2016 -- H 7087

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LC003047

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2016

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives McLaughlin, MacBeth, Messier, McNamara, and Trillo

     Date Introduced: January 08, 2016

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

     SECTION 1. Section 27-18-79 of the General Laws in Chapter 27-18 entitled "Accident

and Sickness Insurance Policies" is hereby amended to read as follows:

     27-18-79. Discretionary clauses. -- (a) No new or existing policy or certificate issued by

an insurer or health care entity may contain any provision:

      (1) Purporting to reserve sole discretion to the insurer or health care entity to determine

eligibility for benefits or interpret the terms of a policy or certificate; or

      (2) Specifying or affecting a standard of review upon which a court may review denial of

a claim or any other decision made by an insurance company with respect to a policyholder or

certificate holder.

     (3) Requiring pre-authorization from a review board of the insurer and/or co-payment for

any medical testing employing or utilizing x-rays, magnetic resonance imaging (MRI), CAT

scans, or ultrasound, in cases where there is an immediate, substantial, and imminent threat to the

person's health, provided:

     (i) That the existence of the immediate, substantial, and imminent threat to the person's

health is certified by a duly licensed physician in Rhode Island;

     (ii) That the medical testing is authorized, and recommended by a duly licensed physician

in Rhode Island; and

     (iii) The medical testing is conducted at a medical health care facility duly licensed by the

Rhode Island Department of Health.

     (A) As used in this section, an "immediate, substantial, and imminent threat to the

person's health," shall include, but not be limited to, any disease, infection, injury, or other

condition that has, in the physician's opinion, a high likelihood of causing permanent or severe

injury or death.

      (b) For purposes of this section, "health care entity" means a health insurance company

or nonprofit hospital or medical or dental service corporation or plan or health maintenance

organization which operates or administers a health plan in this state.

      (c) Any such clause or language included in a contract, policy or certificate issued to or

covering a resident of this state that is contrary to or inconsistent with the provisions of this

section is void and unenforceable.

      (d) Nothing in this section prohibits an insurer from including a provision in a contract

that informs an insured that as part of its routine operations the insurer applies the terms of its

contracts for making decisions, including making determinations regarding eligibility, receipt of

benefits and claims, or explaining policies, procedures, and processes, so long as the provision

could not give rise to a deferential standard of review by any reviewing court.

     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

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     This act would prohibit an insurer or health care entity from requiring pre-authorization

and/or co-payments for certain medical testing prescribed by a physician where the physician

determines there is an immediate, substantial, and imminent threat to that person's health.

     This act would take effect upon passage.

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