Code of Massachusetts Regulations
805 CMR - GROUP INSURANCE COMMISSION
Title 805 CMR 9.00 - ELIGIBILITY AND PARTICIPATION
Section 9.15 - Misstatement of Information and Misuse of Benefit Plans

(1) An Insured's coverage may be terminated, in addition to other civil or criminal penalties, if the Commission determines that the Insured provided incorrect information in submitting a medical evidence of insurability or other such form that resulted in approval of the Insured's coverage request. The Commission shall establish the extent and duration of the termination.

(2) Any Insured who procures services fraudulently or submits false claims for himself or herself, or otherwise enables a person who is not eligible for Commission coverage to fraudulently enroll, procure services for, or submit claims for Commission coverage shall, upon determination by the Commission and, in addition to other civil or criminal penalties that may be imposed, forfeit his or her eligibility for Commission coverage. The Commission shall establish the extent and duration of the forfeiture.

(3) Personal reimbursement of out-of-country health care claims will only be provided to Insureds who produce all related records requested by the plan and, as necessary, their translation; an itemized bill for health care claimed and, as necessary, its translation; and satisfactory proof of personal payment of the claims by cancelled check or credit card statement. Reimbursement is subject to the reasonable and customary payment as determined by the health plan, based on the locality where services were rendered.