10128. The provisions of this article shall apply to all policies
of group life insurance issued in this state pursuant to the
provisions of Sections 10202, 10202.7, 10202.8, 10203 and 10203.7, to
all group disability policies issued in this state pursuant to the
provisions of Section 10270.5, to any group nonprofit hospital
service contract issued in this state pursuant to the provisions of
Section 11512.2, and to any self-insured welfare benefit plan issued
in this state as defined in Section 10121.
10128.1. In this article, unless the context otherwise requires:
(a) "Carrier" means the insurance company, nonprofit hospital
service corporation, or other entity responsible for the payment of
benefits or provision of services under a policy.
(b) "Dependent" shall have the meaning set forth in a policy.
(c) "Discontinuance" shall mean the termination of a policy or the
termination of coverage between an entire employer unit under a
group disability policy, group nonprofit hospital service contract or
self-insured welfare benefit plan, and does not refer to the
termination of any agreement between any individual member under a
contract and the disability insurer, nonprofit hospital service
contract or self-insured welfare benefit plan.
(d) "Employee" means all agents, employees, and members of unions
or associations to whom benefits are provided under a policy.
(e) "Extension of benefits" means the continuation of coverage
under a particular benefit provided under a policy following
discontinuance with respect to an employee or dependent who is
totally disabled on the date of discontinuance.
(f) "Policy" means any group insurance policy, group hospital
service contract or other plan, contract or policy subject to the
provisions of this article.
(g) "Policyholder" means the entity to which a policy or contract
specified in Section 10128 is issued.
(h) "Premium" means the consideration payable to the carrier.
(i) "Replacement coverage" means the benefits provided by a
succeeding carrier.
(j) "Totally disabled" shall have the meaning set forth in a
policy.
10128.2. Every policy containing a life insurance benefit shall
contain a reasonable extension of such benefit upon discontinuance of
the policy with respect to employees who become totally disabled
while insured under the policy on or after the date this article
becomes applicable to such policy and who continue to be totally
disabled at the date of discontinuance of the policy. Every policy
containing a loss of time benefit, a specific indemnity during
hospital confinement, or a hospital, medical, or surgical expense
benefit shall contain a reasonable extension of such benefits upon
discontinuance of the policy with respect to employees or dependents
who become totally disabled while insured under the policy on or
after the date this article becomes applicable to such policy and who
continue to be totally disabled at the date of discontinuance of the
policy.
(a) Every policy containing a life insurance benefit which does
not contain a disability benefit provision of any type (e.g. premium
waiver extension, extended death benefit in event of total
disability, or payment of income for a specified period during total
disability), shall be deemed to include a reasonable extension of
benefits upon discontinuance of the policy if it provides the totally
disabled employee the same rights of conversion to an individual
life insurance policy at the time of discontinuance of the policy
that such employee would have had if his employment or association
membership had terminated on the same date.
The rights of conversion specified above need not be provided with
regard to any amount of insurance for which the employee becomes
insured under any replacement coverage.
(b) Every policy containing a life insurance benefit which
contains a disability benefit provision of any type shall be deemed
to include a reasonable extension of benefits upon discontinuance of
the policy if it provides:
(1) Such discontinuance does not affect the disability benefit;
and
(2) The rights of conversion described in (a) above shall apply to
the amount the individual is insured for at the termination of the
disability benefit unless the disability benefit is a payment of
income for a specified period, in which event the rights of
conversion would apply to the amount of life insurance, if any,
remaining after the payment of income; and
(3) With respect to any amounts of life insurance provided under
the policy to which no disability benefit provision applies, the
rights of conversion described in (a) above shall apply.
No extension of life insurance under either a disability benefit
or the rights of conversion specified above need be provided with
regard to any amount of insurance for which the employee becomes
insured under any replacement coverage.
(c) Every policy providing benefits for loss of time or a specific
indemnity during hospital confinement, shall be deemed to include a
reasonable extension of such benefits upon discontinuance of the
policy if such discontinuance does not affect the benefit provided.
(d) Every policy providing hospital, medical or surgical benefits
on an expense-incurred or service basis shall be deemed to include a
reasonable extension of such benefits upon discontinuance of the
policy if it provides benefits for covered expenses directly relating
to the condition causing total disability existing at the time
premium payments for the employee or dependent cease and incurred
during a period of not less than 12 months thereafter, which period
shall not be interrupted by discontinuance of the policy.
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.
(e) The benefits payable during any extension of benefits may be
subject to all limitations or restrictions contained in the policy.
10128.3. (a) Any carrier providing replacement coverage with
respect to hospital, medical or surgical benefits on an
expense-incurred or service basis within a period of 60 days from the
date of discontinuance of a prior policy providing that hospital,
medical or surgical benefits shall immediately cover all employees
and dependents who were validly covered under the previous policy at
the date of discontinuance, including all former employees entitled
to continuation coverage under Section 10116.5, who are within the
definitions of eligibility under the succeeding carrier's policy, and
who would otherwise be eligible for coverage under the succeeding
carrier's policy, regardless of any provisions of the policy 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 of the Health and Safety Code,
or pursuant to subdivision (d) of Section 10128.2, 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 policy pursuant to subdivision (a) of this section qualifies for
full benefits by meeting all effective date requirements of the
succeeding carrier's policy, the level of benefits shall not be lower
than the benefits provided under the prior carrier's policy reduced
by the amount of benefits paid by the prior carrier. The 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
policy.
(2) In the case of an employee or dependent who was totally
disabled on the date of discontinuance of the prior carrier's policy
and entitled to an extension of benefits pursuant to subdivision (b)
of Section 1399.62 of the Health and Safety Code, or subdivision (d)
of Section 10128.2, the date the period of extension of benefits
terminates, or, if the prior carrier's policy is not subject to this
article, the date to which benefits would have been extended had the
prior carrier's 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 policy, no provision in a
succeeding carrier's policy 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 policy shall be applied with respect to those
employees, former employees entitled to continuation coverage under
Section 10116.5, and dependents validly insured under the prior
carrier's 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 policy
shall not exclude coverage of a dependent child who was covered by
the previous carrier solely because the insured does not provide
primary support for that dependent child.
(f) The fraudulent failure or refusal of an employee or dependent
to disclose a preexisting condition to the succeeding carrier shall
not be ascribed to the entire group and shall not alleviate the duty
of a succeeding carrier under subdivision (a) to immediately cover
all employees, former employees entitled to continuation coverage
under Section 10116.5, and dependents who were validly covered under
the previous policy on the date of discontinuance. Any denial of
benefits on the basis of fraud shall be limited to the employee or
dependent who committed the fraud.
(g) 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 10116.5, 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.
10128.4. This article shall apply to all policies 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.
10128. The provisions of this article shall apply to all policies
of group life insurance issued in this state pursuant to the
provisions of Sections 10202, 10202.7, 10202.8, 10203 and 10203.7, to
all group disability policies issued in this state pursuant to the
provisions of Section 10270.5, to any group nonprofit hospital
service contract issued in this state pursuant to the provisions of
Section 11512.2, and to any self-insured welfare benefit plan issued
in this state as defined in Section 10121.
10128.1. In this article, unless the context otherwise requires:
(a) "Carrier" means the insurance company, nonprofit hospital
service corporation, or other entity responsible for the payment of
benefits or provision of services under a policy.
(b) "Dependent" shall have the meaning set forth in a policy.
(c) "Discontinuance" shall mean the termination of a policy or the
termination of coverage between an entire employer unit under a
group disability policy, group nonprofit hospital service contract or
self-insured welfare benefit plan, and does not refer to the
termination of any agreement between any individual member under a
contract and the disability insurer, nonprofit hospital service
contract or self-insured welfare benefit plan.
(d) "Employee" means all agents, employees, and members of unions
or associations to whom benefits are provided under a policy.
(e) "Extension of benefits" means the continuation of coverage
under a particular benefit provided under a policy following
discontinuance with respect to an employee or dependent who is
totally disabled on the date of discontinuance.
(f) "Policy" means any group insurance policy, group hospital
service contract or other plan, contract or policy subject to the
provisions of this article.
(g) "Policyholder" means the entity to which a policy or contract
specified in Section 10128 is issued.
(h) "Premium" means the consideration payable to the carrier.
(i) "Replacement coverage" means the benefits provided by a
succeeding carrier.
(j) "Totally disabled" shall have the meaning set forth in a
policy.
10128.2. Every policy containing a life insurance benefit shall
contain a reasonable extension of such benefit upon discontinuance of
the policy with respect to employees who become totally disabled
while insured under the policy on or after the date this article
becomes applicable to such policy and who continue to be totally
disabled at the date of discontinuance of the policy. Every policy
containing a loss of time benefit, a specific indemnity during
hospital confinement, or a hospital, medical, or surgical expense
benefit shall contain a reasonable extension of such benefits upon
discontinuance of the policy with respect to employees or dependents
who become totally disabled while insured under the policy on or
after the date this article becomes applicable to such policy and who
continue to be totally disabled at the date of discontinuance of the
policy.
(a) Every policy containing a life insurance benefit which does
not contain a disability benefit provision of any type (e.g. premium
waiver extension, extended death benefit in event of total
disability, or payment of income for a specified period during total
disability), shall be deemed to include a reasonable extension of
benefits upon discontinuance of the policy if it provides the totally
disabled employee the same rights of conversion to an individual
life insurance policy at the time of discontinuance of the policy
that such employee would have had if his employment or association
membership had terminated on the same date.
The rights of conversion specified above need not be provided with
regard to any amount of insurance for which the employee becomes
insured under any replacement coverage.
(b) Every policy containing a life insurance benefit which
contains a disability benefit provision of any type shall be deemed
to include a reasonable extension of benefits upon discontinuance of
the policy if it provides:
(1) Such discontinuance does not affect the disability benefit;
and
(2) The rights of conversion described in (a) above shall apply to
the amount the individual is insured for at the termination of the
disability benefit unless the disability benefit is a payment of
income for a specified period, in which event the rights of
conversion would apply to the amount of life insurance, if any,
remaining after the payment of income; and
(3) With respect to any amounts of life insurance provided under
the policy to which no disability benefit provision applies, the
rights of conversion described in (a) above shall apply.
No extension of life insurance under either a disability benefit
or the rights of conversion specified above need be provided with
regard to any amount of insurance for which the employee becomes
insured under any replacement coverage.
(c) Every policy providing benefits for loss of time or a specific
indemnity during hospital confinement, shall be deemed to include a
reasonable extension of such benefits upon discontinuance of the
policy if such discontinuance does not affect the benefit provided.
(d) Every policy providing hospital, medical or surgical benefits
on an expense-incurred or service basis shall be deemed to include a
reasonable extension of such benefits upon discontinuance of the
policy if it provides benefits for covered expenses directly relating
to the condition causing total disability existing at the time
premium payments for the employee or dependent cease and incurred
during a period of not less than 12 months thereafter, which period
shall not be interrupted by discontinuance of the policy.
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.
(e) The benefits payable during any extension of benefits may be
subject to all limitations or restrictions contained in the policy.
10128.3. (a) Any carrier providing replacement coverage with
respect to hospital, medical or surgical benefits on an
expense-incurred or service basis within a period of 60 days from the
date of discontinuance of a prior policy providing that hospital,
medical or surgical benefits shall immediately cover all employees
and dependents who were validly covered under the previous policy at
the date of discontinuance, including all former employees entitled
to continuation coverage under Section 10116.5, who are within the
definitions of eligibility under the succeeding carrier's policy, and
who would otherwise be eligible for coverage under the succeeding
carrier's policy, regardless of any provisions of the policy 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 of the Health and Safety Code,
or pursuant to subdivision (d) of Section 10128.2, 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 policy pursuant to subdivision (a) of this section qualifies for
full benefits by meeting all effective date requirements of the
succeeding carrier's policy, the level of benefits shall not be lower
than the benefits provided under the prior carrier's policy reduced
by the amount of benefits paid by the prior carrier. The 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
policy.
(2) In the case of an employee or dependent who was totally
disabled on the date of discontinuance of the prior carrier's policy
and entitled to an extension of benefits pursuant to subdivision (b)
of Section 1399.62 of the Health and Safety Code, or subdivision (d)
of Section 10128.2, the date the period of extension of benefits
terminates, or, if the prior carrier's policy is not subject to this
article, the date to which benefits would have been extended had the
prior carrier's 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 policy, no provision in a
succeeding carrier's policy 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 policy shall be applied with respect to those
employees, former employees entitled to continuation coverage under
Section 10116.5, and dependents validly insured under the prior
carrier's 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 policy
shall not exclude coverage of a dependent child who was covered by
the previous carrier solely because the insured does not provide
primary support for that dependent child.
(f) The fraudulent failure or refusal of an employee or dependent
to disclose a preexisting condition to the succeeding carrier shall
not be ascribed to the entire group and shall not alleviate the duty
of a succeeding carrier under subdivision (a) to immediately cover
all employees, former employees entitled to continuation coverage
under Section 10116.5, and dependents who were validly covered under
the previous policy on the date of discontinuance. Any denial of
benefits on the basis of fraud shall be limited to the employee or
dependent who committed the fraud.
(g) 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 10116.5, 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.
10128.4. This article shall apply to all policies 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.
10128. The provisions of this article shall apply to all policies
of group life insurance issued in this state pursuant to the
provisions of Sections 10202, 10202.7, 10202.8, 10203 and 10203.7, to
all group disability policies issued in this state pursuant to the
provisions of Section 10270.5, to any group nonprofit hospital
service contract issued in this state pursuant to the provisions of
Section 11512.2, and to any self-insured welfare benefit plan issued
in this state as defined in Section 10121.
10128.1. In this article, unless the context otherwise requires:
(a) "Carrier" means the insurance company, nonprofit hospital
service corporation, or other entity responsible for the payment of
benefits or provision of services under a policy.
(b) "Dependent" shall have the meaning set forth in a policy.
(c) "Discontinuance" shall mean the termination of a policy or the
termination of coverage between an entire employer unit under a
group disability policy, group nonprofit hospital service contract or
self-insured welfare benefit plan, and does not refer to the
termination of any agreement between any individual member under a
contract and the disability insurer, nonprofit hospital service
contract or self-insured welfare benefit plan.
(d) "Employee" means all agents, employees, and members of unions
or associations to whom benefits are provided under a policy.
(e) "Extension of benefits" means the continuation of coverage
under a particular benefit provided under a policy following
discontinuance with respect to an employee or dependent who is
totally disabled on the date of discontinuance.
(f) "Policy" means any group insurance policy, group hospital
service contract or other plan, contract or policy subject to the
provisions of this article.
(g) "Policyholder" means the entity to which a policy or contract
specified in Section 10128 is issued.
(h) "Premium" means the consideration payable to the carrier.
(i) "Replacement coverage" means the benefits provided by a
succeeding carrier.
(j) "Totally disabled" shall have the meaning set forth in a
policy.
10128.2. Every policy containing a life insurance benefit shall
contain a reasonable extension of such benefit upon discontinuance of
the policy with respect to employees who become totally disabled
while insured under the policy on or after the date this article
becomes applicable to such policy and who continue to be totally
disabled at the date of discontinuance of the policy. Every policy
containing a loss of time benefit, a specific indemnity during
hospital confinement, or a hospital, medical, or surgical expense
benefit shall contain a reasonable extension of such benefits upon
discontinuance of the policy with respect to employees or dependents
who become totally disabled while insured under the policy on or
after the date this article becomes applicable to such policy and who
continue to be totally disabled at the date of discontinuance of the
policy.
(a) Every policy containing a life insurance benefit which does
not contain a disability benefit provision of any type (e.g. premium
waiver extension, extended death benefit in event of total
disability, or payment of income for a specified period during total
disability), shall be deemed to include a reasonable extension of
benefits upon discontinuance of the policy if it provides the totally
disabled employee the same rights of conversion to an individual
life insurance policy at the time of discontinuance of the policy
that such employee would have had if his employment or association
membership had terminated on the same date.
The rights of conversion specified above need not be provided with
regard to any amount of insurance for which the employee becomes
insured under any replacement coverage.
(b) Every policy containing a life insurance benefit which
contains a disability benefit provision of any type shall be deemed
to include a reasonable extension of benefits upon discontinuance of
the policy if it provides:
(1) Such discontinuance does not affect the disability benefit;
and
(2) The rights of conversion described in (a) above shall apply to
the amount the individual is insured for at the termination of the
disability benefit unless the disability benefit is a payment of
income for a specified period, in which event the rights of
conversion would apply to the amount of life insurance, if any,
remaining after the payment of income; and
(3) With respect to any amounts of life insurance provided under
the policy to which no disability benefit provision applies, the
rights of conversion described in (a) above shall apply.
No extension of life insurance under either a disability benefit
or the rights of conversion specified above need be provided with
regard to any amount of insurance for which the employee becomes
insured under any replacement coverage.
(c) Every policy providing benefits for loss of time or a specific
indemnity during hospital confinement, shall be deemed to include a
reasonable extension of such benefits upon discontinuance of the
policy if such discontinuance does not affect the benefit provided.
(d) Every policy providing hospital, medical or surgical benefits
on an expense-incurred or service basis shall be deemed to include a
reasonable extension of such benefits upon discontinuance of the
policy if it provides benefits for covered expenses directly relating
to the condition causing total disability existing at the time
premium payments for the employee or dependent cease and incurred
during a period of not less than 12 months thereafter, which period
shall not be interrupted by discontinuance of the policy.
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.
(e) The benefits payable during any extension of benefits may be
subject to all limitations or restrictions contained in the policy.
10128.3. (a) Any carrier providing replacement coverage with
respect to hospital, medical or surgical benefits on an
expense-incurred or service basis within a period of 60 days from the
date of discontinuance of a prior policy providing that hospital,
medical or surgical benefits shall immediately cover all employees
and dependents who were validly covered under the previous policy at
the date of discontinuance, including all former employees entitled
to continuation coverage under Section 10116.5, who are within the
definitions of eligibility under the succeeding carrier's policy, and
who would otherwise be eligible for coverage under the succeeding
carrier's policy, regardless of any provisions of the policy 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 of the Health and Safety Code,
or pursuant to subdivision (d) of Section 10128.2, 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 policy pursuant to subdivision (a) of this section qualifies for
full benefits by meeting all effective date requirements of the
succeeding carrier's policy, the level of benefits shall not be lower
than the benefits provided under the prior carrier's policy reduced
by the amount of benefits paid by the prior carrier. The 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
policy.
(2) In the case of an employee or dependent who was totally
disabled on the date of discontinuance of the prior carrier's policy
and entitled to an extension of benefits pursuant to subdivision (b)
of Section 1399.62 of the Health and Safety Code, or subdivision (d)
of Section 10128.2, the date the period of extension of benefits
terminates, or, if the prior carrier's policy is not subject to this
article, the date to which benefits would have been extended had the
prior carrier's 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 policy, no provision in a
succeeding carrier's policy 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 policy shall be applied with respect to those
employees, former employees entitled to continuation coverage under
Section 10116.5, and dependents validly insured under the prior
carrier's 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 policy
shall not exclude coverage of a dependent child who was covered by
the previous carrier solely because the insured does not provide
primary support for that dependent child.
(f) The fraudulent failure or refusal of an employee or dependent
to disclose a preexisting condition to the succeeding carrier shall
not be ascribed to the entire group and shall not alleviate the duty
of a succeeding carrier under subdivision (a) to immediately cover
all employees, former employees entitled to continuation coverage
under Section 10116.5, and dependents who were validly covered under
the previous policy on the date of discontinuance. Any denial of
benefits on the basis of fraud shall be limited to the employee or
dependent who committed the fraud.
(g) 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 10116.5, 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.
10128.4. This article shall apply to all policies 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.
