Chapter 58

(a) Upon the issuance or renewal of any policy, contract, certificate, or evidence of coverage of group health or life insurance, the insurer, corporation, or health maintenance organization shall give written notice to the insurance fiduciary of the provisions of G.S. 58-50-40. …

(a) On and after January 1, 1956, each individual or family accident, health, hospitalization policy, certificate or service plan of hospital service corporations shall be issued only on application in writing signed by the insured or the head of the household or guardian. Any ap…

(a) Definitions. - As used in this section: (1) "Insurer" means an insurer or service corporation subject to this Chapter. (2) "Preferred provider" means a health care provider who has agreed to accept special reimbursement or other terms for health care services from an insurer …

(a) Definitions. - The following definitions apply in this section: (1) Exclusive provider benefit plan. - A health benefit plan offered by an insurer in which insureds must receive covered services from health care providers who are under a contract with the insurer and under wh…

(a) Definitions. - The following definitions apply in this section: (1) Ongoing special condition. - One of the following conditions: a. An acute illness that is serious enough to require medical care or treatment to avoid a reasonable possibility of death or permanent harm. b. A…

(a) An insurer that provides a health benefit plan as defined in G.S. 58-3-167 shall not offset or reverse a health plan payment against a provider reimbursement for other medical charges unless the health plan payment was for a specific medical charge for which the employee, emp…

(a) Definitions. - As used in this section, in G.S. 58-50-62, and in Part 4 of this Article, the term: (1) "Certificate of coverage" includes a policy of insurance issued to an individual person or a franchise policy issued pursuant to G.S. 58-51-90. (1a) "Clinical peer" means a …

(a) Purpose and Intent. - The purpose of this section is to provide standards for the establishment and maintenance of procedures by insurers to assure that covered persons have the opportunity for appropriate resolutions of their grievances. (b) Availability of Grievance Process…

(a) Nothing in Articles 50 through 55 of this Chapter applies to or affects any policy of liability or workers' compensation insurance, except that the provisions of G.S. 58-50-56(g) and (h) apply to policies of workers' compensation insurance and to individual and group self-fun…

Any company, association, society, or other insurer or any officer or agent thereof, which or who issues or delivers to any person in this State any policy in willful violation of Articles 50 through 55 of this Chapter, shall be guilty of a Class 3 misdemeanor and, upon convictio…

(a) The purpose of this Part is to provide standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an appeal decision upholding a noncertification or a second-level grievance re…

(a) An insurer shall notify the covered person in writing of the covered person's right to request an external review and include the appropriate statements and information set forth in this section at the time the insurer sends written notice of: (1) A noncertification decision …

(a) Except as provided in G.S. 58-50-82, a request for an external review under G.S. 58-50-80 or G.S. 58-50-82 shall not be made until the covered person has exhausted the insurer's internal appeal and grievance processes under G.S. 58-50-61 and G.S. 58-50-62. (b) A covered perso…

(a) Within 120 days after the date of receipt of a notice under G.S. 58-50-77, a covered person may file a request for an external review with the Commissioner. (b) Upon receipt of a request for an external review under subsection (a) of this section, the Commissioner shall, with…

(a) Except as provided in subsection (g) of this section, a covered person may file a request for an expedited external review with the Commissioner at the time the covered person receives any of the following: (1) A noncertification decision under G.S. 58-50-61(f) if all of the …

(a) An external review decision is binding on the insurer. (b) An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or State law. (c) A covered person may not file a subsequent r…

(a) The Commissioner shall approve independent review organizations eligible to be assigned to conduct external reviews under this Part to ensure that an organization satisfies the minimum qualifications established under G.S. 58-50-87. The Commissioner shall develop an applicati…

(a) As a condition of approval under G.S. 58-50-85 to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review proces…

The Commissioner, an independent review organization, or a clinical peer reviewer working on behalf of an independent review organization shall not be liable for damages to any person for any opinions rendered during or upon completion of an external review conducted under this P…

(a) An organization assigned under G.S. 58-50-80 or G.S. 58-50-82 to conduct an external review shall maintain written records in the aggregate and by insurer on all requests for external review for which it conducted an external review during a calendar year and submit a report …

The insurer against which a request for a standard external review or an expedited external review is filed shall reimburse the Department of Insurance for the fees charged by the organization in conducting the external review, including work actually performed by the organizatio…

(a) Each insurer shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons. (b) The description required under subsection (a) of th…

(a) At least every two years, or more frequently if the Commissioner determines is needed to secure adequate selection of independent review organizations, the Commissioner shall prepare and publish requests for proposals from independent review organizations that want to be appr…

The following definitions apply in this Article: (1) Repealed by Session Laws 2024-57, s. 3G.1(b), effective January 1, 2025, and applicable to licenses issued under Article 50A of Chapter 58 of the General Statutes on or after that date. (2) Employee welfare benefit plan. - The …

All of the following shall apply to an entity that is initially licensed under this Article on or after January 1, 2025: (1) To maintain the license under this Article, the MEWA is required to maintain a minimum level of enrollment of 500 individuals who are employees belonging t…

(a) All of the following provisions of this Chapter apply to MEWAs licensed or administered under this Article: (1) G.S. 58-2-190, Commissioner may require certain [special] reports. (2) G.S. 58-3-150, Forms to be approved by Commissioner. (3) G.S. 58-7-21, Credit allowed a domes…

(a) Repealed by Session Laws 2019-202, s. 3(a), effective October 1, 2019, and applicable to contracts entered into, amended, or renewed on or after January 1, 2020. (b) Each insurer licensed to do business in this State that administers a MEWA shall, at the request of the Commis…

(a) It is unlawful to operate, maintain, or establish a MEWA unless the MEWA has a valid license issued by the Commissioner. Any MEWA operating in this State without a valid license is an unauthorized insurer. (b) This section, G.S. 58-50A-60, and G.S. 58-50A-70 through G.S. 58-5…

(a) To meet the requirements for issuance of a license under this Article and to maintain that license, a MEWA must meet all of the following criteria: (1) The MEWA is a nonprofit organization or administered by a nonprofit organization. (2) One of the following applies to the ME…

No licensed MEWA shall use in its name, contracts, literature, advertising in any medium, or any other printed matter the words "insurance", "casualty", "surety", "mutual", or any other words descriptive of the insurance business or deceptively similar to the name or description …

Applicants for a license under this Article shall file with the Commissioner an application for a license on a form prescribed by the Commissioner and signed under oath by officers of the entity requesting the licensure. The application shall include or have attached all of the f…

(a) The provisions of Articles 2, 5, and 30 of this Chapter regarding examinations, deposits, and supervision and receivership respectively apply to MEWAs licensed under this Article. (b) Repealed by Session Laws 2024-57, s. 3G.1(b), effective January 1, 2025, and applicable to l…

(a) Annually, a MEWA shall file a report with the Commissioner that meets all of the following requirements: (1) The report is due no later than 150 days after the end of the fiscal year applicable to the operation of the MEWA. The Commissioner may, with good cause, grant an exte…

(a) The Commissioner shall deny, suspend, or revoke the license of any MEWA or any entity administering a MEWA if the Commissioner finds that any of the following apply: (1) The MEWA is insolvent. (2) Methods and practices used in the conduct of its business render its further tr…

No policy of insurance against loss or damage from the sickness or the bodily injury or death of the insured by accident shall be issued or delivered to any person in this State until a copy of the form thereof and of the classification of risks and the premium rates pertaining t…

Every individual or family hospitalization policy, certificate, contract or plan issued for delivery in the State of North Carolina on and after July 1, 1961, must have printed thereon or attached thereto a notice stating substantially: "YOUR POLICY MAY NOT BE IN FORCE WHEN YOU H…

Credit accident and health insurance is declared to be insurance against death or personal injury by accident or by any specified kind or kinds of accident, and insurance against sickness, ailment, or bodily injury of a debtor who may be indebted to any person, firm, or corporati…

Hospitalization insurance is declared to be any form of accident and health insurance which provides indemnity or payment for expenses incurred due to or in connection with hospitalization of the insured, or his dependents. (1953, c. 1096, s. 3.)

(a) This section applies to group accident, group health, or group accident and health policies or certificates that are delivered, issued for delivery, renewed, or used in this State which provide hospital, surgical, or major medical expense insurance, or any combination of thes…

(a) As used in this section and in G.S. 58-51-120 and G.S. 58-51-125: (1) "Health benefit plan" means any accident and health insurance policy or certificate; a nonprofit hospital or medical service corporation contract; a health maintenance organization subscriber contract; a pl…

An employee benefit plan as defined in ERISA shall not include any provision which, because an individual is provided or is eligible for benefits or service pursuant to a State plan under Title XIX of the Social Security Act (Medicaid), has the effect of limiting or excluding cov…

(a) No health insurer shall deny enrollment of a child under the health benefit plan of the child's parent on any of the following grounds: (1) The child was born out of wedlock. (2) The child is not claimed as a dependent on the parent's federal income tax return. (3) The child …

(a) Definitions. - As used in this section: (1) "Child" means, in connection with any adoption or placement for adoption of the child, an individual who has not attained 18 years of age as of the date of the adoption or placement for adoption. (2) "Placement for adoption" means t…

(a) Definitions. - As used in this section: (1) "Disability income insurance policy" or "policy" means a policy of accident and health insurance that provides payments when the insured is unable to work because of illness, disease, or injury. (2) "Policy" includes the certificate…

(a) Required Provisions. - Except as provided in subsection (c) of this section each such policy delivered or issued for delivery to any person in this State shall contain the provisions specified in this subsection in the substance of the words that appear in this section. Such …

(a) Except for the payment of benefits for the necessary care and treatment of chemical dependency as provided by law, an accident and health insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence …

(a) Rules Relating to Crediting Previous Coverage. (1) Creditable coverage defined. - For the purposes of this section, "creditable coverage" means, with respect to an individual, coverage of the individual under any of the following: a. A group health plan as defined in G.S. 58-…

(a) Every individual or blanket family hospitalization policy and accident and health policy, other than noncancelable or nonrenewable policies but including group, blanket and franchise policies, as defined in Articles 1 through 64 of this Chapter, covering less than 10 persons,…

(a) An individual or group accident and health insurance policy, hospital service plan policy, or medical service plan policy that provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the policy or con…

(a) As used in this section: (1) "Foster child" means a minor (i) over whom a guardian has been appointed by the clerk of superior court of any county in North Carolina; or (ii) the primary or sole custody of whom has been assigned by order of a court of competent jurisdiction; (…