(a) On and after January 1, 1994, any disability insurer shall pay group insurance benefits contingent upon, or for expenses incurred on account of, hospitalization or medical or surgical aid to the person or persons having provided or having paid for the hospitalization or medical or surgical aid where that person has qualified for reimbursement by submitting the items and information specified in subdivisions (b) and (c). The amount of any such payment shall not exceed the amount of benefit provided by the policy with respect to the service or billing of the provider of aid, and the amount of payments shall not exceed the amount of expenses incurred on account of the hospitalization or medical or surgical aid. Payment so made shall discharge the insurer’s obligation with respect to the amount so paid.
(b) The items which shall be submitted to the insurer for reimbursement pursuant to subdivision (a) are as follows:
(1) Proof of payment of medical services and a provider’s itemized bill for service.
(2) In the case where the insured does not reside with the person or persons seeking hospitalization or medical or surgical aid, either a copy of the judicial order requiring the insured to provide dependent coverage or a state approved form verifying the existence of a judicial order to be filed with the insurer on an annual basis.
(3) In the case where the insured does not reside with the person or persons seeking hospitalization or medical or surgical aid, and the provider is seeking direct reimbursement, an itemized bill with the signature of the custodial parent or guardian certifying that services being billed for have been provided and, on an annual basis, either a copy of the judicial order requiring the insured to provide dependent coverage or a state approved form verifying the existence of a judicial order.
(c) When seeking payment from an insurer, a person shall provide an insurer the items specified in subdivision (b) with the name and address of the person to be reimbursed, the name and policy number of the insured, the name of the individual for whom hospitalization or medical or surgical aid has been provided, and other necessary information directly related to coverage under the policy.
(d) In the case of a Medi-Cal beneficiary, where the State Department of Health Services has paid for the hospitalization or medical or surgical aid, any disability insurer shall pay group insurance benefits to the State Department of Health Services for expenses contingent upon, or incurred on account of hospitalization or medical or surgical aid. Payment so made shall discharge the insurer’s obligation with respect to the amount so paid. The amount of any such payment shall not exceed the amount of benefit provided by the policy with respect to the service or billing of the provider of aid, and the amount of payments shall not exceed the amount of expenses incurred on account of hospitalization or medical or surgical aid.
(Added by Stats. 1993, Ch. 744, Sec. 2.5. Effective January 1, 1994.)
Last modified: October 25, 2018