Title 38.2, Title 38.2. Insurance

Within the permitted classes of beneficiaries prescribed in § 38.2-3544, the issuing insurer may designate the classes of beneficiaries. No change of beneficiary shall be made by assignment, will, or otherwise to any person outside the designated classes without the consent of th…

Every policy of industrial sick benefit insurance issued in this Commonwealth after June 18, 1922, shall contain a provision that: 1. The sick benefit portion of the policy may be cancelled by either the insurer or the insured and the life portion continued by a payment of twenty…

A. Any person holding industrial sick benefit insurance policies of several insurers, that, in the aggregate, provide sick benefits in excess of 150 percent of his weekly salary, wages or earnings, shall not be permitted to recover the excess, nor shall the insurer be compelled t…

Each person representing any insurer in the sale of industrial sick benefit insurance shall be subject to the laws governing agents of insurers.

The payments in weekly or monthly installments to the holder of any policy of industrial sick benefit insurance shall not be subject to the lien of any attachment, garnishment proceeding, writ of fieri facias, or to levy or distress in any manner, for any debt due by the holder o…

No industrial sick benefit insurance policy as defined in § 38.2-3544 shall be delivered or issued for delivery in this Commonwealth after June 30, 1987.

A. As used in this article: "Eligible dependent" means an individual who may be covered as a dependent under a group health policy or policies and who is eligible, as determined by a small employer health group cooperative, for coverage as a dependent of an eligible employee unde…

A. 1. Any person or persons may organize and maintain a small employer health group cooperative for the purpose of offering, providing, or facilitating the provision of coverage for health care services to its employer-members. 2. The membership of the small employer health group…

A. A small employer health group cooperative: 1. Shall not limit, restrict, or condition a small employer's membership in the small employer health group cooperative on any health status-related factor relating to an individual, including an employee of a small employer or a depe…

A. No group health policy shall be offered to a small employer group health cooperative that will cover a resident of the Commonwealth unless the Commission finds that: 1. The issuance of such group health policy is not contrary to Virginia's public policy and is in the best inte…

Pursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this article.

As used in this chapter, unless the context requires a different meaning: "Adverse determination" means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service that is a co…

A. This chapter shall apply to all health carriers, except that the provisions of this chapter shall not apply to a policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, disability income, hospital indemni…

Each health carrier shall establish an internal appeal process, including a process for urgent care appeals, to consider a utilization review adverse determination or other adverse benefit determination or decision that is appealed by a covered person, his authorized representati…

A. A health carrier shall notify the covered person in writing of an adverse determination or final adverse determination and the covered person's right to request an external review within five business days after the adverse determination or final adverse determination has been…

A. A request for an external review shall not be made until the covered person has exhausted the health carrier's internal appeal process, provided that a covered person's exhaustion of the health carrier's internal appeal process shall not be required if the adverse determinatio…

A. Within 120 days after the date of receipt of a notice of the right to an external review of a final adverse determination or an adverse determination if the internal appeal process has been deemed to be exhausted or waived, a covered person or his authorized representative may…

A. A covered person or his authorized representative may make a request for an expedited external review with the Commission at the time the covered person receives: 1. An adverse determination if the adverse determination involves (i) cancer or (ii) a medical condition of the co…

A. Within 120 days after the date of receipt of a notice of the right to an external review of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is…

A. An external review decision is binding on the health carrier. Failure to comply with the assigned independent review organization's external review decision shall be a knowing and willful violation of this section and subject to one or more of the following: (i) punishment as …

A. 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 process and that include, at a minimum: 1. A quality assurance mechanism in place t…

A. Each independent review organization that wishes to be eligible to conduct external reviews shall submit an application to the Commission for approval or reapproval. The Commission may charge a reasonable fee for initial approval and each reapproval. B. The Commission shall ap…

No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent, or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions perfo…

A. An independent review organization shall maintain written records, in the aggregate by state and by health carrier, on all external review requests and external reviews conducted during each calendar year. Each independent review organization shall submit a report to the Commi…

The health carrier against which a request for an external review is filed shall pay the cost incurred by the independent review organization in conducting the external review.

Each health carrier 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. The description shall include a statement that infor…

Pursuant to the authority granted by § 38.2-223, the Commission may adopt such rules and regulations as it may deem necessary to implement this chapter.