Subchapter F. COVERAGE FOR NEWBORN CHILDREN
Sec.
89.201. Definitions.
89.202. Forms which need not provide newborn coverage.
89.203. Forms which must provide newborn coverage.
89.204. Inapplicability of preexisting condition limitation or waiting period limitation.
89.205. Compliance procedure.
89.206. Filing procedure.
89.207. Rates.
89.208. Deferred claims.
89.209. Retroactive compliance provisions.
Authority The provisions of this Subchapter F issued under The Insurance Company Law of 1921 (40 P. S. § § 341—991); The Insurance Department Act of 1921 (40 P. S. § § 1—321); and sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. § § 66, 186, 411 and 412), unless otherwise noted.
Source The provisions of this Subchapter F adopted September 5, 1976, effective September 6, 1976, 6 Pa.B. 2107, unless otherwise noted.
§ 89.201. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
Act 81—The act of August 1, 1975 (P. L. 157, No. 81) (40 P. S. § § 753.1—753.4).
Coverage for newborn children—The same coverage provided under the terms of the form for dependent children for sickness, disease or injury. If the form does not provide coverage for dependent children, the coverage shall be the same as that provided the insured or subscriber. For purposes of compliance with Act 81, injury or sickness shall include medically diagnosed congenital defects, birth abnormalities, prematurity and routine nursery care. If the form provides coverage for routine well baby care, the same coverage shall be provided for newborn children. The coverage shall be provided regardless of whether the form provides for obstetrical coverage.
Insured or subscriber—A person, male or female, covered under the terms of a form to which Act 81 is applicable, regardless of the covered person’s marital or dependency status or eligibility for maternity benefits.
Routine nursery care—Hospital or other qualified health care institution, room, board or miscellaneous institutional care or care rendered by a licensed medical practitioner, performing within the scope of his license, associated with hospital confinement.
Routine well-baby care—Expense for which coverage is available under a form to a covered person for preventive health care, rendered either on an inpatient or outpatient basis, not associated with treatment of an ill or injured person, such as, but not limited to, immunizations, medical examinations or tests not necessary for the treatment of covered injuries, illnesses, birth defects, deformities or diseases, and hospital room, board or miscellaneous institutional expenses.§ 89.202. Forms which need not provide newborn coverage.
Forms of insurers, other than hospital plan corporations, professional health service plan corporations, fraternal benefit societies and voluntary nonprofit health service plans, providing benefits on an indemnity basis, for example, payment on a specified amount without regard to actual expense incurred, need not provide coverage for newborn children.
§ 89.203. Forms which must provide newborn coverage.
(a) Forms providing benefits on an expense incurred or service basis shall extend the benefits to newborn children.
(b) Where a form provides both expense incurred or service benefits and indemnity benefits, for the purposes of implementation of Act 81 and this subchapter, the policy shall be considered an expense incurred or service benefit policy, and benefits thereunder shall be extended to newborn children. Accidental death or accidental death and dismemberment or disability income benefits need not be extended to newborn children, even though the form provides some expense incurred benefits.
§ 89.204. Inapplicability of preexisting condition limitation or waiting period limitation.
A form may not deny a claim for newborn coverage on the basis that the cause of the claim was a sickness or injury which existed on or prior to the effective date of the coverage or date of birth of the newborn. A form may not provide for a waiting period between the date of birth and provision of coverage for a newborn child, unless the waiting period is applicable to all insureds under the form, that is, the form provides coverage from the fourth day of hospitalization due to sickness, provided however, that upon newly issued forms a company, in order to prevent adverse selection against it by persons who may seek to buy coverage solely to have a newborn covered, may impose a limitation that the newborn child shall have been conceived on or after the effective date of coverage of the form.
§ 89.205. Compliance procedure.
Forms issued or renewed on or after November 29, 1975, shall provide at least the coverage specified in Act 81 as interpreted by this subchapter, either by amendatory rider or endorsement or appropriate revision of the form itself.
(1) The form provision shall provide that the newborn child coverage is included automatically for each newborn child for 31 days after birth and that the insured or subscriber shall have the right upon application if such is required by the insurer within the 31 day period to continue coverage beyond the 31 day period if the form provides for coverage of dependents.
(2) If the form does not provide for coverage of dependents, the insured or subscriber shall have the right, upon application within 31 days of the birth of the newborn, to convert to a form which shall provide substantially similar benefits, or to add an appropriate coverage rider to the existing form.
§ 89.206. Filing procedure.
(a) Insurers subject to Act 81 and this subchapter shall submit for review and approval compliance riders or endorsements to affected, currently approved and in-use forms.
(b) Prior to January 1, 1977, required changes in forms submitted for review and approval may contain required Act 81 amendments by an amendatory rider, or the changes may be incorporated into the text of the new or revised policy submission. After that date, contracts submitted for review and approval shall contain Act 81 compliance provisions within the text of the form itself. A form submission made prior to January 1, 1977, should specify within its submission letter how Act 81 has been or will be complied with in the form so submitted.
§ 89.207. Rates.
A necessary and appropriate change in currently approved premium rates required by the 31 day newborn coverage period extension shall be submitted for review and approval in accordance with applicable statutory authority.
§ 89.208. Deferred claims.
Coverage for claims incurred during the 31 day newborn coverage period, extending beyond the period in those cases wherein no valid application for continuation of coverage is made on behalf of the newborn, shall be covered in accordance with the termination provisions otherwise applicable to other covered members.
§ 89.209. Retroactive compliance provisions.
(a) An insurer shall provide affected insureds with a compliance rider, which shall be retroactively effective to November 29, 1975, or a later form renewal date that may be applicable.
(b) An insurer shall retroactively evaluate claims arising on or after November 29, 1975, for applicability of Act 81 and this subchapter in claims settlement.
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