IHC Group, Inc. - Page 11




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          and select the benefit package of his or her choice.  Although              
          petitioner did not deny membership to enrollees with preexisting            
          medical conditions, some SelectMed benefit plans denied enrollees           
          full coverage for certain preexisting conditions during the first           
          12 months of membership.                                                    
               Petitioner could terminate coverage for any employer group             
          (subject to offering conversion coverage for individual members)            
          based upon any of the following events:  (1) Failure of the                 
          employer to pay all premiums in full when due; (2) written notice           
          of termination given by either party; (3) fraud or material                 
          misrepresentation by the employer; or (4) failure by the employer           
          to continue to meet the plan’s minimum enrollment or underwriting           
          obligation.  Petitioner could terminate coverage for any                    
          individual enrollee for the following reasons:  (1) Enrollee                
          fraud or misrepresentation in the enrollment process or in the              
          use of plan services or the services of participating providers             
          or facilities; (2) failure to meet eligibility requirements; and            
          (3) failure to make required payroll deductions, applicable                 
          copayments, coinsurance or deductible payments, or other                    
          authorized charges.                                                         
               Petitioner did not own or operate any medical facilities,              
          nor did it directly employ any physicians or other health care              
          professionals.  Petitioner fulfilled its obligation to arrange              
          for its SelectMed enrollees to receive physician services by                






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Last modified: May 25, 2011