North Carolina Administrative Code
Title 11 - INSURANCE
Chapter 12 - LIFE AND HEALTH DIVISION
Section .1800 - PPO BENEFIT PLAN PRODUCT LIMITATIONS
Section 12 .1903 - JUSTIFICATION OF ADVERSE INSURANCE DECISIONS
Current through Register Vol. 39, No. 6, September 16, 2024
An insurer or insurance professional that takes an action that adversely affects an applicant or insured on the basis of a medical condition that the health insurer or insurance professional knows or has reason to know is abuse-related shall explain the reason for its action to the applicant or insured in writing and shall be able to demonstrate that its action, and any applicable plan provision:
(1) Does not have the purpose or effect of treating abuse status as a medical condition or underwriting criterion;
(2) Is not based upon any actual or perceived correlation between a medical condition and abuse;
(3) Is otherwise permissible by law and applies in the same manner and to the same extent to all applicants and insureds with a similar medical condition without regard to whether the condition or claim is abuse-related; and
(4) Except for claim actions, is based on a determination, made in conformance with sound actuarial principles and supported by actual or reasonably anticipated experience, that there is a correlation between the medical condition and a material increase in insurance risk.
Authority
G.S.
58-2-40;
58-63-65;
Eff. April
1, 2010;
Pursuant to
G.S.
150B-21.3A, rule is necessary without
substantive public interest Eff. May 1, 2018.
