Title 18, Insurance Code

§ 3381. Step therapy exception process [For application of this section, see 82 Del. Laws, c. 44, § 3]. (a) When coverage of a prescription drug for the treatment of any medical condition is restricted for use by an insurer, health plan, or utilization review entity through the u…

§ 3381A. Definitions [For application of this subchapter, see 83 Del. Laws, c. 522, § 4]. For purposes of this subchapter: (1) “Cost-sharing requirement” means any copayment, coinsurance, deductible, or annual limitation on cost-sharing (including a limitation subject to 42 U.S.C…

§ 3382A. Fairness in cost-sharing [For application of this subchapter, see 83 Del. Laws, c. 522, § 4]. (a) Cost-sharing calculation. — When calculating an enrollee’s contribution to any applicable cost-sharing requirement, a pharmacy benefits manager shall include any cost-sharin…

§ 3401. Definitions. As used in this chapter: (1) “Applicant” means: a. In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and b. In the case of a group Medicare supplement policy, the proposed certificate holder. (2)…

§ 3402. Applicability; scope. (a) Except as otherwise specifically provided in this title, this chapter shall apply to: (1) All Medicare supplement policies delivered or issued for delivery in this State on or after May 13, 1992; and (2) All certificates issued under group Medica…

§ 3403. Standards for policy provisions and authority to promulgate regulations. (a) No Medicare supplement policy or certificate in force in this State shall contain benefits that duplicate benefits provided by Medicare. (b) Notwithstanding any other provision of law of this Sta…

§ 3404. Loss ratio standards. Medicare supplement policies shall return to policyholders benefits which are reasonable in relation to the premium charged. The Commissioner shall issue reasonable regulations to establish minimum standards for loss ratios of Medicare supplement pol…

§ 3405. Disclosure standards. (a) In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no Medicare supplement policy or certificate shall be delivered in this State unless an outline of coverage is delivered to the applicant at the time ap…

§ 3406. Notice of free examination. Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certif…

§ 3407. Filing requirements for advertising. Every issuer of Medicare supplement insurance policies or certificates in this State shall provide a copy of any Medicare supplement advertisement intended for use in this State whether through written, radio or television medium to th…

§ 3408. Administrative procedures. Regulations adopted pursuant to this chapter shall be subject to the provisions of Chapter 101 of Title 29.68 Del. Laws, c. 237, § 1;

§ 3409. Penalties. In addition to any other applicable penalties for violations of the Insurance Code, the Commissioner may require issuers violating any provision of this chapter or regulations promulgated pursuant to this chapter to cease marketing any Medicare supplement polic…

§ 3410. Coverage for persons eligible for Medicare due to disability. (a) Each Medicare supplement policy or applicable certificate that an issuer currently, or at any time hereafter, makes available in this State shall be made available to any applicant under the age of 65 who i…

§ 3411. Enrollment periods. (a) A person enrolled in a Medicare supplement policy or certificate may cancel that person’s existing Medicare supplement policy or certificate and purchase or select another Medicare supplement policy or certificate with the same or lesser benefits d…

§ 3501. Group policies must meet group requirements. Except as provided in § 3509 of this title, no policy of group health insurance shall be delivered in this State unless it conforms to one of the descriptions contained in §§ 3502-3508 of this title.66 Del. Laws, c. 175, § 1;

§ 3502. Employee groups. A policy may be issued to an employer, or to the trustees of a fund established by an employer, which employer or trustees shall be deemed the policyholder, to insure employees of the employer for the benefit of persons other than the employer, subject to…

§ 3503. Debtor groups. A policy may be issued to a creditor or its parent holding company or to a trustee or trustees or agent designated by 2 or more creditors, which creditor, holding company, affiliate, trustee, trustees or agent shall be deemed the policyholder, to insure deb…

§ 3504. Labor union or employee organization groups. A policy may be issued to a labor union, or similar employee organization which shall be deemed to be the policyholder, to insure members of such union or organization for the benefit of persons other than the union or organiza…

§ 3505. Trustee groups. A policy may be issued to a trust, or to the trustee or trustees of a fund, established or adopted by 2 or more employers, or by 1 or more labor unions or similar employee organizations, or by 1 or more employers and 1 or more labor unions or similar emplo…

§ 3506. Association groups. (a) “Bona fide association” means, with respect to health insurance coverage offered in Delaware, an association which: (1) Has been actively in existence for at least 5 years; (2) Has been formed and maintained in good faith for purposes other than ob…

§ 3507. Credit union groups. A policy may be issued to a credit union or to a trustee or trustees or agent designated by 2 or more credit unions, which credit union, trustee, trustees or agent shall be deemed the policyholder, to insure members of such credit unions for the benef…

§ 3508. Discretionary groups. A policy may be issued to any other substantially similar group which, in the discretion of the Commissioner, may be subject to the issuance of a group health policy or contract.66 Del. Laws, c. 175, § 1;

§ 3509. Requirements for other groups; out-of-state groups. (a) Group health insurance offered to a resident of this State under a group health insurance policy issued to a group other than those described in §§ 3502-3508 of this title shall be subject, where applicable, to the r…

§ 3510. Disclosure requirements for other groups. (a) With respect to a program of insurance which if issued on a group basis would not qualify under §§ 3502-3508 of this title, if compensation of any kind will or may be paid to: (1) A policyholder or sponsoring or endorsing enti…

§ 3511. Dependents’ coverage. Except for a policy issued under § 3503 of this title, a group health insurance policy may be extended to insure the employees or members with respect to their family members or dependents, or any class or classes thereof, subject to the following: (…

§ 3512. Group health insurance standard provisions generally. No policy of group health insurance shall be delivered in this State unless it contains in substance the provisions set forth in §§ 3513-3527 of this title or provisions which in the opinion of the Commissioner are mor…

§ 3513. Grace period. A group health insurance policy shall contain a provision that the policyholder is entitled to a grace period of 31 days for the payment of any premium due except the first, during which grace period the policy shall continue in force, unless the policyholde…

§ 3514. Incontestability. A group health insurance policy shall contain a provision that the validity of the policy shall not be contested except for nonpayment of premiums, after it has been in force for 2 years from its date of issue; and that no statement made by any person co…

§ 3515. Application; statements deemed representations. A group health insurance policy shall contain a provision that a copy of the application, if any, of the policyholder shall be attached to the policy when issued, that all statements made by the policyholder or by the person…

§ 3516. Insurability. A group health insurance policy shall contain a provision setting forth the conditions, if any, under which the insurer reserves the right to require a person eligible for insurance to furnish evidence of individual insurability satisfactory to the insurer a…

§ 3517. Preexisting conditions; limits [For application of this section, see 79 Del. Laws, c. 99, § 19]. (a) A group health insurance policy shall not include a provision that excludes coverage, and a health insurer shall not deny a claim under the policy, as a result of a diseas…

§ 3518. Misstatement of age. If the premiums or benefits vary by age, there shall be a provision specifying an equitable adjustment of premiums or of benefits, or both, to be made in the event the age of a covered person has been misstated, such provision to contain a clear state…

§ 3519. Certificate. A group health insurance policy shall contain a provision that the insurer will issue to the policyholder for delivery to each person insured a certificate setting forth a statement as to the insurance protection to which that person is entitled, to whom the …

§ 3520. Notice of claim. A group health insurance policy shall contain a provision that written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy. Failure to give notice within such time shall not in…

§ 3521. Claim forms. A group health insurance policy shall contain a provision that the insurer will furnish to the person making claim, or to the policyholder for delivery to such person, such forms as are usually furnished by it for filing proof of loss. If such forms are not f…

§ 3522. Proofs of loss; disability. When applicable, a group health insurance policy shall contain a provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within 90 days after the commencement of the perio…

§ 3523. Time for payment of benefits. A group health insurance policy shall contain a provision that all benefits payable under the policy other than benefits for loss of time will be payable not more than 60 days after receipt of proof, and that, subject to due proof of loss, al…

§ 3524. Payment of benefits. A group health insurance policy shall contain a provision that benefits for loss of life of the person insured shall be payable to the beneficiary designated by the person insured. However, if the policy contains conditions pertaining to family status…

§ 3525. Physical examinations. A group health insurance policy shall contain a provision that the insurer shall have the right and opportunity to examine the person or the individual for whom claim is made when and so often as it may reasonably require during the pendency of clai…

§ 3526. Legal actions. A group health insurance policy shall contain a provision that no action at law or in equity shall be brought to recover on the policy prior to the expiration of 90 days after proof of loss has been filed in accordance with the requirements of the policy an…

§ 3527. Information to debtors. In the case of a policy insuring debtors, a group health insurance policy shall contain a provision that the insurer will furnish to the policyholder for delivery to each debtor insured under the policy a certificate of insurance describing the cov…

§ 3528. Direct payment of hospital or medical services. Any group health policy may provide that all or any portion of any indemnities provided by any such policy on account of hospital, nursing, medical or surgical services may, at the insurer’s option, be paid directly to the h…

§ 3529. Readjustment of premiums; dividends. Any contract of group health insurance may provide for the readjustment of the rate of premium based upon the experience thereunder. If a policy dividend is hereafter declared or a reduction in rate is hereafter made or continued for t…

§ 3530. Limitations on preexisting condition limitations for minor children [Repealed].78 Del. Laws, c. 141, § 2; repealed by 82 Del. Laws, c. 186, § 3, effective Aug. 6, 2019.;

§ 3540. “Blanket health insurance” defined. Blanket health insurance is hereby declared to be that form of health insurance covering groups of persons as enumerated in 1 of the following paragraphs: (1) Under a policy or contract issued to any common carrier or to any operator, o…

§ 3541. Filing and required provisions in blanket policies. Any insurer authorized to write health insurance in this State shall have the power to issue blanket health insurance. No such blanket policy, except as provided in § 2712 of this title, may be issued or delivered in thi…