Subchapter G. PREEXISTING CONDITION EXCLUSION
IN GROUP CONTRACTS
Sec.
89.401. Scope.
89.402. Approval.
89.403. Disclosure.
89.404. Preexisting condition.
89.405. Exclusion.
89.406. Acceptability.
89.407. Effective date.
Source The provisions of this Subchapter G adopted August 4, 1978, 8 Pa.B. 2182, effective date postponed until further notice January 26, 1979, 9 Pa.B. 314, unless otherwise noted.
§ 89.401. Scope.
This subchapter applies to:
(1) Policies of group accident, group sickness or group accident and sickness insurance policies, as defined in section 621.2 of the act (40 P. S. § 756.2), issued or issued for delivery in this Commonwealth.
(2) Policies of blanket accident and sickness insurance, as defined in section 621.3 of the act (40 P. S. § 756.3) issued or issued for delivery in this Commonwealth.
(3) Group master agreements issued by a hospital plan corporation subject to the prior approval of the Department under 40 Pa.C.S. § 6124 (relating to rates and contracts).
(4) Group master agreements issued by a professional health services plan corporation subject to the prior approval of the Department under 40 Pa.C.S. § 6329 (relating to rates and contracts).
(5) Blanket or group student accident sickness insurance and group mortgage disability insurance policies subject to the prior approval of the Department under section 621.2 of the act (40 P. S. § 756.2) issued or issued for delivery in this Commonwealth.
Source The provisions of this § 89.401 amended August 24, 1979, effective November 23, 1979, 9 Pa.B. 2891. Immediately preceding text appears at serial pages (39799) to (39800).
Cross References This section cited in 31 Pa. Code § 89.407 (relating to effective date).
§ 89.402. Approval.
(a) A preexisting condition limitation will not be approved for use with a policy or contract which is more restrictive than the following definition: A preexisting condition is a disease or physical condition for which medical advice or treatment has been received within 90 days immediately prior to becoming covered under the group contract. The condition shall be covered after the individual has been covered for more than 12 months under the group contract.
(b) Long-term disability benefit provisions may require that the total disability resulting from a preexisting condition commence after the individual has been covered for more than 12 months under the group contract.
Source The provisions of this § 89.402 amended August 24, 1979, effective November 23, 1979, 9 Pa.B. 2891. Immediately preceding text appears at serial page (39800).
Cross References This section cited in 31 Pa. Code § 89.404 (relating to preexisting condition).
§ 89.403. Disclosure.
(a) A disclosure statement substantially similar to the following shall be given in writing to a group member at the time of the enrollment under the group contract.
NOTICE If you or any dependents have received medical care or advice within the past 90 days for a disease or physical condition, you, he or she will not be covered for such disease or physical condition until you, he or she has been covered for one year under this contract. This exclusion, however, only applies to a disease or physical condition for which medical care or advice has been received in the past 90 days.
(b) The statement set forth in subsection (a) shall be printed in bold face type.
Authority The provisions of this § 89.403 issued under The Insurance Company Law of 1921 (40 P. S. § § 1—321); The Insurance Company Law of 1921 (40 P. S. § § 341—991); sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. § § 66, 186, 411 and 412); and 40 Pa.C.S. § § 6124 and 6329.
Source The provisions of this § 89.403 amended through June 27, 1980, effective June 28, 1980, 10 Pa.B. 2591. Immediately preceding text appears at serial page (42687).
§ 89.404. Preexisting condition.
A preexisting condition limitation defined other than as set forth in § 89.402 (relating to approval) shall substantially conform to the standards set forth in this subchapter. The preexisting condition limitation would be considered for approval by the Department only upon appropriate justification by the submitting company proposing to use it.
§ 89.405. Exclusion.
(a) Every group contract issued to a policyholder to replace another group contract shall only exclude a preexisting condition excluded by the other group policy.
(b) The provisions of subsection (a) applies to those individuals covered under the group policy being replaced.
Source The provisions of this § 89.405 amended August 24, 1979 effective November 23, 1979, 9 Pa.B. 2891. Immediately preceding text appears at serial page (39801).
§ 89.406. Acceptability.
A preexisting condition exclusion will not be acceptable in blanket or group student accident and sickness insurance and group mortgage disability insurance.
§ 89.407. Effective date.
This subchapter applies to policies and agreements set forth in § 89.401 (relating to scope) issued, renewed, substantially altered or amended, on or after November 23, 1979.
Source The provisions of this § 89.407 amended August 24, 1979, effective November 23, 1979, 9 Pa.B. 2891. Immediately preceding text appears at serial page (39801).
No part of the information on this site may be reproduced for profit or sold for profit.
This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
