Current through August, 2024
Section 1 PURPOSE
This regulation is promulgated to eliminate unfair
discrimination in health insurance policies and contracts covering Vermont
residents.
Currently, men are able to purchase health insurance policies
which provide coverage for virtually all types of medical expenses. Women
cannot obtain this type of comprehensive health insurance at comparable prices.
Benefits for medical expenses attributable to pregnancy, including related
conditions, are typically excluded from health insurance policies and
contracts. When such coverage is available, it can only be obtained at rates
significantly higher than the rates charged for policies sold to men.
The Vermont Legislature has prohibited unfair discrimination
based on sex in the issuance of insurance policies and contracts. Inclusion of
coverage for maternity related medical expenses in health insurance policies
eliminates such unfair discrimination.
Section 2 AUTHORITY
This regulation is issued pursuant to the authority of the
Commissioner of Banking and Insurance to promulgate regulations. 8 V.S.A.
Section 75. The regulation is based on the legislative prohibition against
unfair discrimination based on sex. See
8 V.S.A. Sections
4062 and
4724(7)
(b).
Section 3 APPLICABILITY
(a) This regulation applies to all health
insurers, non-profit hospital and medical service corporations and health
maintenance organizations transacting the business of insurance in Vermont. All
health insurance policies and contracts sold in Vermont are subject to this
regulation, including but not limited to policies and contracts for payment of
medical expenses incurred and for indemnification of insureds. This regulation
does not limit the scope of insurance coverage set forth in Regulation
80-1.
(b) The regulation does not
apply to policies or contracts issued on a specified disease or accident basis.
In addition, this regulation does not apply to disability income
policies.
(c) The regulation shall
apply to all health insurance policies and contracts issued or renewed on or
after October 1, 1989. If the policy has no renewal date, this regulation will
apply on the first anniversary of the policy effective date following the date
on which this regulation takes effect.
Section 4 DEFINITION
"Complication of Pregnancy" shall include but not be limited
to:
(1) conditions, requiring hospital
confinement (when the pregnancy is not terminated), whose diagnosis are
distinct from pregnancy but are adversely affected by pregnancy or are caused
by pregnancy, such as acute nephritis, nephroses, cardiac decompensation,
missed abortion and similar medical and surgical conditions of comparable
severity, but shall not include false labor, occasional spotting, physician
prescribed rest during the period of pregnancy, morning sickness, hyperemesis
gravidarum, pre-eclampsia and similar conditions associated with the management
of a difficult pregnancy not constituting a nosologically distinct complication
of pregnancy; and
(2) non-elective
cesarean section, ectopic pregnancy which is terminated and spontaneous
termination of pregnancy, which occurs during a period of gestation in which a
viable birth is not possible.
Section
5 REQUIREMENTS
(a) All health
insurance policies and contracts, unless expressly excluded by this regulation,
shall provide maternity coverage. Maternity coverage means the payment of
benefits to insureds for medical expenses resulting from pregnancy, childbirth,
prenatal care, and related conditions and complications. This coverage shall be
subject to the same deductibles, durational limits and co-insurance factors as
other conditions, illnesses or accidents covered by the policy or
contract.
(b) No health insurance
policy or contract shall limit the terms, conditions or benefits for maternity
coverage except to the extent that such terms, conditions, or benefits for
other conditions or illnesses are so limited under the policy or
contract.
(c) maternity coverage
may be limited or excluded as a pre-existing condition provision only to the
extent that all other illnesses and conditions are so limited or excluded. In
the event of a change of coverage or insurance carriers, the pre-existing
limitation, exclusion or waiting period, if any, shall be applied equally to
all conditions. However, the six month maximum waiting period for certain
conditions established by Regulation 80-1 does not apply in determining whether
or not a waiting period for maternity coverage is discriminatory. This
provision does not impose a requirement that a new policy or contract must have
a waiting period or exclusion.
(d)
Insurers, non-profit hospital and medical service corporations and health
maintenance organizations shall refile their policies and contracts to provide
the required coverage within thirty days after the date on which this
regulation is adopted. Policies or contracts which are exempt or which already
include coverages provided for in this regulation need not be
refiled.
Section 6
SEVERABILITY
Should a court hold any provision of this regulation invalid
or inapplicable to any person, the remainder of the regulation or the
application of it to other persons shall not be affected.
Statutory Authority: 8 V.S.A. §
75
