2015 -- H 6218

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LC002698

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2015

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A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

     

     Introduced By: Representatives McLaughlin, Barros, MacBeth, Shekarchi, and

     Date Introduced: May 20, 2015

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

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     SECTION 1. Section 27-18-79 of the General Laws in Chapter 27-18 entitled "Accident

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and Sickness Insurance Policies" is hereby amended to read as follows:

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     27-18-79. Discretionary clauses. -- (a) No new or existing policy or certificate issued by

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an insurer or health care entity may contain any provision:

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      (1) Purporting to reserve sole discretion to the insurer or health care entity to determine

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eligibility for benefits or interpret the terms of a policy or certificate; or

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      (2) Specifying or affecting a standard of review upon which a court may review denial of

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a claim or any other decision made by an insurance company with respect to a policyholder or

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certificate holder.

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     (3) Requiring pre-authorization from a review board of the insurer and/or co-payment for

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any medical testing employing or utilizing x-rays, magnetic resonance imaging (MRI), CAT

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scans, or ultrasound, in cases where there is an immediate, substantial and imminent threat to the

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person's health, provided:

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     (i) That the existence of the immediate, substantial and imminent threat to the person's

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health is certified by a duly licensed physician in Rhode Island;

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     (ii) That the medical testing is authorized and recommended by a duly licensed physician

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in Rhode Island; and

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     (iii) The medical testing is conducted at a medical health care facility duly licensed by the

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Rhode Island department of health.

 

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     (A) As used in this section, an "immediate, substantial and imminent threat to the

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person’s health," shall include, but not be limited to, any disease, infection, injury, or other

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condition that has, in the physician’s opinion, a high likelihood of causing permanent or severe

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injury or death.

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      (b) For purposes of this section, "health care entity" means a health insurance company

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or nonprofit hospital or medical or dental service corporation or plan or health maintenance

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organization which operates or administers a health plan in this state.

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      (c) Any such clause or language included in a contract, policy or certificate issued to or

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covering a resident of this state that is contrary to or inconsistent with the provisions of this

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section is void and unenforceable.

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      (d) Nothing in this section prohibits an insurer from including a provision in a contract

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that informs an insured that as part of its routine operations the insurer applies the terms of its

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contracts for making decisions, including making determinations regarding eligibility, receipt of

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benefits and claims, or explaining policies, procedures, and processes, so long as the provision

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could not give rise to a deferential standard of review by any reviewing court.

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     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

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     This act would prohibit an insurer or health care entity from requiring pre-authorization

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and/or co-payments for certain medical testing prescribed by a physician where the physician

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determines there is an immediate, substantial and imminent threat to the person's health.

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     This act would take effect upon passage.

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