North Carolina General Statutes 58-53-70. Exclusions
An insurer shall not be required to issue a converted policy covering any person if such person is or can be covered by Medicare. Furthermore, an insurer shall not be required to issue a converted policy covering any person if:
(1) a. Such person is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy, or hospital or medical service subscriber contract or medical practice or other prepayment plan, or by any other plan or program;
b. Such person is or could be covered for similar benefits, whether or not covered for such benefits, under any arrangement of coverage for individuals in a group, whether insured or uninsured; or
c. Similar benefits are provided for or available to such person, whether or not covered for such benefits, by reason of any State or federal law; and
(2) The benefits under sources of the kind referred to in subdivision (1)a of this section for such person, or benefits provided or available under sources of the kind referred to in subdivisions (1)b and (1)c of this section for such person, together with the converted policy’s benefits would result in overinsurance according to the insurer’s standards for overinsurance; or
Terms Used In North Carolina General Statutes 58-53-70
- Contract: A legal written agreement that becomes binding when signed.
- converted policy: means an individual health insurance policy issued by an insurance company or an individual contract issued by a service corporation or health maintenance organization or similar corporation or organization. See North Carolina General Statutes 58-53-1
- 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.
- insured: refer to coverage under a group policy, individual policy or converted policy on a premium-paying basis, and do not include coverage provided by reason of a disability extension. See North Carolina General Statutes 58-53-1
- Insurer: means the entity issuing a group policy or an individual or converted policy. See North Carolina General Statutes 58-53-1
- Medicare: means Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded. See North Carolina General Statutes 58-53-1
- state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories, so called; and the words "United States" shall be construed to include the said district and territories and all dependencies. See North Carolina General Statutes 12-3
(3) An enrollee’s enrollment in a health maintenance organization has been terminated for cause in accord with the terms of the enrollee’s evidence of coverage or the health maintenance organization’s contract with the group. (1981, c. 706, s. 1; 1991, c. 195, s. 2.)