Washington State Statutes - Washington Attorney Directory

48.21.200 - Group disability, health care service contract, health maintenance agreement -- Reduction or refusal of benefits on basis of other existing coverages.

(1) No individual or group disability insurance policy, health care service contract, or health maintenance agreement which provides benefits for hospital, medical, or surgical expenses shall be delivered or issued for delivery in this state which contains any provision whereby the insurer, contractor, or health maintenance organization may reduce or refuse to pay such benefits otherwise payable thereunder solely on account of the existence of similar benefits provided under any disability insurance policy, health care service contract, or health maintenance agreement.

     (2) No individual or group disability insurance policy, health care service contract, or health maintenance agreement providing hospital, medical or surgical expense benefits and which contains a provision for the reduction of benefits otherwise payable or available thereunder on the basis of other existing coverages, shall provide that such reduction will operate to reduce total benefits payable below an amount equal to one hundred percent of total allowable expenses exclusive of copayments, deductibles, and other similar cost-sharing arrangements.

     (3) The commissioner shall by rule establish guidelines for the application of this section, including:

     (a) The procedures by which persons covered under such policies, contracts, and agreements are to be made aware of the existence of such a provision;

     (b) The benefits which may be subject to such a provision;

     (c) The effect of such a provision on the benefits provided;

     (d) Establishment of the order of benefit determination;

     (e) Exceptions necessary to preserve policy, contract, or agreement requirements for use of particular health care facilities or providers; and

     (f) Reasonable claim administration procedures to expedite claim payments and prevent duplication of payments or benefits under such a provision.

[1993 c 492 § 282. Prior: 1983 c 202 § 16; 1983 c 106 § 24; 1975 1st ex.s. c 266 § 20.]

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