Delaware Code Title 18 Sec. 3808 – Evidence of coverage
(a) An enrollee shall be entitled to receive evidence of coverage or a certificate indicating specifically the nature and extent of coverage, and evidence of the total amount or percentage of payment, if any, which the enrollee is obligated to pay for dental services. If an individual enrollee obtains coverage through an insurance policy or through a contract issued by a medical or dental service corporation, whether by option or otherwise, the insurer or medical or dental service corporation shall issue the evidence of coverage. Otherwise, the dental plan organization shall issue the evidence of coverage.
Terms Used In Delaware Code Title 18 Sec. 3808
- Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Dental plan: means any contractual arrangement for dental services provided directly or arranged for or administered directly on a prepaid or postpaid individual or group capitation basis. See Delaware Code Title 18 Sec. 3802
- Dental plan organization: means any person who undertakes to provide directly or to arrange for or administer 1 or more dental plans providing dental services. See Delaware Code Title 18 Sec. 3802
- Dental services: means services included in the practice of dentistry as defined in § 1121 of Title 24. See Delaware Code Title 18 Sec. 3802
- Enrollee: means an individual and that individual's dependents who are enrolled in a dental plan organization. See Delaware Code Title 18 Sec. 3802
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Evidence of coverage: means any certificate, agreement or contract issued to an enrollee setting out the dental services to which the enrollee is entitled. See Delaware Code Title 18 Sec. 3802
(b) No evidence of coverage or amendment thereto shall be issued or delivered to any person until a copy of the form of evidence of coverage or amendment thereto has been filed with the Commissioner.
(c) Evidence of coverage shall contain a clear and complete statement if a contract, or a reasonably complete summary if a certificate, of:
(1) The dental services and the insurance and other benefits, if any, to which enrollees are entitled;
(2) Any limitations on the services, kind of services, benefits, or kind of benefits to be provided including any charge, deductible or co-payment features;
(3) Where and in what manner information is available as to how services may be obtained; and
(4) A clear and understandable description of the dental plan organization‘s method for resolving enrollees’ complaints.
(d) Any subsequent change in the evidence of coverage, or the amount or percentage of payment which the enrollee is obligated to pay, shall be evidenced in a separate document issued to the enrollee.