Section 3216. Individual accident and health insurance policy provisions

(a) In this section the term:
    (1) "Policy of accident and health insurance" includes any  individual
  policy  or contract covering the kind or kinds of insurance described in
  paragraph three of subsection (a) of section one  thousand  one  hundred
  thirteen of this chapter.
    (2) "Indemnity" means benefits promised.
    (3) "Family"  may include husband, wife, or dependent children, or any
  other person dependent upon the policyholder.
    (4) "Dependent children"  (A)  shall  include  any  children  under  a
  specified age which shall not exceed age nineteen except:
    (i) Any unmarried dependent child, regardless of age, who is incapable
  of self-sustaining employment by reason of mental illness, developmental
  disability,  or mental retardation as defined in the mental hygiene law,
  or physical handicap and who became so incapable prior  to  the  age  at
  which dependent coverage would otherwise terminate, shall be included in
  coverage subject to any pre-existing conditions limitation applicable to
  other dependents.
    (ii)  Any  unmarried  student at an accredited institution of learning
  may be considered a dependent child until attaining age twenty-three.
    (B) may include, at the option of the  insurer,  any  unmarried  child
  until attaining age twenty-five.
    (C)  In  addition  to the requirements of subparagraphs (A) and (B) of
  this paragraph, every insurer issuing a policy pursuant to this  section
  that  provides  coverage for dependent children must make available and,
  if requested by the policyholder, extend coverage under the policy to an
  unmarried child through age twenty-nine,  without  regard  to  financial
  dependence  who  is  not  insured  by  or eligible for coverage under an
  employer sponsored health benefit plan covering them as an  employee  or
  member, whether insured or self-insured, and who lives, works or resides
  in  New  York  state  or  the service area of the insurer. Such coverage
  shall be made available at the inception of all new policies and at  the
  first  anniversary date of a policy following the effective date of this
  subparagraph. Written notice of the availability of such coverage  shall
  be  delivered  to the policyholder thirty days prior to the inception of
  such group policy and thirty days prior to the  first  anniversary  date
  following the effective date of this subparagraph.
    (b)   No   policy   of   accident   and  health  insurance,  including
  non-cancellable disability insurance, except as provided  in  subsection
  (h)  hereof,  shall  be  delivered  or issued for delivery in this state
  until the rate manual showing rates, rules and classifications of  risks
  for  use  in connection with such accident and health insurance policies
  or with  riders  or  endorsements  thereon,  has  been  filed  with  the
  superintendent.
    (c)  No  policy of accident and health insurance shall be delivered or
  issued for delivery to any person in this state unless:
    (1) The entire money and other considerations therefor  are  expressed
  therein.
    (2)  The  time  at  which the insurance takes effect and terminates is
  expressed therein.
    (3) It purports to insure only one person, except that  a  policy  may
  insure,  originally  or by subsequent amendment, members of a family, as
  defined herein, upon the application of an adult member  of  the  family
  who shall be deemed the policyholder.
    (4)  (A)  Coverage of an unmarried dependent child who is incapable of
  self-sustaining employment by reason of  mental  illness,  developmental
  disability, or mental retardation, as defined in the mental hygiene law,
  or  physical handicap and who became so incapable prior to attainment of

  the age at which dependent coverage would otherwise terminate and who is
  chiefly dependent upon such policyholder for  support  and  maintenance,
  shall  not terminate while the policy remains in force and the dependent
  remains  in  such  condition,  if the policyholder has within thirty-one
  days of such dependent's attainment of the limiting age submitted  proof
  of such dependent's incapacity as described herein.
    (B)  Coverage  of  a  dependent  spouse  or  named insured which would
  terminate upon such spouse or named insured attaining the age prescribed
  in subchapter XVIII of the federal Social Security  Act,  42  U.S.C.  §§
  1395  et  seq.  ("medicare"),  as  the  age of first eligibility for the
  benefits provided by such law shall not so terminate, if such  dependent
  spouse is not then eligible for all of such benefits, for as long as the
  policy  remains in force and such dependent spouse remains ineligible to
  receive  any  of  such  "medicare"  benefits,  provided  proof  of  such
  ineligibility  is submitted to the insurer within thirty-one days of the
  date notice of termination of coverage be sent by first  class  mail  by
  the insurer to the last known address of the policyholder.
    (C)  Any  family  coverage  shall  provide  that  coverage  of newborn
  infants,  including  newly  born  infants  adopted  by  the  insured  or
  subscriber  if  such insured or subscriber takes physical custody of the
  infant upon such infant's release from the hospital and files a petition
  pursuant to section one hundred fifteen-c of the domestic relations  law
  within  thirty  days  of  birth;  and provided further that no notice of
  revocation to the adoption  has  been  filed  pursuant  to  section  one
  hundred  fifteen-b  of  the  domestic  relations  law and consent to the
  adoption has not been revoked, shall be effective  from  the  moment  of
  birth  for injury or sickness including the necessary care and treatment
  of  medically  diagnosed  congenital  defects  and  birth  abnormalities
  including premature birth, except that in cases of adoption, coverage of
  the initial hospital stay shall not be required where a birth parent has
  insurance  coverage  available  for  the  infant's  care. In the case of
  individual coverage the insurer must also permit the person to whom  the
  policy  is  issued  to  elect  such coverage of newborn infants from the
  moment of birth. If notification and/or payment of an additional premium
  or contribution is required to make coverage  effective  for  a  newborn
  infant, the coverage may provide that such notice and/or payment be made
  within  no  less  than  thirty days of the day of birth to make coverage
  effective from the moment of birth. This election shall not be  required
  in the case of student insurance.
    (5)  (A)  Any  family  policy  providing  hospital or surgical expense
  insurance (but not including such insurance  against  accidental  injury
  only)  shall  provide  that,  in the event such insurance on any person,
  other than the policyholder, is terminated  because  the  person  is  no
  longer  within  the  definition of the family as set forth in the policy
  but before such person has  attained  the  limiting  age,  if  any,  for
  coverage  of  adults  specified  in  the  policy,  such  person shall be
  entitled to have issued to him  by  the  insurer,  without  evidence  of
  insurability,  upon  application  therefor  and  payment  of  the  first
  premium,  within  thirty-one  days  after  such  insurance  shall   have
  terminated,  an  individual  conversion policy. The conversion privilege
  afforded herein shall also be available upon the divorce or annulment of
  the  marriage  of  the  policyholder  to  the  former  spouse  of   such
  policyholder.
    (B)  Written  notice  of  entitlement  to a conversion policy shall be
  given by the insurer to the policyholder at least fifteen and  not  more
  than  sixty days prior to the termination of coverage due to the initial
  limiting age of the covered dependent.  Such  notice  shall  include  an
  explanation  of  the  rights  of the dependent with respect to his being

  enrolled in an accredited institution of learning or his incapacity  for
  self-sustaining  employment  by  reason of mental illness, developmental
  disability or mental retardation as defined in the mental hygiene law or
  physical handicap.
    (C)  Such  individual  conversion  policy  shall  be  subject  to  the
  following terms and conditions:
    (i) The premium shall be that applicable to the class of risk to which
  such person belongs, to the age of such  person  and  to  the  form  and
  amount of insurance therefor.
    (ii)  Such  policy  shall  provide, on a basis specified in the family
  policy, the same or substantially the same benefits as those provided in
  the family  policy  or  such  benefits  as  are  provided  in  a  policy
  specifically   approved  as  an  individual  conversion  policy  by  the
  superintendent.
    (iii) The benefits provided under such policy shall  become  effective
  upon  the  date that such person was no longer eligible under the family
  policy.
    (iv) The policy may exclude  any  condition  excluded  by  the  family
  policy  for  such person at the time of the termination of his insurance
  thereunder.  The  policy  shall  not  exclude  any  other   pre-existing
  conditions,  but  the  benefits paid under such policy may be reduced by
  the amount of any such benefits payable under the  family  policy  after
  the  termination  of  such person's insurance thereunder and, during the
  first policy year of the conversion policy, the benefits  payable  under
  the  policy  may be reduced so that they are not in excess of those that
  would have been payable had such person's  insurance  under  the  family
  policy remained in force and effect.
    (v)  No  insurer  shall be required to issue a conversion policy if it
  appears that the person applying for such policy shall have at that time
  in force another insurance policy or hospital service or medical expense
  indemnity contract providing similar benefits or is  covered  by  or  is
  eligible  for coverage by a group insurance policy or contract providing
  similar benefits or shall be covered by similar benefits required by any
  statute or provided by any welfare plan or program, which together  with
  the  conversion  policy  would result in overinsurance or duplication of
  benefits according to standards on file with the superintendent relating
  to individual policies.
    (vi) The policy may  include  a  provision  whereby  the  insurer  may
  request  information at any premium due date of the policy of the person
  covered thereunder as to whether he is then covered by another policy or
  hospital service or medical  expense  indemnity  corporation  subscriber
  contract  providing  similar  benefits  or  is  then  covered by a group
  contract or policy providing similar benefits or is then  provided  with
  similar benefits required by any statute or provided by any welfare plan
  or program. If any such person is so covered or so provided and fails to
  furnish  the  details  of  such  coverage  when  requested, the benefits
  payable under the  conversion  policy  may  be  based  on  the  hospital
  surgical  or medical expenses actually incurred after excluding expenses
  to the extent they are payable under such  other  coverage  or  provided
  under such statute, plan, or program.
    (6)  The  style, arrangement and overall appearance of the policy give
  no undue prominence to any portion of the text, and unless every printed
  portion of the text of the policy and of any  endorsements  or  attached
  papers is plainly printed in light-faced type of a style in general use,
  the  size  of  which shall be uniform and not less than ten-point with a
  lower-case  unspaced  alphabet  length  not  less   than   one   hundred
  twenty-point  (the  "text"  shall  include all printed matter except the

  name and address of the insurer, name or title of the policy, the  brief
  description, if any, and captions and subcaptions).
    (7)  The  exceptions  and reductions of indemnity are set forth in the
  policy and, except those which are set forth in subsection (d)  of  this
  section,  are printed, at the insurer's option, either included with the
  benefit provision to which they apply, or under an  appropriate  caption
  such  as  "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided that if
  an exception or reduction specifically  applies  only  to  a  particular
  benefit  of the policy, a statement of such exception or reduction shall
  be included with the benefit provision to which it applies.
    (8) Each such  form,  including  riders  and  endorsements,  shall  be
  identified  by  a form number in the lower left-hand corner of the first
  page thereof.
    (9) It contains no provision purporting to make  any  portion  of  the
  charter,  rules,  constitution,  or by-laws of the insurer a part of the
  policy unless such portion is set forth in full in the policy, except in
  the case of the incorporation of, or reference to, a statement of  rates
  or   classification  of  risks,  or  short-rate  table  filed  with  the
  superintendent.
    (10) There is prominently printed on the first page thereof  or  there
  is  attached  thereto  a  notice  to  the effect that during a specified
  period of time, which shall not be less than  ten  days  nor  more  than
  twenty  days  from the date the policy is delivered to the policyholder,
  it may be surrendered to the insurer together with a written request for
  cancellation of the policy and in such event the insurer will refund any
  premium paid therefor  including  any  policy  fees  or  other  charges,
  provided, however, that this paragraph shall not apply to single premium
  nonrenewable  policies  insuring  against  accidents  only or accidental
  bodily injuries only; provided, however, that a contract or  certificate
  sold  by  mail  order  and  a contract or certificate providing medicare
  supplemental insurance  or  long-term  care  insurance  must  contain  a
  provision  permitting  the  contract  or certificate holder a thirty day
  period for such surrender.
    (11) The age limit or date or period, if any, after which the coverage
  provided by the policy will not be effective or the age limit,  date  or
  period  after which the policy may not be renewed is stated in a renewal
  provision set forth on the first page of the policy  or  as  a  separate
  provision bearing an appropriate caption on the first page of the policy
  or in a brief description in not less than fourteen-point bold face type
  set  forth  on  the  first  page of the policy. Nothing herein contained
  shall limit or restrict the right of the insurer to continue the  policy
  after the age or period so stated.
    (12)  Any  policy,  other  than  one  issued  in  fulfillment  of  the
  continuing care responsibilities of an operator  of  a  continuing  care
  retirement  community in accordance with article forty-six of the public
  health  law,  made  available  because  of  residence  in  a  particular
  facility,  housing development, or community shall contain the following
  notice in twelve point type in bold face on the first page:
    "NOTICE - THIS POLICY DOES NOT MEET THE REQUIREMENTS OF  A  CONTINUING
  CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE WILL NOT QUALIFY
  A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY."
    (13)  Any  persons  covered  by  the  policy who are also members of a
  reserve component of the armed forces of the  United  States,  including
  the  National  Guard,  shall  be entitled, upon written request, to have
  their coverage suspended during a period of  active  duty  as  described
  herein.    The  policy  shall  provide  that the insurer will refund any
  unearned premiums for the period of such suspension. Persons covered  by
  the  policy  shall  be  entitled to resumption of coverage, upon written

  application and payment of the required premium within sixty days  after
  the  date  of  termination  of  the  period  of  active  duty,  with  no
  limitations or conditions imposed as a result of such period  of  active
  duty  except  as set forth in subparagraphs (A) and (B) herein. Coverage
  shall be retroactive to the date of termination of the period of  active
  duty.  Such right of resumption provided for herein shall be in addition
  to other existing rights granted pursuant to state and federal laws  and
  regulations  and  shall not be deemed to qualify or limit such rights in
  any way. No exclusion or waiting period may  be  imposed  in  connection
  with  coverage of a health or physical condition of a person entitled to
  such right of resumption, or a health or physical condition of any other
  person who is covered by the policy unless:
    (A) the condition arose during the  period  of  active  duty  and  the
  condition has been determined by the secretary of veterans affairs to be
  a condition incurred in the line of duty; or
    (B)  a  waiting period was imposed and had not been completed prior to
  the period of suspension; in no event, however, shall  the  sum  of  the
  waiting  periods  imposed  prior  to  and  subsequent  to  the period of
  suspension exceed the length of the waiting period originally imposed.
    (14) To be entitled to the right defined in paragraph thirteen of this
  subsection a person must be a member of a component of the armed  forces
  of the United States, including the National Guard, who either:
    (A)  voluntarily  or involuntarily enters upon active duty (other than
  for the purpose of determining his or her  physical  fitness  and  other
  than for training), or
    (B)  has  his or her active duty voluntarily or involuntarily extended
  during a period when the president is authorized to order units  of  the
  ready reserve or members of a reserve component to active duty, provided
  that  such  additional  active  duty  is  at  the  request  and  for the
  convenience of the federal government, and
    (C) serves no more than four years of active duty.
    (d) Each policy of accident and health insurance delivered  or  issued
  for  delivery  to  any person in this state shall contain the provisions
  specified herein  in  the  words  in  which  the  same  appear  in  this
  subsection,  except  that the insurer may, at its option, substitute for
  one or more of such provisions  corresponding  provisions  of  different
  wording  approved  by the superintendent which are not less favorable in
  any respect to the insured or the beneficiary. Each provision  contained
  in  the policy shall be preceded by the applicable caption herein or, at
  the insurer's option, by such appropriate captions or subcaptions as the
  superintendent may approve.
    (1) Each policy shall, except with respect to designation  by  numbers
  or letters as used below, contain the following provisions:
    (A)  ENTIRE CONTRACT; CHANGES: This policy, including the endorsements
  and the attached papers, if any,  constitutes  the  entire  contract  of
  insurance.  No change in this policy shall be valid until approved by an
  executive officer of the insurer and unless such  approval  be  endorsed
  hereon  or  attached  hereto. No agent or broker has authority to change
  this policy or to waive any of its provisions.
    (B) TIME LIMIT ON CERTAIN DEFENSES:
    (i) After two  years  from  the  date  of  issue  of  this  policy  no
  misstatements, except fraudulent misstatements, made by the applicant in
  the  application  for such policy shall be used to void the policy or to
  deny a claim for loss incurred or disability (as defined in the  policy)
  commencing after the expiration of such two year period.
    (The foregoing policy provision shall not be so construed as to affect
  any  legal  requirement  for  avoidance of a policy or denial of a claim
  during such initial two year period, nor to  limit  the  application  of

  subparagraphs (A) through (E), inclusive, of this paragraph in the event
  of misstatement with respect to age or occupation or other insurance.)
    (A policy which the insured has the right to continue in force subject
  to  its  terms by the timely payment of premium until at least age fifty
  or, in the case of a policy issued after age forty-four,  for  at  least
  five  years from its date of issue, may contain in lieu of the foregoing
  the following provision (from which the clause  in  parentheses  may  be
  omitted at the insurer's option) under the caption "INCONTESTABLE":
    After  this  policy has been in force for a period of two years during
  the lifetime of the insured  (excluding  any  period  during  which  the
  insured is disabled), it shall become incontestable as to the statements
  contained in the application.)
    (ii)  No  claim  for  loss  incurred  or disability (as defined in the
  policy) commencing after two years from the date of issue of this policy
  shall be reduced or denied on the ground  that  a  disease  or  physical
  condition  not  excluded  from  coverage by name or specific description
  effective on the date of loss had existed prior to the effective date of
  coverage of this policy.
    (C) GRACE PERIOD: A grace period of ........................ (insert a
  number not less than "7" for weekly premium policies, "10"  for  monthly
  premium  policies  and "31" for all other policies) days will be granted
  for the payment of each premium falling due  after  the  first  premium,
  during which grace period the policy shall continue in force.
    (A  policy  in  which the insurer reserves the right to refuse renewal
  shall have, at the beginning  of  the  above  provision,  the  following
  clause:
    "Unless  not  less  than  thirty  days  prior  to the renewal date the
  insurer has delivered to the insured or has sent by first class mail  to
  his  last  address as shown by the records of the insurer written notice
  of its intention not to renew this policy beyond the  period  for  which
  the premium has been accepted,"
    Furthermore, such a policy, except an accident only policy, shall also
  provide  in  substance,  in  a  provision  thereof, or in an endorsement
  thereon or in a rider attached thereto,  that  the  insurer  may  refuse
  renewal  of  the  policy  only  as  of the renewal date occurring on, or
  nearest its first anniversary, or as of an anniversary of  such  renewal
  date,  or  at the option of the insurer as of the renewal date occurring
  on or nearest the anniversary of its date of last reinstatement.)
    (D) REINSTATEMENT: If any renewal premium be not paid within the  time
  granted  the insured for payment, a subsequent acceptance of the premium
  by the insurer or by any agent or broker duly authorized by the  insurer
  to  accept  such  premium,  without requiring in connection therewith an
  application for reinstatement, shall  reinstate  the  policy;  provided,
  however,  that  if  the  insurer  or  such  agent  or broker requires an
  application for reinstatement and issues a conditional receipt  for  the
  premium  tendered,  the  policy will be reinstated upon approval of such
  application  by  the  insurer  or,  lacking  such  approval,  upon   the
  forty-fifth  day  following  the date of such conditional receipt unless
  the insurer has previously  notified  the  insured  in  writing  of  its
  disapproval  of such application. The reinstated policy shall cover only
  loss resulting from such accidental injury as may be sustained after the
  date of reinstatement and loss due to such sickness as  may  begin  more
  than  ten  days  after  such date. In all other respects the insured and
  insurer shall have the same rights thereunder  as  they  had  under  the
  policy immediately before the due date of the defaulted premium, subject
  to  any provisions endorsed hereon or attached hereto in connection with
  the  reinstatement.  Any  premium  accepted   in   connection   with   a
  reinstatement  shall  be  applied  to a period for which premium has not

  been previously paid, but not to any period more than sixty  days  prior
  to the date of reinstatement.
    (The  last  sentence  of  the  above provision may be omitted from any
  policy which the insured has the right to continue in force  subject  to
  its terms by the timely payment of premiums until at least age fifty or,
  in  the  case of a policy issued after age forty-four, for at least five
  years from its date of issue.)
    (E) NOTICE OF CLAIM: Written notice of claim  must  be  given  to  the
  insurer  within  twenty days after the occurrence or commencement of any
  loss covered by the policy, or  as  soon  thereafter  as  is  reasonably
  possible. Notice given by or on behalf of the insured or the beneficiary
  to  the insurer at -------------- (insert the location of such office as
  the insurer may designate for the purpose), or to any  authorized  agent
  of  the insurer or to any authorized broker, with information sufficient
  to identify the insured, shall be deemed notice to the  insurer.  (In  a
  policy  providing  a  loss-of-time  benefit  which may be payable for at
  least two years, an insurer may  at  its  option  insert  the  following
  between  the  first and second sentences of the above provision: Subject
  to the qualifications set forth below, if the insured  suffers  loss  of
  time  on account of disability for which indemnity may be payable for at
  least two years, he shall, at least  once  in  every  six  months  after
  having  given notice of claim, give to the insurer notice of continuance
  of said disability, except in the event of legal incapacity. The  period
  of  six  months  following  any  filing  of  proof by the insured or any
  payment by the insurer on  account  of  such  claim  or  any  denial  of
  liability  in  whole  or  in  part  by  the insurer shall be excluded in
  applying this provision. Delay in the giving of such  notice  shall  not
  impair  the  insured's right to any indemnity which would otherwise have
  accrued during the period of six months preceding the date on which such
  notice is actually given.)
    (F) CLAIM FORMS: The insurer, upon receipt of a notice of claim,  will
  furnish  to  the  claimant such forms as are usually furnished by it for
  filing proofs of loss. If such forms are not  furnished  within  fifteen
  days  after  the  giving  of such notice the claimant shall be deemed to
  have complied with the requirements of this policy as to proof  of  loss
  upon  submitting,  within the time fixed in the policy for filing proofs
  of loss, written proof covering the occurrence, the character and extent
  of the loss for which claim is made.
    * (G) PROOFS OF LOSS: Written proof of loss must be furnished  to  the
  insurer  at  its  said  office  in case of claim for loss for which this
  policy provides any periodic payment  contingent  upon  continuing  loss
  within  ninety  days  after  the termination of the period for which the
  insurer is liable and in case of claim for any other loss within  ninety
  days  after  the date of such loss. Failure to furnish such proof within
  the time required shall not invalidate nor reduce any claim  if  it  was
  not  reasonably  possible  to give proof within such time, provided such
  proof is furnished as soon as  reasonably  possible  and  in  no  event,
  except  in  the  absence of legal capacity, later than one year from the
  time proof is otherwise required.
    * NB Effective until January 1, 2011
    * (G) PROOFS OF LOSS: Written proof of loss must be furnished  to  the
  insurer  at  its  said  office  in case of claim for loss for which this
  policy provides any periodic payment  contingent  upon  continuing  loss
  within  ninety  days  after  the termination of the period for which the
  insurer is liable and in case of claim for any  other  loss  within  one
  hundred twenty days after the date of such loss. Failure to furnish such
  proof within the time required shall not invalidate nor reduce any claim
  if  it  was  not  reasonably  possible  to  give proof within such time,

  provided such proof is furnished as soon as reasonably possible  and  in
  no  event,  except in the absence of legal capacity, later than one year
  from the time proof is otherwise required.
    * NB Effective January 1, 2011
    (H)  TIME  OF PAYMENT OF CLAIMS: Indemnities payable under this policy
  for any loss other than loss for which this policy provides any periodic
  payment will be paid immediately upon receipt of due  written  proof  of
  such loss. Subject to due written proof of loss, all accrued indemnities
  for  loss  for  which  this  policy  provides  periodic  payment will be
  paid ------------ (insert period for payment  which  must  not  be  less
  frequently  than  monthly)  and  any  balance  remaining unpaid upon the
  termination of liability will be paid immediately upon  receipt  of  due
  written proof.
    (I)  PAYMENT OF CLAIMS: Any indemnity for loss of life will be payable
  in accordance  with  the  beneficiary  designation  and  the  provisions
  respecting  such payment which may be prescribed herein and effective at
  the time of payment.  If  no  such  designation  or  provision  is  then
  effective, such indemnity shall be payable to the estate of the insured.
  Any  other accrued indemnities unpaid at the insured's death may, at the
  option of the insurer, be paid either to such  beneficiary  or  to  such
  estate. All other indemnities will be payable to the insured.
    (The following provisions, or either of them, may be included with the
  foregoing  provision  at  the option of the insurer: If any indemnity of
  this policy shall be payable to the estate of  the  insured,  or  to  an
  insured or beneficiary who is a minor or otherwise not competent to give
  a valid release, the insurer may pay such indemnity, up to an amount not
  exceeding  $--------------  (insert an amount which shall not exceed one
  thousand dollars), to any relative by blood or connection by marriage of
  the insured or beneficiary who is deemed by the insurer to be  equitably
  entitled thereto. Any payment made by the insurer in good faith pursuant
  to  this  provision  shall  fully discharge the insurer to the extent of
  such payment.
    Subject to any written direction of the insured in the application  or
  otherwise all or a portion of any indemnities provided by this policy on
  account  of hospital, nursing, medical, or surgical services may, at the
  insurer's option and unless the insured requests  otherwise  in  writing
  not  later than the time of filing proofs of such loss, be paid directly
  to the hospital or  person  rendering  such  services;  but  it  is  not
  required  that  the  service  be  rendered  by  a particular hospital or
  person.)
    (J) PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own  expense
  shall  have  the  right  and  opportunity  to  examine the person of the
  insured when and as often  as  it  may  reasonably  require  during  the
  pendency  of  a  claim hereunder and to make an autopsy in case of death
  where it is not forbidden by law.
    (K) LEGAL ACTIONS: No action at law or in equity shall be  brought  to
  recover  on  this  policy  prior  to  the expiration of sixty days after
  written proof  of  loss  has  been  furnished  in  accordance  with  the
  requirements  of  this policy. No such action shall be brought after the
  expiration of three years after  the  time  written  proof  of  loss  is
  required to be furnished.
    (L)  CHANGE  OF  BENEFICIARY:  Unless the insured makes an irrevocable
  designation of beneficiary,  the  right  to  change  of  beneficiary  is
  reserved   to  the  insured  and  the  consent  of  the  beneficiary  or
  beneficiaries shall not be requisite to surrender or assignment of  this
  policy or to any change of beneficiary or beneficiaries, or to any other
  changes in this policy.

  (The  first  clause  of  this  provision,  relating  to  the irrevocable
  designation of beneficiary, may be omitted at the insurer's option.)
    (M)  "CONVERSION  PRIVILEGE"  (under  this  caption) a provision which
  shall set forth in  substance  the  conversion  privileges  and  related
  provisions  required of certain policies by paragraph five of subsection
  (c) of this section.
    (2) Other provisions. No such policy delivered or issued for  delivery
  to  any  person  in  this  state shall contain provisions respecting the
  matters set forth below unless such provisions are  in  the  words  (not
  including  the designation by number or letter) in which the same appear
  in this paragraph except that the insurer may, at  its  option,  use  in
  lieu  of  any  such  provision  a  corresponding  provision of different
  wording approved by the superintendent which is not  less  favorable  in
  any  respect  to  the  insured  or  the  beneficiary. Any such provision
  contained  in  the  policy  shall  be  preceded  individually   by   the
  appropriate  caption  appearing herein or, at the option of the insurer,
  by such appropriate individual or group captions or subcaptions  as  the
  superintendent may approve.
    (A)  CHANGE  OF  OCCUPATION:  If  the  insured  be injured or contract
  sickness after having changed his occupation to one  classified  by  the
  insurer as more hazardous than that stated in this policy or while doing
  for compensation anything pertaining to an occupation so classified, the
  insurer  will  pay only such portion of the indemnities provided in this
  policy as the premium paid would have purchased at the rates and  within
  the  limits  fixed by the insurer for such more hazardous occupation. If
  the insured changes his occupation to one classified by the  insurer  as
  less  hazardous  than  that  stated  in  this  policy, the insurer, upon
  receipt of proof of such change of occupation, will reduce  the  premium
  rate  accordingly,  and will return the excess pro-rata unearned premium
  from the date of change of occupation or  from  the  policy  anniversary
  date  immediately preceding receipt of such proof, whichever is the more
  recent. In applying this provision, the classification  of  occupational
  risk  and the premium rates shall be such as have been last filed by the
  insurer prior to the occurrence of the loss for  which  the  insurer  is
  liable  or prior to date of proof of change in occupation with the state
  official having supervision of insurance in the state where the  insured
  resided  at  the time this policy was issued; but if such filing was not
  required, then the classification of occupational risk and  the  premium
  rates  shall  be  those last made effective by the insurer in such state
  prior to the occurrence of the loss or prior to the  date  of  proof  of
  change in occupation.
    (B)  MISSTATEMENT OF AGE: If the insured's age has been misstated, all
  amounts payable under this policy shall be  such  as  the  premium  paid
  would have purchased at the correct age.
    (C)  OTHER  INSURANCE  IN  THIS INSURER: If an accident or sickness or
  accident and health policy or policies previously issued by the  insurer
  to the insured be in force concurrently herewith,
    making   the  aggregate  indemnity  for  ------------(insert  type  of
  coverage or coverages) in excess of $-------------(insert maximum  limit
  of  indemnity or indemnities) the excess insurance shall be void and all
  premiums paid for such excess shall be returned to the insured or to his
  estate,
  or, in lieu thereof:
    Insurance effective at any one time on the insured under a like policy
  or policies in this insurer is limited to the one such policy elected by
  the insured, his beneficiary or his estate, as the case may be, and  the
  insurer will return all premiums paid for all other such policies.

    (D)  INSURANCE  WITH OTHER INSURERS: If there be other valid coverage,
  not with this insurer,  providing  benefits  for  the  same  loss  on  a
  provision  of service basis or on an expense incurred basis and of which
  this insurer has not been given written notice prior to  the  occurrence
  or  commencement  of loss, the only liability under any expense incurred
  coverage of this policy shall be for such proportion of the loss as  the
  amount  which would otherwise have been payable hereunder plus the total
  of the like amounts under all such other valid coverages  for  the  same
  loss  of  which  this insurer had notice bears to the total like amounts
  under all valid coverages for such loss, and  for  the  return  of  such
  portion  of  the  premiums paid as shall exceed the pro-rata portion for
  the amount so determined. For the purpose  of  applying  this  provision
  when  other  coverage  is  on  a  provision  of service basis, the "like
  amount" of such other coverage shall be taken as the  amount  which  the
  services rendered would have cost in the absence of such coverage.
    (If  the foregoing policy provision is included in a policy which also
  contains the next following policy provision there shall be added to the
  caption of the foregoing provision  the  phrase  "---  EXPENSE  INCURRED
  BENEFITS".  The  insurer may, at its option, include in this provision a
  definition of "other  valid  coverage",  approved  as  to  form  by  the
  superintendent,  which  definition shall be limited in subject matter to
  coverage provided by organizations subject to  regulation  by  insurance
  law or by insurance authorities of this or any other state of the United
  States  or  any  province  of Canada, and by hospital or medical service
  organizations, and to any other coverage the inclusion of which  may  be
  approved  by  the superintendent. In the absence of such definition such
  term shall not include  group  insurance,  automobile  medical  payments
  insurance,   or   coverage  provided  by  hospital  or  medical  service
  organizations or by union welfare plans or employer or employee  benefit
  organizations.  For the purpose of applying the foregoing provision with
  respect to any insured, any amount of benefit provided for such  insured
  pursuant  to  any  compulsory  benefit  statute  (including any workers'
  compensation or employer's liability  statute)  whether  provided  by  a
  governmental  agency  or  otherwise  shall  in all cases be deemed to be
  "other valid coverage" of which the insurer has had notice. In  applying
  the  foregoing  policy provision no third party liability coverage shall
  be included as "other valid coverage".)
    (E) INSURANCE WITH OTHER INSURERS: If there be other  valid  coverage,
  not  with  this  insurer,  providing benefits for the same loss on other
  than an expense incurred basis and of which this insurer  has  not  been
  given  written  notice  prior to the occurrence or commencement of loss,
  the only liability for such benefits under this policy shall be for such
  proportion of the indemnities otherwise provided hereunder for such loss
  as the like indemnities of which the insurer had notice  (including  the
  indemnities  under  this  policy)  bear  to the total amount of all like
  indemnities for such loss, and for the return of  such  portion  of  the
  premium  paid  as  shall exceed the pro-rata portion for the indemnities
  thus determined.
    (If the foregoing policy provision is included in a policy which  also
  contains the next preceding policy provision there shall be added to the
  caption  of the foregoing provision the phrase "--- OTHER BENEFITS". The
  insurer may, at its option, include in this provision  a  definition  of
  "other valid coverage", approved as to form by the superintendent, which
  definition  shall  be  limited in subject matter to coverage provided by
  organizations subject to regulation by insurance  law  or  by  insurance
  authorities  of  this  or  any  other  state of the United States or any
  province of Canada, and to any other coverage the inclusion of which may
  be approved by the superintendent. In the  absence  of  such  definition

  such  term  shall  not  include group insurance, or benefits provided by
  union welfare plans or by employer or  employee  benefit  organizations.
  For  the purpose of applying the foregoing policy provision with respect
  to any insured, any amount of benefit provided for such insured pursuant
  to  any  compulsory benefit statute (including any workers' compensation
  or employer's liability statute)  whether  provided  by  a  governmental
  agency  or  otherwise  shall  in  all cases be deemed to be "other valid
  coverage" of which the insurer has had notice. In applying the foregoing
  policy provision no third party liability coverage shall be included  as
  "other valid coverage".)
    (F)  RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of
  loss of time benefits promised for the same loss under all valid loss of
  time coverage upon the insured, whether payable on a weekly  or  monthly
  basis,  shall  exceed  the  monthly  earnings of the insured at the time
  disability commenced or his average monthly earnings for the  period  of
  two  years  immediately  preceding a disability for which claim is made,
  whichever is the greater, the insurer  will  be  liable  for  only  such
  proportionate amount of such benefits under this policy as the amount of
  such  monthly  earnings  or such average monthly earnings of the insured
  bears to the total amount of monthly benefits for the  same  loss  under
  all such coverage upon the insured at the time such disability commences
  and  for  the  return  of such part of the premiums paid during such two
  years as shall exceed the  pro-rata  amount  of  the  premiums  for  the
  benefits  actually  paid hereunder; but this shall not operate to reduce
  the total monthly amount of benefits payable  under  all  such  coverage
  upon  the insured below the sum of two hundred dollars or the sum of the
  monthly benefits specified in such coverages, whichever is  the  lesser,
  nor  shall  it  operate  to reduce benefits other than those payable for
  loss of time.
    (The foregoing policy provision may be inserted only in a policy which
  the insured has the right to continue in force subject to its  terms  by
  the  timely payment of premiums until at least age fifty or, in the case
  of a policy issued after age forty-four, for at least  five  years  from
  its  date  of  issue.  The  insurer  may, at its option, include in this
  provision a definition of "valid loss of time coverage", approved as  to
  form by the superintendent, which definition shall be limited in subject
  matter to coverage provided by governmental agencies or by organizations
  subject  to  regulation by the insurance law or by insurance authorities
  of this or any other state of the  United  States  or  any  province  of
  Canada,  or to any other coverage the inclusion of which may be approved
  by the superintendent or any  combination  of  such  coverages.  In  the
  absence  of  such  definition  such  term shall not include any coverage
  provided for such insured pursuant to  any  compulsory  benefit  statute
  (including  any  workers' compensation or employer's liability statute),
  or benefits provided by union welfare plans or by employer  or  employee
  benefit organizations.)
    (G) UNPAID PREMIUM: Upon the payment of a claim under this policy, any
  premium  then due and unpaid or covered by any note or written order may
  be deducted therefrom.
    (H) CANCELLATION: Within the first  ninety  days  after  the  date  of
  issue, the insurer may cancel this policy by written notice delivered to
  the insured, or sent by first class mail to his last address as shown by
  the  records  of  the  insurer,  stating  when,  not  less than ten days
  thereafter, such cancellation  shall  be  effective.  In  the  event  of
  cancellation,  the  insurer  will  return promptly the pro-rata unearned
  portion of any premium paid. Cancellation shall be without prejudice  to
  any claim originating prior to the effective date of cancellation.

    (Nothing  in this subsection shall be construed to prohibit an insurer
  from granting to the insured the right to cancel a policy  at  any  time
  and  to  receive  in  such event a refund of the unearned portion of any
  premium paid, computed by the use of the  short-rate  table  last  filed
  with  the  state  official  having supervision of insurance in the state
  where the insured resided when the policy was issued).
    (I) CONFORMITY WITH STATE  STATUTES:  Any  provision  of  this  policy
  which,  on  its  effective date, is in conflict with the statutes of the
  state in which the insured resides on such date  is  hereby  amended  to
  conform to the minimum requirements of such statutes.
    (J)  ILLEGAL  OCCUPATION: The insurer shall not be liable for any loss
  to which a contributing cause was the insured's commission of or attempt
  to commit a felony or to which a contributing cause  was  the  insured's
  being engaged in an illegal occupation.
    (K) INTOXICANTS AND NARCOTICS: The insurer shall not be liable for any
  loss  sustained  or  contracted  in  consequence  of the insured's being
  intoxicated or under the influence of any narcotic  unless  administered
  on the advice of a physician.
    (3)  If  any  provision  of  this  subsection  is  in whole or in part
  inapplicable  to  or  inconsistent  with  the  coverage  provided  by  a
  particular  form  of  policy  the  insurer,  with  the  approval  of the
  superintendent, shall omit from such policy any  inapplicable  provision
  or  part  of a provision, and shall modify any inconsistent provision or
  part of the provision in  such  manner  as  to  make  the  provision  as
  contained  in  the  policy  consistent with the coverage provided by the
  policy.
    (4) The provisions which are the subject of paragraphs one and two  of
  this  subsection, or any corresponding provisions which are used in lieu
  thereof in accordance with such paragraphs,  shall  be  printed  in  the
  consecutive order of the provisions in such paragraphs or, at the option
  of  the  insurer, any such provision may appear as a unit in any part of
  the policy, with other provisions to which it may be logically  related,
  provided  the  resulting  policy  shall  not  be  in  whole  or  in part
  unintelligible, uncertain, ambiguous, abstruse, or likely to  mislead  a
  person to whom the policy is offered, delivered or issued.
    (5)  The  word  "insured",  as  used  in  this  section,  shall not be
  construed as preventing a person other than the insured  with  a  proper
  insurable  interest  from  making  application  for  and owning a policy
  covering the insured or from being entitled under such a policy  to  any
  indemnities, benefits and rights provided therein.
    (6)  The superintendent may make such reasonable rules and regulations
  concerning the procedure  for  the  filing  or  submission  of  policies
  subject  to  this  section  as are necessary, proper or advisable to the
  administration of this section. This provision  shall  not  abridge  any
  other authority granted the superintendent by law.
    (e)  The  acknowledgment by any insurer of the receipt of notice given
  under any policy covered by this section, or the furnishing of forms for
  filing proofs of  loss,  or  the  acceptance  of  such  proofs,  or  the
  investigation  of any claim thereunder, shall not operate as a waiver of
  any of the rights of the insurer in defense of any claim  arising  under
  such policy.
    (f)  If  any  such policy contains a provision establishing, as an age
  limit or otherwise, a date after which  the  coverage  provided  by  the
  policy will not be effective, and if such date falls within a period for
  which  premium  is  accepted  by the insurer or if the insurer accepts a
  premium after such date,  the  coverage  provided  by  the  policy  will
  continue  in force subject to any right of cancellation until the end of
  the period for which premium has been accepted. In the event the age  of

  the  insured  has been misstated and if, according to the correct age of
  the insured, the coverage provided by the policy would not  have  become
  effective,  or would have ceased prior to the acceptance of such premium
  or  premiums,  then the liability of the insurer shall be limited to the
  refund, upon request, of all premiums paid for the period not covered by
  the policy.
    (g)(1) No insurer shall refuse to renew a policy of hospital, surgical
  or medical expense insurance, an individual  converted  policy,  or  any
  other  policy  in  which  one-third  or  more  of  the  total premium is
  allocable to hospital, surgical or  medical  expense  benefits,  or  any
  combination  thereof  (but  not  including  insurance against accidental
  injury only), except for one or more of the following reasons:
    (A) nonpayment of premiums,
    (B) fraud in applying for the policy or in applying for  any  benefits
  under the policy or intentional misrepresentation of material fact under
  the terms of the coverage,
    (C) discontinuance of a class of policies in accordance with paragraph
  two of this subsection, except that no insurer or organization certified
  pursuant  to article forty-four of the public health law shall refuse to
  renew the policies of insureds holding  contracts  which  provide  major
  medical  or  similar comprehensive type coverage in effect prior to June
  first, two thousand one who are ineligible to purchase policies  offered
  pursuant  to  section  four  thousand  three  hundred twenty-one or four
  thousand three hundred twenty-two of this chapter due to the  provisions
  of  section  42 USC 1395ss in effect on January first, two thousand one,
  and who are eligible for Medicare benefits by reason of disability.
    (i) Coverage shall be reinstated only for such insureds terminated  on
  or  after  January  first,  two  thousand one and such coverage shall be
  reinstated on a prospective basis only, irrespective of any pre-existing
  conditions.
    (ii) In the event  any  such  insured  becomes  eligible  to  purchase
  policies  offered  pursuant  to  section  four  thousand  three  hundred
  twenty-one or four thousand three hundred twenty-two  of  this  chapter,
  then  such  insured  may  be discontinued upon not less than five months
  prior written notice. In the event any such insured becomes eligible for
  Medicare by reason of age, then such insured may be  terminated  by  not
  less than thirty days notice with prior written notice.
    (iii)  Within  sixty  days  of this item taking effect, the insurer or
  organization shall notify the insured of the  prospective  reinstatement
  of  coverage  under  this section. Within thirty days of receipt of such
  notice, an insured shall notify the insurer or organization  of  his  or
  her election for prospective coverage,
    (D)  discontinuance  of  all  hospital,  surgical  and medical expense
  coverage in the individual market  in  this  state  in  accordance  with
  paragraph three of this subsection,
    (E)  in  the case of an insurer that offers coverage in the individual
  market through a network plan,  termination  of  an  individual  who  no
  longer  resides,  lives  or works in the service area (or in an area for
  which the insurer is  authorized  to  do  business)  but  only  if  such
  coverage  is terminated under this subparagraph uniformly without regard
  to any health status-related factor of covered individuals, and
    (F) for such other reasons as are acceptable to the superintendent and
  authorized by the Health Insurance Portability and Accountability Act of
  1996,  Public  Law  104-191,  and  any  later  amendments  or  successor
  provisions,  or  by  any federal regulations or rules that implement the
  provisions of the Act.
    In no event shall any insurer refuse to renew any such policy  because
  of  the physical or mental condition or the health of any person covered

  thereunder. Furthermore, no insurer shall require as a condition for the
  renewal of any such policy any rider, endorsement  or  other  attachment
  which  shall  limit  the  nature  or  extent  of  the  benefits provided
  thereunder.  The  superintendent  may require every insurer to file with
  him such  documents,  statistics  or  other  information  regarding  the
  refusal  to  renew permitted by this subsection as he may deem necessary
  for the proper administration of this subsection.
    (2) In any case in which an insurer decides to discontinue offering  a
  class   of  hospital,  surgical  or  medical  expense  policies  in  the
  individual health insurance market, coverage of the  class  of  policies
  may be discontinued by the insurer only if:
    (A)  the  insurer  gives  at least ninety days prior written notice of
  such discontinuance to the superintendent;
    (B) the insurer provides written notice of such discontinuance to each
  covered  individual  at  least  ninety  days  prior  to  the   date   of
  discontinuance of such coverage;
    (C)  the  insurer  offers  to  each  covered  individual the option to
  purchase all other individual hospital,  surgical  and  medical  expense
  coverage currently being offered by the insurer in the individual health
  insurance market; and
    (D)  in  exercising  the  option to discontinue coverage of a class of
  policies and in offering the option of coverage under  subparagraph  (C)
  of  this  paragraph, the insurer acts uniformly without regard to claims
  experience or to any health status-related factor of insured individuals
  or individuals who may become eligible for such coverage.
    (3) In any case in which an insurer elects to discontinue offering all
  hospital, surgical and medical expense coverage in the individual market
  in this state, health insurance coverage  may  be  discontinued  by  the
  insurer only if:
    (A)  the  insurer gives at least one hundred eighty days prior written
  notice of such discontinuance to the superintendent;
    (B) the insurer provides written notice of such discontinuance to each
  covered individual at least one hundred eighty days prior to the date of
  termination of such coverage;
    (C) all hospital, surgical and  medical  expense  coverage  issued  or
  delivered  for  issuance  in  this  state  in  the  individual market is
  discontinued and coverage under such health insurance coverage  in  such
  market is not renewed; and
    (D)  in addition to the notice referred to in subparagraph (A) of this
  paragraph, the insurer must provide the superintendent  with  a  written
  plan  to  minimize potential disruption in the marketplace occasioned by
  its withdrawal from the individual market.
    (4) In the case of a discontinuance  under  paragraph  three  of  this
  subsection,  the  insurer may not provide for the issuance of any policy
  of hospital, surgical or medical expense  insurance  in  the  individual
  market  in  this state during the five year period beginning on the date
  of the discontinuance of the  last  health  insurance  coverage  not  so
  renewed.
    (5)  At the time of coverage renewal, an insurer may modify the health
  insurance coverage for a policy  form  offered  to  individuals  in  the
  individual  market  so long as such modification is consistent with this
  chapter and effective on a uniform basis among all individuals with that
  policy form.
    (6) For purposes of this subsection the term "network plan" shall mean
  a health insurance policy under which  the  financing  and  delivery  of
  health  care  (including  items  and services paid for as such care) are
  provided, in whole or in part, through a defined set of providers  under

  contract  with  the  insurer or another entity which has contracted with
  the insurer.
    (h) This section shall not apply to or affect:
    (1)  Any  contract  of  non-cancellable  disability insurance which is
  governed by or excepted from section three thousand two hundred  fifteen
  of this article.
    (2) Any policy or contract of reinsurance.
    (3)  Any  policy  of  group  or blanket insurance which is governed by
  section three thousand two hundred twenty-one  of  this  article  except
  that  the provisions of subsection (b) hereof and paragraphs one through
  ten of subsection (i) hereof and the provisions of subsection (j) hereof
  shall be applicable to a policy  of  group  insurance  authorized  under
  subparagraph  (J)  of  paragraph  one  of subsection (c) of section four
  thousand two hundred thirty-five of this chapter.
    (4) Any policy providing disability benefits pursuant to article  nine
  of the workers' compensation law.
    (5)  Any  policy of a co-operative life and accident insurance company
  except as was provided in section two hundred thirty-seven of the former
  insurance law.
    (6) Life insurance,  endowment  or  annuity  contracts,  or  contracts
  supplemental  thereto  which  contain  only  such provisions relating to
  accident and health insurance as provide additional benefits in case  of
  death  or  dismemberment  or loss of sight by accident, or as operate to
  safeguard such contracts against lapse, or to give a  special  surrender
  value  or special benefit or an annuity in the event that the insured or
  annuitant shall become totally and permanently disabled, as  defined  by
  the contract or supplemental contract.
    (i)  Every  person  insured  under  a  policy  of  accident and health
  insurance delivered or issued  for  delivery  in  this  state  shall  be
  entitled to the reimbursements and coverages specified below.
    (1)  If a policy provides for reimbursement for any optometric service
  which is within the lawful scope of practice of a licensed  optometrist,
  the  insured shall be entitled to reimbursement for such service whether
  it is performed by a physician  or  licensed  optometrist.  Unless  such
  policy  shall  otherwise  provide  there  shall  be no reimbursement for
  ophthalmic materials, lenses, spectacles, eyeglasses,  or  appurtenances
  thereto.
    (2) If a policy provides for reimbursement for any podiatrical service
  within  the  lawful  scope  of  practice  of  a licensed podiatrist, the
  insured shall be entitled to reimbursement for such service  whether  it
  is performed by a physician or licensed podiatrist.
    (3)  If  a  policy  provides  for reimbursement for any dental service
  within the lawful scope of practice of a licensed dentist,  the  insured
  shall  be  entitled  to  reimbursement  for  such  service whether it is
  performed by a physician or a licensed dentist.
    (4)  If  a  policy  provides  for  reimbursement  for  psychiatric  or
  psychological  services  or  for  diagnosis  and  treatment  of  mental,
  nervous, or emotional disorders or  ailments,  however  defined  in  the
  policy,  the  insured  shall  be  entitled  to  reimbursement  for  such
  services, diagnosis or  treatment  whether  performed  by  a  physician,
  psychiatrist  or  a  certified  and  registered  psychologist,  when the
  services rendered are within the lawful scope of their practice.
    (5) Every policy providing for reimbursement for laboratory  tests  or
  reimbursement   for   diagnostic   X-ray   services  shall  provide  for
  reimbursement at the same percentage of reimbursement whether such tests
  or services are provided to the insured as  an  admitted  patient  in  a
  health care facility or as an out-patient.

    (6)  Every policy which provides coverage for in-patient hospital care
  shall provide coverage for home care to residents in  this  state.  Such
  home  care  coverage  shall  be  included  at  the  inception of all new
  policies and, with respect to all other  policies,  at  any  anniversary
  date of the policy subject to evidence of insurability.
    (A)  Home care means the care and treatment of a covered person who is
  under the care of a physician but only if hospitalization or confinement
  in a nursing facility as defined in  subchapter  XVIII  of  the  federal
  Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been
  required  if  home care was not provided, and the plan covering the home
  health service is established and approved in writing by such physician.
  Home care shall be provided by an agency possessing a valid  certificate
  of  approval  or  license  issued  pursuant to article thirty-six of the
  public health law and shall consist of one or more of the following:
    (i) Part-time or intermittent  home  nursing  care  by  or  under  the
  supervision of a registered professional nurse (R.N.).
    (ii) Part-time or intermittent home health aide services which consist
  primarily of caring for the patient.
    (iii) Physical, occupational or speech therapy if provided by the home
  health service or agency.
    (iv)   Medical   supplies,  drugs  and  medications  prescribed  by  a
  physician, and laboratory services by or on behalf of a  certified  home
  health  agency  or licensed home care services agency to the extent such
  items would have been covered under the contract if the  covered  person
  had  been  hospitalized  or  confined  in  a skilled nursing facility as
  defined in title subchapter XVIII of the federal Social Security Act, 42
  U.S.C.  §§ 1395 et seq.
    (B) Coverage may be subject to an annual deductible of not  more  than
  fifty  dollars  for  each  person  covered  under  the policy and may be
  subject to a coinsurance provision which provides for  coverage  of  not
  less  than  seventy-five  percent  of  the  reasonable  charges for such
  services. For the purpose of determining  the  benefits  for  home  care
  available  to  a  covered  person, each visit by a member of a home care
  team shall be considered as  one  home  care  visit;  the  contract  may
  contain  a  limitation  on  the number of home care visits, but not less
  than forty such visits in any calendar year or in any continuous  period
  of  twelve months for each person covered under the contract; four hours
  of home health aide service shall be considered as one home care visit.
    (7) Every policy which provides coverage for in-patient hospital  care
  shall  also  provide  coverage  for  pre-admission  tests  performed  in
  hospital out-patient facilities prior to scheduled surgery provided:
    (A) the tests are ordered by a physician as a planned  preliminary  to
  admission  of  the  patient  as  an  in-patient  for surgery in the same
  hospital;
    (B) tests are necessary for and  consistent  with  the  diagnosis  and
  treatment of the condition for which surgery is to be performed;
    (C)  reservations  for  a hospital bed and for an operating room shall
  have been made prior to the performance of the tests;
    (D) the surgery  actually  takes  place  within  seven  days  of  such
  presurgical tests; and
    (E) the patient is physically present at the hospital for the tests.
    (8)  Every policy which provides coverage for in-patient surgical care
  shall include coverage for a second  surgical  opinion  by  a  qualified
  physician on the need for surgery.
    (9)  Every  policy which provides coverage for inpatient hospital care
  shall also include coverage for services to treat an emergency condition
  in hospital facilities. An "emergency  condition"  means  a  medical  or
  behavioral  condition,  the  onset  of  which  is sudden, that manifests

  itself by symptoms of sufficient severity, including severe pain, that a
  prudent layperson, possessing  an  average  knowledge  of  medicine  and
  health,  could  reasonably  expect  the  absence  of  immediate  medical
  attention  to  result  in (A) placing the health of the person afflicted
  with such condition in serious jeopardy, or in the case of a  behavioral
  condition  placing  the  health  of  such  person  or  others in serious
  jeopardy, or (B) serious impairment to such person's  bodily  functions;
  (C)  serious  dysfunction of any bodily organ or part of such person; or
  (D) serious disfigurement of such person.
    (10) (A) (i) Every policy which provides hospital, surgical or medical
  coverage shall provide coverage for maternity care, including  hospital,
  surgical  or  medical care to the same extent that hospital, surgical or
  medical coverage is provided for illness or disease  under  the  policy.
  Such   maternity  care  coverage,  other  than  coverage  for  perinatal
  complications, shall include inpatient hospital coverage for mother  and
  for  newborn  for  at  least  forty-eight hours after childbirth for any
  delivery other than a caesarean section, and  for  at  least  ninety-six
  hours  after a caesarean section. Such coverage for maternity care shall
  include the services of a  midwife  licensed  pursuant  to  article  one
  hundred forty of the education law, practicing consistent with a written
  agreement  pursuant  to  section  sixty-nine  hundred  fifty-one  of the
  education law  and  affiliated  or  practicing  in  conjunction  with  a
  facility  licensed pursuant to article twenty-eight of the public health
  law, but no insurer shall be required to  pay  for  duplicative  routine
  services actually provided by both a licensed midwife and a physician.
    (ii)  Maternity  care  coverage shall also include, at minimum, parent
  education, assistance and training in breast or bottle feeding, and  the
  performance of any necessary maternal and newborn clinical assessments.
    (iii)  The  mother shall have the option to be discharged earlier than
  the time periods established in item (i) of this subparagraph.  In  such
  case,  the  inpatient  hospital  coverage must include at least one home
  care visit, which shall be in addition to, rather than in lieu  of,  any
  home  health  care  coverage available under the policy. The policy must
  cover the home care visit which may be  requested  at  any  time  within
  forty-eight  hours of the time of delivery (ninety-six hours in the case
  of caesarean section) and shall be delivered within  twenty-four  hours,
  (I)  after  discharge,  or  (II)  of  the  time of the mother's request,
  whichever is later. Such home care coverage shall  be  pursuant  to  the
  policy  and  subject  to  the  provisions  of this subparagraph, and not
  subject to deductibles, coinsurance or copayments.
    (B) Coverage provided under this  paragraph  for  care  and  treatment
  during pregnancy shall include provision for not less than two payments,
  at reasonable intervals and for services rendered, for prenatal care and
  a separate payment for the delivery and postnatal care provided.
    (11)  (A)  Every policy which provides coverage for hospital, surgical
  or medical care shall provide the  following  coverage  for  mammography
  screening for occult breast cancer:
    (i) upon the recommendation of a physician, a mammogram at any age for
  covered  persons having a prior history of breast cancer or whose mother
  or sister has a prior history of breast cancer;
    (ii) a single baseline mammogram for covered persons aged  thirty-five
  through thirty-nine, inclusive;
    (iii)  a  mammogram  every  two  years,  or  more  frequently upon the
  recommendation of a physician, for covered persons  aged  forty  through
  forty-nine, inclusive; and
    (iv) an annual mammogram for covered persons aged fifty and older.

    (B) Such coverage may be subject to annual deductibles and coinsurance
  as may be deemed appropriate by the superintendent and as are consistent
  with those established for other benefits within a given policy.
    (C)  For  purposes  of  this paragraph, mammography screening means an
  X-ray examination of the breast  using  dedicated  equipment,  including
  X-ray  tube,  filter,  compression device, screens, films and cassettes,
  with an average glandular radiation dose less than 0.5 rem per view  per
  breast.
    (11-a) (A) Every policy delivered or issued for delivery in this state
  which  provides  medical  coverage  that includes coverage for physician
  services in a physician's office and every policy which  provides  major
  medical  or  similar comprehensive-type coverage shall provide, upon the
  prescription of a health care provider legally authorized  to  prescribe
  under  title  eight  of  the  education  law, the following coverage for
  diagnostic screening for prostatic cancer:
    (i) standard diagnostic testing  including,  but  not  limited  to,  a
  digital  rectal  examination and a prostate-specific antigen test at any
  age for men having a prior history of prostate cancer; and
    (ii) an annual standard  diagnostic  examination  including,  but  not
  limited to, a digital rectal examination and a prostate-specific antigen
  test  for  men  age  fifty and over who are asymptomatic and for men age
  forty and over with  a  family  history  of  prostate  cancer  or  other
  prostate cancer risk factors.
    (B) Such coverage may be subject to annual deductibles and coinsurance
  as may be deemed appropriate by the superintendent and as are consistent
  with those established for other benefits within a given policy.
    (12)  (A)  Every  policy  which provides coverage for prescribed drugs
  approved by the food  and  drug  administration  of  the  United  States
  government  for  the  treatment  of  certain  types  of cancer shall not
  exclude coverage of any such drug on the basis that such drug  has  been
  prescribed  for the treatment of a type of cancer for which the drug has
  not been  approved  by  the  food  and  drug  administration.  Provided,
  however, that such drug must be recognized for treatment of the specific
  type  of  cancer  for  which  the drug has been prescribed in one of the
  following established reference compendia:
    (i) the American Medical Association Drug Evaluations;
    (ii) the American Hospital Formulary Service Drug Information; or
    (iii) the United States Pharmacopeia Drug Information; or  recommended
  by  review  article  or  editorial  comment  in  a  major  peer reviewed
  professional journal.
    (B) Notwithstanding the provisions of this paragraph,  coverage  shall
  not  be  required  for  any experimental or investigational drugs or any
  drug which the  food  and  drug  administration  has  determined  to  be
  contraindicated  for  treatment of the specific type of cancer for which
  the drug has been prescribed. The provisions  of  this  paragraph  shall
  apply  to  cancer  drugs  only  and nothing herein shall be construed to
  create, impair, alter, limit,  modify,  enlarge,  abrogate  or  prohibit
  reimbursement  for  drugs  used in the treatment of any other disease or
  condition.
    (13) (A) Every policy which provides coverage for hospital care  shall
  not  exclude  coverage  for hospital care for diagnosis and treatment of
  correctable medical conditions otherwise covered by  the  policy  solely
  because the medical condition results in infertility.
    (B) Every policy which provides coverage for surgical and medical care
  shall  not  exclude coverage for surgical and medical care for diagnosis
  and treatment of correctable medical conditions otherwise covered by the
  policy solely because the medical condition results in infertility.

    (14) If a policy  provides  for  reimbursement  for  the  services  of
  licensed  health  professionals  who  can bill for services, the insured
  shall be entitled to reimbursement for such service provided pursuant to
  a clinical practice plan established pursuant to subdivision fourteen of
  section two hundred six of the public health law.
    (15)  (A)  Every  policy  which provides hospital, surgical or medical
  care  coverage  or  provides  reimbursement  for  laboratory  tests   or
  reimbursement  for  diagnostic X-ray services shall provide coverage for
  an annual cervical  cytology  screening  for  cervical  cancer  and  its
  precursor states for women aged eighteen and older.
    (B)  For purposes of this paragraph, cervical cytology screening shall
  include an annual pelvic examination, collection and  preparation  of  a
  Pap smear, and laboratory and diagnostic services provided in connection
  with examining and evaluating the Pap smear.
    (C) Such coverage may be subject to annual deductibles and coinsurance
  as may be deemed appropriate by the superintendent and as are consistent
  with those established for other benefits within a given policy.
    (15-a)  (A) Every policy which provides medical coverage that includes
  coverage for physician services in a physician's office and every policy
  which provides major  medical  or  similar  comprehensive-type  coverage
  shall  include coverage for the following equipment and supplies for the
  treatment of diabetes, if recommended or prescribed by  a  physician  or
  other  licensed  health  care  provider  legally authorized to prescribe
  under title eight of the education law: blood glucose monitors and blood
  glucose monitors for the visually  impaired,  data  management  systems,
  test  strips  for  glucose monitors and visual reading and urine testing
  strips, insulin, injection aids, cartridges for the  visually  impaired,
  syringes,  insulin  pumps  and  appurtenances  thereto, insulin infusion
  devices, and oral agents for controlling blood sugar. In  addition,  the
  commissioner  of the department of health shall provide and periodically
  update by rule or regulation a list of additional diabetes equipment and
  related supplies such as are medically necessary for  the  treatment  of
  diabetes,  for  which  there shall also be coverage. Such policies shall
  also include coverage for diabetes self-management education  to  ensure
  that persons with diabetes are educated as to the proper self-management
  and  treatment  of  their  diabetic  condition, including information on
  proper diets. Such coverage for self-management education and  education
  relating to diet shall be limited to visits medically necessary upon the
  diagnosis  of diabetes, where a physician diagnoses a significant change
  in the patient's symptoms or conditions which necessitate changes  in  a
  patient's  self-management,  or where reeducation or refresher education
  is necessary. Such education may be provided by the physician  or  other
  licensed  health  care  provider  legally  authorized to prescribe under
  title eight of the education law, or their staff, as part of  an  office
  visit  for  diabetes  diagnosis or treatment, or by a certified diabetes
  nurse  educator,  certified   nutritionist,   certified   dietitian   or
  registered  dietitian upon the referral of a physician or other licensed
  health care provider legally authorized to prescribe under  title  eight
  of the education law. Education provided by the certified diabetes nurse
  educator,  certified  nutritionist,  certified  dietitian  or registered
  dietitian  may  be  limited  to  group  settings  wherever  practicable.
  Coverage  for  self-management  education and education relating to diet
  shall also include home visits when medically necessary.
    (B) Such coverage may be subject to annual deductibles and coinsurance
  as may be deemed appropriate by the superintendent and as are consistent
  with those established for other benefits within a given policy.
    (16) If  a  policy  provides  for  reimbursement  for  speech-language
  pathology  or  audiology  service  which  is  within the lawful scope of

  practice of a duly licensed speech-language pathologist or  audiologist,
  an  insured  shall be entitled to reimbursement for such service whether
  the  said  service  is  performed  by  a  physician  or  duly   licensed
  speech-language  pathologist  or  audiologist,  provided  however,  that
  nothing contained herein shall be construed to impair any terms of  such
  policy  which  may  require  said  service to be performed pursuant to a
  medical order, or a similar or related service of a physician, in  which
  case  coverage  need  not  be  provided  for  any  tests, evaluations or
  diagnoses if such tests, evaluations  or  diagnoses  have  already  been
  provided  by or through a physician within twelve months of the referral
  or order from the physician. However, nothing herein shall be  construed
  as  preventing an insurer from covering more than one test or evaluation
  provided by  a  speech-language  pathologist  or  audiologist  within  a
  twelve-month  period  where  such  test  or  evaluation  is ordered by a
  physician as medically necessary. Nor shall anything herein be construed
  as prohibiting the  limitation  of  such  services,  where  covered,  to
  specified  settings other than offices, such as hospitals or to services
  provided by such professionals as part of a home care agency's services.
    (17) (A) Every policy which provides medical, major-medical or similar
  comprehensive-type coverage shall provide coverage for the provision  of
  preventive and primary care services.
    (B)  For  the  purposes of this paragraph, preventive and primary care
  services means the following services rendered to a dependent  child  of
  an  insured  from  the  date of birth through the attainment of nineteen
  years;
    (i) an initial hospital check-up and well-child  visits  scheduled  in
  accordance   with  the  prevailing  clinical  standards  of  a  national
  association of pediatric physicians designated by  the  commissioner  of
  health  (except for any standard that would limit the specialty or forum
  of licensure of the practitioner providing the service  other  than  the
  limits  under  state  law). Coverage for such services rendered shall be
  provided only to the extent that such services are provided by or  under
  the  supervision  of  a  physician, or other professional licensed under
  article one hundred thirty-nine of the  education  law  whose  scope  of
  practice  pursuant  to  such  law  includes the authority to provide the
  specified  services.  Coverage  shall  be  provided  for  such  services
  rendered  in  a hospital, as defined in section twenty-eight hundred one
  of the public health law, or in  an  office  of  a  physician  or  other
  professional  licensed  under  article  one  hundred  thirty-nine of the
  education law whose scope of practice pursuant to such law includes  the
  authority to provide the specified services;
    (ii)  at  each  visit,  services  in  accordance  with  the prevailing
  clinical standards of such designated association, including  a  medical
  history,  a  complete  physical  examination,  developmental assessment,
  anticipatory guidance, appropriate immunizations  and  laboratory  tests
  which  tests  are  ordered at the time of the visit and performed in the
  practitioner's  office,  as  authorized  by  law,  or  in   a   clinical
  laboratory; and
    (iii)  necessary  immunizations as determined by the superintendent in
  consultation with the commissioner of  health  consisting  of  at  least
  adequate  dosages  of  vaccine  against  diphtheria, pertussis, tetanus,
  polio, measles,  rubella,  mumps,  haemophilus  influenzae  type  b  and
  hepatitis  b  which  meet  the  standards  approved by the United States
  public health service for such biological products.
    (C) Such coverage shall not be subject to  annual  deductibles  and/or
  coinsurance.
    (D)  Such  coverage  shall not restrict or eliminate existing coverage
  provided by the policy.

    (18) (A) Every policy which provides coverage for  inpatient  hospital
  care shall provide such coverage for such period as is determined by the
  attending  physician  in  consultation  with the patient to be medically
  appropriate for such covered person undergoing a lymph  node  dissection
  or  a  lumpectomy  for  the  treatment  of breast cancer or a mastectomy
  covered  by  the  policy.  Such  coverage  may  be  subject  to   annual
  deductibles  and  coinsurance  as  may  be  deemed  appropriate  by  the
  superintendent and as are consistent with those  established  for  other
  benefits  within  a  given policy. Written notice of the availability of
  such coverage shall be delivered to the policyholder prior to  inception
  of such policy and annually thereafter.
    (B)  An  insurer  providing  coverage  under  this  paragraph  and any
  participating entity through which the insurer  offers  health  services
  shall not:
    (i) deny to a covered person eligibility, or continued eligibility, to
  enroll  or  to  renew coverage under the terms of the policy or vary the
  terms of the policy for the purpose  or  with  the  effect  of  avoiding
  compliance with this paragraph;
    (ii) provide incentives (monetary or otherwise) to encourage a covered
  person  to accept less than the minimum protections available under this
  paragraph;
    (iii) penalize in any way or reduce or limit  the  compensation  of  a
  health care practitioner for recommending or providing care to a covered
  person in accordance with this paragraph;
    (iv)  provide  incentives  (monetary  or  otherwise)  to a health care
  practitioner  relating  to  the  services  provided  pursuant  to   this
  paragraph  intended  to  induce  or  have  the  effect  of inducing such
  practitioner  to  provide  care  to  a  covered  person  in   a   manner
  inconsistent with this paragraph; or
    (v)  restrict  coverage  for any portion of a period within a hospital
  length of stay required under  this  paragraph  in  a  manner  which  is
  inconsistent  with  the  coverage  provided for any preceding portion of
  such stay.
    (C) The prohibitions in subparagraph (B) of this paragraph shall be in
  addition to the  provisions  of  sections  three  thousand  two  hundred
  thirty-one and three thousand two hundred thirty-two of this article and
  nothing  in  this subparagraph shall be construed to suspend, supersede,
  amend or otherwise modify such sections.
    (19) (A) Every  policy  which  provides  medical,  major  medical,  or
  similar  comprehensive-type  coverage must provide coverage for a second
  medical opinion by an appropriate specialist, including but not  limited
  to  a  specialist  affiliated  with  a  specialty  care  center  for the
  treatment of cancer, in the event of a positive or negative diagnosis of
  cancer or a recurrence of cancer or a  recommendation  of  a  course  of
  treatment for cancer, subject to the following:
    (i)  In  the  case  of  a  policy that requires, or provides financial
  incentives for, the insured to receive covered services from health care
  providers participating in a provider network  maintained  by  or  under
  contract  with  the  insurer,  the  policy  shall include coverage for a
  second medical opinion from a  non-participating  specialist,  including
  but  not limited to a specialist affiliated with a specialty care center
  for the treatment of cancer, when the  attending  physician  provides  a
  written  referral  to  a  non-participating specialist, at no additional
  cost to the insured  beyond  what  such  insured  would  have  paid  for
  services  from  a participating appropriate specialist. Provided however
  that nothing herein shall impair an insured's rights (if any) under  the
  policy  to  obtain  the  second medical opinion from a non-participating
  specialist without  a  written  referral,  subject  to  the  payment  of

  additional  coinsurance  (if  any)  required  by the policy for services
  provided by non-participating providers. The  insurer  shall  compensate
  the  non-participating specialist at the usual, customary and reasonable
  rate,  or  at  a rate listed on a fee schedule filed and approved by the
  superintendent which provides a comparable level of reimbursement.
    (ii) In  the  case  of  a  policy  that  does  not  provide  financial
  incentives  for,  and  does  not require, the insured to receive covered
  services from health care providers participating in a provider  network
  maintained  by  or  under  contract  with  the insurer, the policy shall
  include coverage for a second medical opinion from a  specialist  at  no
  additional  cost  to the insured beyond what the insured would have paid
  for comparable services covered under the policy.
    (iii)  Such  coverage  may  be  subject  to  annual  deductibles   and
  coinsurance  as  may  be deemed appropriate by the superintendent and as
  are consistent with those established for other benefits within a  given
  policy, and, where applicable, consistent with the provisions of clauses
  (i) and (ii) of this subparagraph.
    Nothing  in  this  paragraph  shall eliminate or diminish an insurer's
  obligation to comply with the provisions of section four thousand  eight
  hundred  four  of  this  chapter where applicable. Written notice of the
  availability of such coverage shall be  delivered  to  the  policyholder
  prior to the inception of such policy and annually thereafter.
    (B)  An  insurer  providing  coverage  under  this  paragraph  and any
  participating entity through which the insurer  offers  health  services
  shall not:
    (i) deny to a covered person eligibility, or continued eligibility, to
  enroll  or  to  renew coverage under the terms of the policy or vary the
  terms of the policy for the purpose  or  with  the  effect  of  avoiding
  compliance with this paragraph;
    (ii) provide incentives (monetary or otherwise) to encourage a covered
  person  to accept less than the minimum protections available under this
  paragraph;
    (iii) penalize in any way or reduce or limit  the  compensation  of  a
  health care practitioner for recommending or providing care to a covered
  person in accordance with this paragraph; or
    (iv)  provide  incentives  (monetary  or  otherwise)  to a health care
  practitioner  relating  to  the  services  provided  pursuant  to   this
  paragraph  intended  to  induce  or  have  the  effect  of inducing such
  practitioner  to  provide  care  to  a  covered  person  in   a   manner
  inconsistent with this paragraph.
    (C) The prohibitions in subparagraph (B) of this paragraph shall be in
  addition  to  the  provisions  of  sections  three  thousand two hundred
  thirty-one and three thousand two hundred thirty-two of this article and
  nothing in this subparagraph shall be construed to  suspend,  supersede,
  amend or otherwise modify such sections.
    (20)  (A)  Every  policy  which  provides  medical,  major medical, or
  similar comprehensive-type coverage shall provide the following coverage
  for breast reconstruction surgery after a mastectomy:
    (i) all stages of reconstruction of the breast on which the mastectomy
  has been performed; and
    (ii) surgery and reconstruction of  the  other  breast  to  produce  a
  symmetrical appearance;
  in  the  manner determined by the attending physician and the patient to
  be appropriate. Such coverage may be subject to annual  deductibles  and
  coinsurance   provisions   as   may   be   deemed   appropriate  by  the
  superintendent and as are consistent with those  established  for  other
  benefits  within  a  given policy. Written notice of the availability of

  such coverage shall be delivered to the policyholder prior to  inception
  of such policy and annually thereafter.
    (B)  An  insurer  providing  coverage  under  this  paragraph  and any
  participating entity through which the insurer  offers  health  services
  shall not:
    (i) deny to a covered person eligibility, or continued eligibility, to
  enroll  or  to  renew coverage under the terms of the policy or vary the
  terms of the policy for the purpose  or  with  the  effect  of  avoiding
  compliance with this paragraph;
    (ii) provide incentives (monetary or otherwise) to encourage a covered
  person  to accept less than the minimum protections available under this
  paragraph;
    (iii) penalize in any way or reduce or limit  the  compensation  of  a
  health care practitioner for recommending or providing care to a covered
  person in accordance with this paragraph;
    (iv)  provide  incentives  (monetary  or  otherwise)  to a health care
  practitioner  relating  to  the  services  provided  pursuant  to   this
  paragraph  intended  to  induce  or  have  the  effect  of inducing such
  practitioner  to  provide  care  to  a  covered  person  in   a   manner
  inconsistent with this paragraph; or
    (v)  restrict  coverage  for any portion of a period within a hospital
  length of stay required under  this  paragraph  in  a  manner  which  is
  inconsistent  with  the  coverage  provided for any preceding portion of
  such stay.
    (C) The prohibitions in this paragraph shall be  in  addition  to  the
  provisions  of  sections three thousand two hundred thirty-one and three
  thousand two hundred thirty-two of this  article  and  nothing  in  this
  paragraph  shall  be construed to suspend, supersede, amend or otherwise
  modify such sections.
    * (21) Every policy which provides  coverage  for  prescription  drugs
  shall include coverage for the cost of enteral formulas for home use for
  which  a  physician  or  other  licensed  health  care  provider legally
  authorized to prescribe under title  eight  of  the  education  law  has
  issued  a written order. Such written order shall state that the enteral
  formula is clearly medically necessary and has been proven effective  as
  a  disease-specific  treatment  regimen for those individuals who are or
  will become  malnourished  or  suffer  from  disorders,  which  if  left
  untreated,  cause  chronic  physical  disability,  mental retardation or
  death. Specific diseases for which enteral  formulas  have  been  proven
  effective  shall  include, but are not limited to, inherited diseases of
  amino acid or organic acid metabolism; Crohn's Disease; gastroesophageal
  reflux with failure to thrive; disorders  of  gastrointestinal  motility
  such as chronic intestinal pseudo-obstruction; and multiple, severe food
  allergies  which  if  left  untreated will cause malnourishment, chronic
  physical disability, mental retardation or death. Enteral formulas which
  are medically necessary and taken under written order from  a  physician
  for  the  treatment  of  specific  diseases  shall be distinguished from
  nutritional supplements taken electively. Coverage for certain inherited
  diseases of  amino  acid  and  organic  acid  metabolism  shall  include
  modified  solid  food  products  that  are  low protein or which contain
  modified protein which are medically necessary, and  such  coverage  for
  such  modified  solid  food  products  for  any calendar year or for any
  continuous period of twelve months for any insured individual shall  not
  exceed two thousand five hundred dollars.
    * NB There are 2 par (21)'s
    * (21)(A) Every policy which is a "managed care product" as defined in
  subparagraph  (D) of this paragraph that provides coverage for physician
  services in a physician's office, and every policy which is  a  "managed

  care  product" that provides major medical or similar comprehensive-type
  coverage, shall include coverage for chiropractic care,  as  defined  in
  section  six  thousand  five  hundred  fifty-one  of  the education law,
  provided  by  a  doctor of chiropractic licensed pursuant to article one
  hundred  thirty-two  of  the  education  law,  in  connection  with  the
  detection  or  correction  by  manual  or mechanical means of structural
  imbalance, distortion or subluxation in the human body for  the  purpose
  of  removing  nerve  interference,  and  the effects thereof, where such
  interference is the result of or related to distortion, misalignment  or
  subluxation  of  or  in the vertebral column. However, chiropractic care
  and services may be subject to  reasonable  deductible,  co-payment  and
  co-insurance  amounts,  reasonable fee or benefit limits, and reasonable
  utilization review, provided that any such amounts, limits  and  review:
  (a)  shall  not  function to direct treatment in a manner discriminative
  against chiropractic care, and (b) individually and  collectively  shall
  be  no  more  restrictive than those applicable under the same policy to
  care  or  services  provided  by  other  health  professionals  in   the
  diagnosis,  treatment  and management of the same or similar conditions,
  injuries,  complaints,  disorders  or  ailments,   even   if   differing
  nomenclature  is  used  to  describe  the  condition, injury, complaint,
  disorder or ailment. Nothing herein  contained  shall  be  construed  as
  impeding  or preventing either the provision or coverage of chiropractic
  care and services by duly licensed doctors of chiropractic,  within  the
  lawful scope of chiropractic practice, in hospital facilities on a staff
  or employee basis.
    (C)  Every  policy which includes coverage for physician services in a
  physician's office, and every policy which  provides  major  medical  or
  similar comprehensive-type coverage, other than a "managed care product"
  as defined in subparagraph (D) of this paragraph, shall provide coverage
  for  chiropractic  care, as defined in section six thousand five hundred
  fifty-one of the education law, provided by  a  doctor  of  chiropractic
  licensed  pursuant  to  article  one hundred thirty-two of the education
  law, in connection  with  the  detection  or  correction  by  manual  or
  mechanical  means  of structural imbalance, distortion or subluxation in
  the human body for the purpose of removing nerve interference,  and  the
  effects  thereof, where such interference is the result of or related to
  distortion, misalignment or subluxation of or in the  vertebral  column.
  However,  chiropractic  care  and  services may be subject to reasonable
  deductible, co-payment  and  co-insurance  amounts,  reasonable  fee  or
  benefit  limits,  and  reasonable  utilization review, provided that any
  such amounts, limits and  review:  (a)  shall  not  function  to  direct
  treatment  in a manner discriminative against chiropractic care, and (b)
  individually and collectively shall be no more  restrictive  than  those
  applicable  under  the same policy to care or services provided by other
  health professionals in the diagnosis, treatment and management  of  the
  same or similar conditions, injuries, complaints, disorders or ailments,
  even  if  differing  nomenclature  is  used  to  describe the condition,
  injury, complaint, disorder or ailment. Nothing herein  contained  shall
  be  construed as impeding or preventing either the provision or coverage
  of  chiropractic  care  and  services  by  duly  licensed   doctors   of
  chiropractic,  within  the  lawful  scope  of  chiropractic practice, in
  hospital facilities on a staff or employee basis.
    (D) For purposes of this paragraph, a  "managed  care  product"  shall
  mean  a policy which requires that medical or other health care services
  covered under  the  policy,  other  than  emergency  care  services,  be
  provided  by,  or  pursuant to a referral from, a primary care provider,
  and that services provided pursuant to such a referral be rendered by  a
  health  care  provider  participating  in  the  insurer's  managed  care

  provider network. In addition, a managed care product  shall  also  mean
  the  in-network  portion  of  a  contract which requires that medical or
  other health care  services  covered  under  the  contract,  other  than
  emergency care services, be provided by, or pursuant to a referral from,
  a  primary  care provider, and that services provided pursuant to such a
  referral be rendered by a health  care  provider  participating  in  the
  insurer's  managed care provider network, in order for the insured to be
  entitled to the maximum reimbursement under the contract.
    (E) The coverage required by this paragraph shall not be  abridged  by
  any regulation promulgated by the superintendent.
    * NB There are 2 par (21)'s
    (22)  No  policy  shall  exclude coverage of a health care service, as
  defined in paragraph two of subsection (e) of section four thousand nine
  hundred of this chapter, rendered or  proposed  to  be  rendered  to  an
  insured   on   the   basis   that   such   service  is  experimental  or
  investigational, is rendered as part of a clinical trial as  defined  in
  subsection  (b-2)  of  section  forty-nine hundred of this chapter, or a
  prescribed pharmaceutical product  referenced  in  subparagraph  (B)  of
  paragraph  two  of  subsection (e) of section forty-nine hundred of this
  chapter provided that coverage of the patient costs of such service  has
  been  recommended  for  the  insured by an external appeal agent upon an
  appeal conducted pursuant to  subparagraph  (B)  of  paragraph  four  of
  subsection  (b)  of  section four thousand nine hundred fourteen of this
  chapter. The determination of the external appeal agent shall be binding
  on the parties. For purposes of this paragraph, patient costs shall have
  the same meaning as such term has for purposes of  subparagraph  (B)  of
  paragraph  four  of subsection (b) of section four thousand nine hundred
  fourteen of this chapter;  provided,  however,  that  coverage  for  the
  services  required under this paragraph shall be provided subject to the
  terms and conditions generally applicable  to  other  benefits  provided
  under the policy.
    (23)   If  a  policy  provides  for  reimbursement  for  physical  and
  occupational therapy  service  which  is  within  the  lawful  scope  of
  practice  of  a  duly  licensed  physical  or occupational therapist, an
  insured shall be entitled to reimbursement for such service whether  the
  said  service  is  performed  by  a physician or through a duly licensed
  physical or  occupational  therapist,  provided  however,  that  nothing
  contained  herein  shall be construed to impair any terms of such policy
  including appropriate utilization review and the requirement  that  said
  service  be  performed  pursuant  to  a  medical  order, or a similar or
  related service of a physician.
    (24)(A)  Every  policy  which  provides  major  medical   or   similar
  comprehensive-type  coverage  shall  include  coverage  for  prehospital
  emergency medical services for the treatment of an  emergency  condition
  when  such  services  are  provided  by  an  ambulance  service issued a
  certificate to operate pursuant to section three thousand  five  of  the
  public health law.
    (B) Payment by an insurer pursuant to this section shall be payment in
  full for the services provided. An ambulance service reimbursed pursuant
  to this section shall not charge or seek any reimbursement from, or have
  any  recourse  against  an insured for the services provided pursuant to
  this paragraph, except for the collection of copayments, coinsurance  or
  deductibles  for which the insured is responsible for under the terms of
  the policy.
    (C)  An  insurer  shall  provide  reimbursement  for  those   services
  prescribed  by  this section at rates negotiated between the insurer and
  the provider of such services. In the absence of agreed upon  rates,  an

  insurer  shall  pay for such services at the usual and customary charge,
  which shall not be excessive or unreasonable.
    (D)  The  provisions  of  this  paragraph shall have no application to
  transfers of patients between hospitals or health care facilities by  an
  ambulance service as described in subparagraph (A) of this paragraph.
    (E) As used in this paragraph:
    (i)   "Prehospital   emergency  medical  services"  means  the  prompt
  evaluation and treatment  of  an  emergency  medical  condition,  and/or
  non-air-borne  transportation  of  the  patient  to a hospital, provided
  however,   where   the   patient   utilizes   non-air-borne    emergency
  transportation  pursuant  to this paragraph, reimbursement will be based
  on whether a prudent  layperson,  possessing  an  average  knowledge  of
  medicine  and  health,  could  reasonably  expect  the  absence  of such
  transportation to result  in  (1)  placing  the  health  of  the  person
  afflicted  with  such condition in serious jeopardy, or in the case of a
  behavioral condition placing the health of  such  person  or  others  in
  serious  jeopardy;  (2)  serious  impairment  to  such  person's  bodily
  functions; (3) serious dysfunction of any bodily organ or part  of  such
  person; or (4) serious disfigurement of such person.
    (ii)  "Emergency  condition"  means a medical or behavioral condition,
  the onset of which is sudden,  that  manifests  itself  by  symptoms  of
  sufficient  severity,  including  severe pain, that a prudent layperson,
  possessing an average knowledge of medicine and health, could reasonably
  expect the absence of immediate  medical  attention  to  result  in  (1)
  placing  the  health  of  the  person  afflicted  with such condition in
  serious jeopardy, or in the case of a behavioral condition  placing  the
  health  of  such  person  or  others  in  serious  jeopardy; (2) serious
  impairment to such person's bodily functions; (3) serious dysfunction of
  any bodily organ or part of such person; or (4) serious disfigurement of
  such person.
    (25) Every policy which provides coverage for hospital,  surgical,  or
  medical  care  coverage  shall  not  exclude  coverage for diagnosis and
  treatment of medical conditions otherwise covered by the  policy  solely
  because  the  treatment is provided to diagnose or treat autism spectrum
  disorder. For purposes of this section, "autism spectrum disorder" means
  a neurobiological condition that  includes  autism,  Asperger  syndrome,
  Rett's syndrome, or pervasive developmental disorder.
    * (26)(A)  No  managed  care  health  insurance  policy  that provides
  coverage for hospital, medical  or  surgical  care  shall  provide  that
  services  of  a participating hospital will be covered as out-of-network
  services solely on the basis that the health care provider admitting  or
  rendering services to the insured is not a participating provider.
    (B) No managed care health insurance policy that provides coverage for
  hospital,  medical  or  surgical  care  shall provide that services of a
  participating health care provider will  be  covered  as  out-of-network
  services  solely  on  the  basis  that  the  services  are rendered in a
  non-participating hospital.
    (C) For purposes of this paragraph, a  "health  care  provider"  is  a
  health  care  professional licensed, registered or certified pursuant to
  title  eight  of  the  education  law  or  a  health  care  professional
  comparably licensed, registered or certified by another state.
    (D)  For  purposes of this paragraph, a "managed care health insurance
  policy" is a policy  that  requires  that  services  be  provided  by  a
  provider participating in the insurer's network in order for the insured
  to receive the maximum level of reimbursement under the policy.
    * NB Effective January 1, 2010
    (j)  (1)  Every  insurer  issuing  a  policy  of  accident  and health
  insurance for  delivery  in  this  state  which  provides  coverage  for

  in-patient  hospital  care  must make available and, if requested by the
  policyholder, provide coverage for care in a nursing home. Such coverage
  shall be made available at the inception of all new policies  and,  with
  respect  to  all  other  policies  at any anniversary date of the policy
  subject to evidence of insurability.
    (A) In this paragraph nursing home care means the continued  care  and
  treatment  of  a covered person who is under the care of a physician but
  only if (i) the care is provided in a nursing home as defined in section
  twenty-eight hundred one of the public health law or a  skilled  nursing
  facility  as  defined in subchapter XVIII of the federal Social Security
  Act, 42 U.S.C. §§ 1395 et seq, (ii) the covered person  has  been  in  a
  hospital  for  at  least three days immediately preceding admission, and
  (iii)  further  hospitalization  would  otherwise  be   necessary.   The
  aggregate  of  the  number of covered days of care in a hospital and the
  number of covered days of care in a nursing home, with two days of  care
  in  a  nursing home equivalent to one day of care in a hospital, may not
  exceed the number of covered days of hospital care  provided  under  the
  contract  in  a benefit period. The level of benefits to be provided for
  nursing home care must be reasonably related to  the  benefits  provided
  for hospital care.
    (B)  Ambulatory care means care in hospital out-patient facilities, as
  a hospital is defined in section twenty-eight hundred one of the  public
  health  law  or  subchapter XVIII of the federal Social Security Act, 42
  U.S.C. §§ 1395 et seq,  and  physicians'  offices.  Ambulatory  care  in
  hospital  out-patient  facilities  means services for diagnostic X-rays,
  laboratory and pathological examinations, physical therapy and radiation
  therapy, and services and medications used  for  nonexperimental  cancer
  chemotherapy and cancer hormone therapy, provided that such services and
  medications  are  (i)  related  to  and  necessary  for the treatment or
  diagnosis of  the  patient's  illness  or  injury,  (ii)  ordered  by  a
  physician  and (iii) in the case of physical therapy, services are to be
  furnished in connection with the same illness for which the patient  had
  been  hospitalized  or in connection with surgical care, but in no event
  need benefits be provided for physical therapy which commences more than
  six months after discharge from a hospital or the date surgical care was
  rendered, and in no event need benefits for physical therapy be provided
  after three hundred sixty-five days from the date of  discharge  from  a
  hospital  or  the  date  surgical  care was rendered. Ambulatory care in
  physicians' offices means  services  for  diagnostic  X-rays,  radiation
  therapy,  laboratory  and  pathological  examinations,  and services and
  medications used for  nonexperimental  cancer  chemotherapy  and  cancer
  hormone therapy, provided that such services and medications are related
  to and necessary for the treatment or diagnosis of the patient's illness
  or  injury,  and  ordered  by  a  physician. Such coverage shall be made
  available at the inception of all new policies and, with respect to  all
  other  policies,  at  any  anniversary  date  of  the  policy subject to
  evidence of insurability.
    (2) Every insurer issuing a policy of accident  and  health  insurance
  for  delivery in this state which provides coverage supplementing part A
  and part B of subchapter XVIII of the federal Social  Security  Act,  42
  U.S.C.    §§  1395  et seq, must make available and, if requested by the
  insured, provide coverage of supplemental home care visits beyond  those
  provided  by  part  A  and  part  B,  sufficient to produce an aggregate
  coverage of three hundred sixty-five home case visits per  policy  year.
  Such  coverage  shall  be provided pursuant to regulations prescribed by
  the superintendent.
    (3) Consistent with federal law, every insurer  issuing  a  policy  of
  accident  and health insurance for delivery in this state which provides

  coverage supplementing part A and part B  of  subchapter  XVIII  of  the
  federal  Social  Security  Act,  42  USC  §§  1395  et  seq., shall make
  available and, if requested by the  insured,  provide  coverage  for  at
  least  ninety  days  of  care  in  a  nursing home as defined in section
  twenty-eight hundred one of the public health  law,  except  where  such
  coverage   would   duplicate   coverage  that  is  available  under  the
  aforementioned subchapter XVIII. Such coverage shall be  made  available
  at  the  inception  of  all  new policies and, with respect to all other
  policies, at each anniversary date of the policy.
    (A) Coverage shall be subject to a copayment  of  twenty-five  dollars
  per day.
    (B)  Brochures  describing  such  coverage  must  be  provided  to all
  applicants  at  the  time  of  application  for  all  new  policies  and
  thereafter  on  each anniversary date of the policy, and with respect to
  all other policies annually at each anniversary date of the policy. Such
  brochures must be approved by the superintendent  in  consultation  with
  the commissioner of health.
    (C)  The  commensurate  rate  for the coverage must be approved by the
  superintendent.
    (D) Such insurers shall report to the  superintendent  each  year  the
  number  of  contract  holders  to  whom  such  insurers have issued such
  policies for nursing home coverage and the approximate number of persons
  covered by such policies.
    (k) Any person, partnership or  corporation  willfully  violating  any
  provision  of  this  section,  regulation or order of the superintendent
  made in accordance with this section, shall forfeit to the people of the
  state a sum not to exceed one hundred dollars for each  such  violation.
  The  superintendent may also suspend or revoke the license of an insurer
  or agent or broker for any such willful violation.
    (l) On and after January  first,  nineteen  hundred  ninety-seven,  no
  insurer  shall  offer  major  medical, comprehensive or other comparable
  individual contracts, other than for purposes of conversion, unless  the
  benefits  of  such contracts, including deductibles and coinsurance, are
  identical to the out-of-plan benefits  of  the  contracts  described  in
  section  four  thousand  three  hundred twenty-two of this chapter. Such
  contracts must include a prescription drug benefit  complying  with  the
  requirements of that section.