H. B. 2212

(By Delegates Warner, Pulliam, Adkins, Pettit

and Petersen)
[Introduced January 24, 1995; referred to the
Committee on Banking and Insurance.]

A BILL to amend and reenact section eight, article sixteen-a, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended; and to amend and reenact section seven, article twenty-eight of said chapter, all relating to group health insurance conversion; individual accident and sickness insurance minimum standards; providing a uniform definition of preexisting condition; establishing a mandatory credit for prior coverage and prohibiting exclusion for pregnancy or newborns.

Be it enacted by the Legislature of West Virginia:
That section eight, article sixteen-a, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended and reenacted; and that section seven, article twenty-eight of said chapter be amended and reenacted, all to read as follows:

ARTICLE 16A. GROUP HEALTH INSURANCE CONVERSION.

§33-16A-8. Preexisting conditions; definition; applicability;

mandatory credit; exclusion for pregnancy or newborns prohibited.

The converted policy shall not exclude a preexisting condition not excluded by the group policy. However, the converted policy may provide that any hospital, surgical or medical benefits payable thereunder may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance thereunder. The converted policy may also include provisions so that during the first policy year the benefits payable under the converted policy, together with the benefits payable under the group policy, shall not exceed those that would have been payable had the individual's insurance under the group policy remained in force and effect.
(a) A preexisting condition may include a condition existing during a specified period immediately preceding the effective date of coverage that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment; or a condition for which medical advice, diagnosis, care or treatment was recommended or received during a specified period of time.
(b) The converted policy shall not exclude a preexisting condition not excluded by the group policy. Any limitation of coverage shall not exceed a maximum period of twelve months from the effective date of coverage of the conversion policy for any preexisting condition which existed within twelve months preceding the date of coverage.
In determining whether a preexisting condition limitation provision applies to an eligible employee, insured or dependent, all health benefit plans shall credit the time such person was covered under a previous employer-based health benefit plan, a comparable individual health benefit plan, or a self-insured plan if the previous coverage was continuous to a date not more than thirty days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such plan.
(c) An exclusion of coverage for preexisting conditions may not be applied to health care services furnished for pregnancy or newborns.

ARTICLE 28. INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM

STANDARDS.

§33-28-7. Preexisting conditions; definition; applicability;

mandatory credit; exclusion for pregnancy or newborns prohibited.

(a) Notwithstanding the provisions of section four, article fifteen of this chapter if an insurer or a hospital, medical or dental service corporation elects to use a simplified application form containing no questions concerning the applicant's health history or medical treatment history, the policy or contract applied for must cover any loss occurring after twelve months from the inception date of coverage which loss is traceable to a preexisting condition as defined in section eight, article sixteen-a of this chapter not specifically excluded from coverage by the terms of the policy, and, except as so provided, the policy or contract shall not include wording which would permit a defense based upon preexisting conditions.
(b) In determining whether a preexisting condition limitation provision applies to an eligible employee or dependent, all health benefit plans shall credit the time such person was covered under a previous employer-based health benefit plan, a comparable individual health benefit plan, or a self-insured plan if the previous coverage was continuous to a date not more than thirty days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such plan.
(c) An exclusion of coverage for preexisting conditions may not be applied to health care services furnished for pregnancy or newborns.

NOTE: The purpose of this bill is to establish a uniform definition for preexisting conditions, mandatory time credits for prior coverage and prohibition of use of preexisting conditions to exclude pregnancy and newborns.

Strike-throughs indicate language that would be stricken from the present law, and underscoring indicates new language that would be added.