Current through Register Vol. 49, No. 9, September, 2024
SECTION 1.
PURPOSE
The purpose of this rule is to eliminate the act of denying
benefits or coverage on the basis of sex or marital status in the terms and
conditions of insurance contracts and in the underwriting criteria of insurance
carriers. This rule is directed at eliminating two forms of discrimination:
(1) overt discrimination which is the
act of explicitly and intentionally denying benefits of coverage on the basis
of sex,
(2) disparate treatment of
the sexes, which is the practice of applying different rules for each sex when
the same situation prevails.
SECTION
2.
AUTHORITY
This rule is issued pursuant to the power given to the Insurance
Commissioner by Ark. Code Ann. §§
23-61-108,
23-79-109,
23-66-201, et
seq.,25-15-201,
et seq., and other applicable provisions of the Arkansas
Insurance Code.
SECTION 3.
APPLICABILITY AND SCOPE
This rule shall apply to all contracts delivered or issued for
delivery in This State by an insurer on or after the effective date of this
rule and to all existing group contracts which are amended or renewed on or
after the effective date of this rule, including group contracts issued in
another State insofar as their coverage of residents of this State is
concerned. This rule does not apply to or affect the right of fraternal benefit
societies to determine eligibility requirements for membership. If a fraternal
benefit society does, however, admit members of both sexes, this rule is
applicable to the insurance benefits available to members thereof.
SECTION 4.
EFFECTIVE
DATE
This rule shall be effective January 1, 2006. Until that time,
Rule 19, effective January 1, 1985, will remain in effect.
SECTION 5.
DEFINITIONS
A.
"Insurer" means any stock or mutual insurance company, reciprocal insurer,
stipulated premium insurer, mutual assessment life or accident and health
insurer, farmers mutual aid association, hospital or medical services
corporation, health maintenance organization, or fraternal benefit
society.
B. "Contract" or "policy"
shall mean any contract or policy of insurance, coverage by a health
maintenance organization, indemnity, medical or hospital service, suretyship or
annuity issued, proposed for issuance, or intended for issuance by any
person.
C. The following services
will be considered "Complications of Pregnancy":
(1) Hospital confinement required to treat
conditions, such as the following, in a pregnant female:
(1) acute nephritis;
(2) nephrosis;
(3) cardiac decompensation;
(4) HELLP syndrome;
(5) uterine rupture;
(6) amniotic fluid embolism;
(7) chorioamnionitis;
(8) fatty liver in pregnancy;
(9) septic abortion;
(10) placenta accreta;
(11) gestational hypertension;
(12) puerperal sepsis;
(13) peripartum cardiomyopathy;
(14) cholestasis in pregnancy;
(15) thrombocytopenia in pregnancy;
(16) placenta previa;
(17) placental abruption;
(18) acute cholecystitis and pancreatitis in
pregnancy;
(19) postpartum
hemmorrhage;
(20) septic pelvic
thromboplebitis;
(21) retained
placenta;
(22) venous air embolus
associated with pregnancy;
(23)
miscarriage; or
(24) an emergency
c-section required because of (a) fetal or maternal distress during labor, or
(b) severe pre-eclampsia, or (c) arrest of descent or dilitation, or (d)
obstruction of the birth canal by fibroids or ovarian tumors, or (e) necessary
because of the sudden onset of a medical condition manifesting itself by acute
symptoms of sufficient severity that, in the absence of immediate medical
attention, will result in placing the life of the mother or fetus in jeopardy.
For purposes of this paragraph, a c-section delivery is not considered to be an
emergency c-section if it is merely for the convenience of the patient and/or
doctor or solely due to a previous c-section.
(2) Treatment, diagnosis or care for
conditions, including the following, in a pregnant female when the condition
was caused by, necessary because of, or aggravated by the pregnancy:
(1) hyperthyroidism,
(2) hepatitis B 0r C,
(3) HIV
(4) Human papilloma virus,
(5) abnormal PAP,
(6) syphilis,
(7) chlamydia,
(8) herpes,
(9) urinary tract infections,
(10) thromboembolism,
(11) appendicitis,
(12) hypothyroidism,
(13) pulmonary embolism,
(14) sickle cell disease,
(15) tuberculosis,
(16) migraine headaches,
(17) depression,
(18) acute myocarditis,
(19) asthma,
(20) maternal cytomegalovirus,
(21) urolithiasis,
(22) DVT prophylaxis,
(23) ovarian dermoid tumors,
(24) biliary atresia and/or
cirrhosis,
(25) first trimester
adnexal mass,
(25) hyditidiform
mole or
(26) ectopic
pregnancy.
D.
"Accident and health insurer" means any insurer which issues "accident and
health" insurance as defined in Ark. Code Ann. §
23-62-103,
a hospital or medical services corporation or a health maintenance
organization.
SECTION 6.
UNDERWRITING
Availability of any contract shall not be denied to an insured or
prospective insured on the basis of sex or marital status of the insured or
prospective insured. However, nothing in this rule shall prohibit an insurer
from taking marital status into account for the purpose of defining persons
eligible for dependent's benefits. Specific examples of practices prohibited by
this rule include but are not limited to the following:
A. Denying coverage to females gainfully
employed at home, employed part time or employed by relatives when coverage is
offered to males similarly employed.
B. Denying benefits offered by policy riders
to females when the riders are available to males.
C. Requiring the purchase of family coverage
under individual or group accident and health policies providing hospital or
medical expense benefits as a prerequisite to obtaining maternity
benefits.
D. Denying, under group
contracts, coverage as dependents to husbands of female employees, when similar
dependent coverage is available to wives of male employees.
E. Denying disability income contracts to
employed females when coverage is offered to males similarly
employed.
SECTION 7.
CONTRACT TERMS AND CONDITIONS
The amount of benefits payable, or any term, condition or type of
coverage shall not be restricted, modified, excluded, or reduced on the basis
of the sex or marital status of the insurer or prospective insured. Specific
practices prohibited by this rule shall include but not be limited to the
following:
A. Treatment of
complications of pregnancy on a different basis from any other illness or
sickness under the contract. Pregnancy on the effective date of the contract
may be considered a pre-existing condition to the complication of
pregnancy.
B. Restriction,
reduction, modification or exclusion of benefits for disorders of the genital
organs of only one sex.
C.
Application of arbitrary waiting period to maternity benefits in such a way as
to exclude coverage for premature births when normal maternity benefits are
included in the contract.
D.
Offering of lower maximum benefits to females than to males who are in the same
risk classifications, solely because of sex.
E. Providing more restrictive benefit periods
or more restrictive definitions of the risk assumed under the contract to one
sex than to the other.
F.
Establishing different conditions under which the policyholder may exercise
benefit options contained in a contract where the differences are determined by
the sex of the insured.
G. Limiting
the amount of coverage an insured or prospective insured may purchase based on
the insured's or prospective insured's marital status.
H. Denying benefits for normal pregnancy to
an unmarried female when such benefits are available to a married female.
However, this does not mandate coverage for normal pregnancy benefits for
dependent children.
SECTION
8.
RATES
When rates are differentiated on the basis of sex, the insurer
must justify in writing to the satisfaction of the Commissioner, the rate
differential. All rates shall be based on sound actuarial principles and a
valid classification system and must be related to actual loss statistics, and
must use proven loss statistics, where possible.
SECTION 9.
CONVERSION
A. If a
dependent spouse becomes ineligible for continuation of coverage under a group
insurance contract due to change in marital status, the dependent spouse will
be eligible to convert to an individual policy subject to the conditions of the
group policy dealing with conversion privileges.
B. Change in marital status shall not be used
as a reason for denying group conversion coverage to group members who wish to
exercise their group conversion privileges.
SECTION 10.
REVISION OF POLICY
FORMS AND CERTIFICATION
A. All
policy forms previously filed and approved by the Department need not be
refiled if such forms meet the requirements of this rule. Any previously
approved forms which are to be used in this State and which do not comply must
be revised and resubmitted in duplicate, with a duplicate letter of
transmittal, in accordance with this rule.
B. All new or revised filings submitted must
contain a certification that the submission meets the provisions of this rule
as well as all applicable requirements of this Department.
SECTION 11.
SEVERABILITY
Any section or provisions of this rule held by a court to be
invalid or unconstitutional will not affect the validity of any other section
or provision of this rule.
(Signed by Julie Benafield Bowman)
__________________________________
JULIE BENAFIELD BOWMAN
INSURANCE COMMISSIONER
STATE OF ARKANSAS
(signed November 28, 2005)
__________________________________
DATE
