§ 58-53-95. Major medical plans.
§58‑53‑95. Major medical plans.
Subject to the provisions ofthis Article, if the group policy from which conversion is made insures theemployee or member for major medical expense insurance, the employee or membershall be entitled to obtain a converted policy providing catastrophic or majormedical coverage under a plan meeting the following requirements:
(1) A maximum benefit atleast equal to either, at the option of the insurer,
a. A maximum paymentper covered person for all covered medical expenses incurred during thatperson's lifetime, equal to the lesser of the maximum benefit provided underthe group policy or one hundred thousand dollars ($100,000); or
b. A maximum paymentfor each unrelated injury or sickness, equal to the lesser of the maximumbenefit provided under the group policy or one hundred thousand dollars($100,000).
(2) Payment of benefitsat the rate of eighty percent (80%) of covered medical expenses that are inexcess of the deductible, until twenty percent (20%) of such expenses in abenefit period reaches one thousand dollars ($1,000), after which benefits willbe paid at the rate of one hundred percent (100%) during the remainder of suchbenefit period. Payment of benefits for outpatient treatment of mental illness,if provided in the converted policy, may be at a lesser rate but not less thanfifty percent (50%).
(3) A deductible foreach benefit period which, at the option of the insurer, shall be (i) the sumof the benefits deductible and one hundred dollars ($100.00), or (ii) thecorresponding deductible in the group policy. The term "benefitsdeductible," as used in this Part, means the value of any benefitsprovided on an expense incurred basis that are provided with respect to coveredmedical expenses by any other group or individual hospital, surgical, ormedical insurance policy or medical practice or other prepayment plan, or anyother plan, or program whether insured or uninsured, or by reason of any Stateor federal law and if, pursuant to G.S. 58‑53‑100, the convertedpolicy provides both basic hospital or surgical coverage and major medicalcoverage, the value of such basic benefits.
Ifthe maximum benefit is determined by subdivision (1)a of this section, theinsurer may require that the deductible be satisfied during a period of notless than three months if the deductible is one hundred dollars ($100.00) orless, and not less than six months if the deductible exceeds one hundreddollars ($100.00).
(4) The benefit periodshall be each calendar year when the maximum benefit is determined bysubdivision (1)a of this section or 24 months when the maximum benefit isdetermined by subdivision (1)b of this section.
(5) The term"covered medical expenses," as used in this Part, shall include, inthe case of hospital room and board charges, at a minimum the lesser of thedollar amount in G.S. 58‑53‑90(a)(1) and the average semiprivateroom and board rate for the hospital in which the individual is confined, andat a minimum twice such amount for charges in an intensive care unit. Anysurgical procedures schedule shall be consistent with those customarily offeredby the insurer under group or individual health insurance policies and mustprovide at least a one thousand two hundred dollar ($1,200) maximum. (1981,c. 706, s. 1.)