates or, if the prior carrier's contract or policy
is not subject to this article, the date to which benefits would
have been extended had the prior carrier's contract or policy been
subject to this article.
(c) Except as otherwise provided in this section, and except to
the extent that benefits for the condition would have been reduced or
excluded under the prior carrier's contract or policy, no provision
in a succeeding carrier's contract of replacement coverage which
would operate to reduce or exclude benefits on the basis that the
condition giving rise to benefits preexisted the effective date of
the succeeding carrier's contract shall be applied with respect to
those employees, former employees entitled to continuation coverage
under Section 1373.621, and dependents validly covered under the
prior carrier's contract or policy on the date of discontinuance.
(d) In a situation where a determination of the prior carrier's
benefit is required by the succeeding carrier, at the succeeding
carrier's request, the prior carrier shall furnish a statement of
benefits available or pertinent information, sufficient to permit
verification of the benefit determination by the succeeding carrier.
(e) For purposes of subdivision (a), a succeeding carrier's
coverage shall not exclude any dependent child who was covered by the
previous carrier solely because the plan member does not provide the
primary support for that dependent child.
(f) Except to the extent that benefits for the condition would
have been reduced or excluded under the prior carrier's contract or
policy, no provision in the succeeding carrier's contract, where an
employee changes carriers due to a change in employment or other
circumstances, that would operate to reduce or exclude benefits for
the following congenital craniofacial anomalies: cleft lip and palate
(as defined in ICD-9-CM Diagnosis Code 749, International
Classification of Diseases, 9th Revision, Clinical Modification,
Volume 1, Second Edition, September, 1980), acrocephalosyndactyly (as
defined in ICD-9-CM Diagnosis Code 755.55, cranio only), and other
congenital musculoskeletal anomalies (as defined in ICD-9-CM
Diagnosis Code 756.0), on the basis that the condition giving rise to
benefits preexisted the effective date of the succeeding carrier's
contract, shall be applied to those employees, former employees
entitled to continuation coverage under Section 1373.621, and
dependents validly covered under the prior carrier's contract or
policy on the date the prior contract or policy terminated when
payment or services had been commenced by the previous carrier. That
succeeding coverage shall otherwise be subject to all other
provisions of the contract between the insured and the succeeding
carrier. Nothing in this subdivision shall be construed to limit or
otherwise affect any obligation of a succeeding carrier to provide
benefits for a condition not specified in this subdivision, where
expressly or impliedly required by other provisions of this chapter;
this subdivision is not intended to affect the construction of the
language of any other provision of this chapter.
1399.64. This article shall apply to all contracts issued,
delivered, amended, or renewed in this state after January 1, 1977. A
policy subject to the provisions of this article which is issued,
delivered, amended as to benefits, or renewed in this state on or
after the effective date of amendments to this article made at the
1977-1978 Regular Session of the Legislature shall be construed to be
in compliance with the provisions of this article and such
amendments to this article.
1399.60. The provisions of this article shall apply to all group
health care service contracts issued in this state pursuant to this
chapter.
1399.61. In this article, unless the context otherwise requires:
(a) "Carrier" shall mean the health care service plan or other
entity responsible for the payment of benefits or provision of
services under a group contract.
(b) "Dependent" shall have the meaning set forth in a contract.
(c) "Discontinuance" shall mean the termination of the contract
between the entire employer unit under a contract and the health care
service plan, and does not refer to the termination of any agreement
between any individual member under a contract and the health care
service plan.
(d) "Employee" shall mean all agents, employees, and members of
unions or associations to whom benefits are provided under a
contract.
(e) "Extension of benefits" shall mean the continuation of
coverage under a particular benefit provided under a contract
following discontinuance with respect to an employee or dependent who
is totally disabled on the date of discontinuance.
(f) "Contract" shall mean any group health care service plan or
contract subject to the provisions of this article.
(g) "Contractholder" shall mean the entity to which a contract is
issued.
(h) "Dues" shall mean the consideration payable to the carrier.
(i) "Replacement coverage" shall mean the benefits provided by a
succeeding carrier.
(j) "Totally disabled" shall have the meaning set forth in a
contract.
1399.62. (a) Every contract containing hospital, medical, or
surgical expense benefits or service benefits shall contain a
reasonable extension of such benefits upon discontinuance of the
contract with respect to employees or dependents who become totally
disabled while enrolled under the contract on or after the date this
article becomes applicable to such contract and who continue to be
totally disabled at the date of discontinuance of the contract.
(b) Every contract providing hospital, medical or surgical expense
benefits or service benefits shall be deemed to include a reasonable
extension of such benefits upon discontinuance of the contract if it
provides benefits for covered services directly relating to the
condition causing total disability existing at the time dues payments
cease for the employee or dependent and incurred during a period of
not less than 12 months thereafter, which period shall not be
interrupted by discontinuance of the contract.
That extension of benefits may be terminated at such time as the
employee or dependent is no longer totally disabled or at such time
as a succeeding carrier may elect to provide replacement coverage to
that employee or dependent without limitation as to the disabling
condition.
(c) The services provided during any extension of benefits may be
subject to all limitations or restrictions contained in the contract.
1399.63. (a) Any carrier providing replacement coverage with
respect to hospital, medical or surgical expense or service benefits
within a period of 60 days from the date of discontinuance of a prior
contract or policy providing such hospital, medical or surgical
expense or service benefits shall immediately cover all employees and
dependents who were validly covered under the previous contract or
policy at the date of discontinuance, including all former employees
entitled to continuation coverage under Section 1373.621, who are
within the definitions of eligibility under the succeeding carrier's
contract and who would otherwise be eligible for coverage under the
succeeding carrier's contract, regardless of any provisions of the
contract relating to active full-time employment or hospital
confinement or pregnancy. However, with respect to employees or
dependents who are totally disabled on the date of discontinuance of
the prior carrier's contract or policy and entitled to an extension
of benefits pursuant to subdivision (b) of Section 1399.62, or
pursuant to subdivision (d) of Section 10128.2 of the Insurance Code,
the succeeding carrier is not required to provide benefits for
services or expenses directly related to any conditions which caused
the total disability.
(b) Except as otherwise provided in subdivision (a), until an
employee or dependent entitled to coverage under a succeeding carrier'
s contract pursuant to subdivision (a) of this section qualifies for
full benefits by meeting all effective date requirements of the
succeeding carrier's contract, the level of benefits shall not be
lower than the benefits provided under the prior carrier's contract
or policy reduced by the amount of benefits paid by the prior
carrier. Such employee or dependent shall continue to be covered by
the succeeding carrier until the earlier of the following dates:
(1) The date coverage would terminate for an employee or dependent
in accordance with the provisions of the succeeding carrier's
contract, or
(2) In the case of an employee or dependent who was totally
disabled on the date of discontinuance of the prior carrier's
contract or policy and entitled to an extension of benefits pursuant
to subdivision (d) of Section 10128.2 of the Insurance Code or
subdivision (b) of Section 1399. 62, the date the period of extension
of benefits terminates or, if the prior carrier's contract or policy
is not subject to this article, the date to which benefits would
have been extended had the prior carrier's contract or policy been
subject to this article.
(c) Except as otherwise provided in this section, and except to
the extent that benefits for the condition would have been reduced or
excluded under the prior carrier's contract or policy, no provision
in a succeeding carrier's contract of replacement coverage which
would operate to reduce or exclude benefits on the basis that the
condition giving rise to benefits preexisted the effective date of
the succeeding carrier's contract shall be applied with respect to
those employees, former employees entitled to continuation coverage
under Section 1373.621, and dependents validly covered under the
prior carrier's contract or policy on the date of discontinuance.
(d) In a situation where a determination of the prior carrier's
benefit is required by the succeeding carrier, at the succeeding
carrier's request, the prior carrier shall furnish a statement of
benefits available or pertinent information, sufficient to permit
verification of the benefit determination by the succeeding carrier.
(e) For purposes of subdivision (a), a succeeding carrier's
coverage shall not exclude any dependent child who was covered by the
previous carrier solely because the plan member does not provide the
primary support for that dependent child.
(f) Except to the extent that benefits for the condition would
have been reduced or excluded under the prior carrier's contract or
policy, no provision in the succeeding carrier's contract, where an
employee changes carriers due to a change in employment or other
circumstances, that would operate to reduce or exclude benefits for
the following congenital craniofacial anomalies: cleft lip and palate
(as defined in ICD-9-CM Diagnosis Code 749, International
Classification of Diseases, 9th Revision, Clinical Modification,
Volume 1, Second Edition, September, 1980), acrocephalosyndactyly (as
defined in ICD-9-CM Diagnosis Code 755.55, cranio only), and other
congenital musculoskeletal anomalies (as defined in ICD-9-CM
Diagnosis Code 756.0), on the basis that the condition giving rise to
benefits preexisted the effective date of the succeeding carrier's
contract, shall be applied to those employees, former employees
entitled to continuation coverage under Section 1373.621, and
dependents validly covered under the prior carrier's contract or
policy on the date the prior contract or policy terminated when
payment or services had been commenced by the previous carrier. That
succeeding coverage shall otherwise be subject to all other
provisions of the contract between the insured and the succeeding
carrier. Nothing in this subdivision shall be construed to limit or
otherwise affect any obligation of a succeeding carrier to provide
benefits for a condition not specified in this subdivision, where
expressly or impliedly required by other provisions of this chapter;
this subdivision is not intended to affect the construction of the
language of any other provision of this chapter.
1399.64. This article shall apply to all contracts issued,
delivered, amended, or renewed in this state after January 1, 1977. A
policy subject to the provisions of this article which is issued,
delivered, amended as to benefits, or renewed in this state on or
after the effective date of amendments to this article made at the
1977-1978 Regular Session of the Legislature shall be construed to be
in compliance with the provisions of this article and such
amendments to this article.
