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CHAPTER 58-17

HEALTH INSURANCE POLICIES

58-17-1      Requirements for all health insurance policies delivered in state.
58-17-1.1      Grandfathered plans required to cover low-dose mammography--Extent of coverage.
58-17-1.2      Policies to provide coverage for diabetes supplies, equipment and education--Exceptions--Conditions and limitations.
58-17-1.3      Diabetes coverage not required of certain plans and policies.
58-17-1.4      Policies required to cover occult breast cancer screening.
58-17-2      Persons covered by policy.
58-17-2.1      Health insurance on a franchise plan.
58-17-2.2      Conversion privileges of insured's spouse upon divorce.
58-17-2.3      Dependent coverage termination--Age--Full-time students.
58-17-3      Time of commencement and termination to be set out in policy.
58-17-4      Consideration for policy to be stated.
58-17-4.1      Filing and approval of individual policy premium rates.
58-17-4.2      Premium rates required to be reasonable--Rules to establish minimum standards promulgated by director.
58-17-4.3      Transferred.
58-17-5      Identification of forms, riders and endorsements--Form number, location.
58-17-6      Style and arrangement of policy provisions--Printing, size of type.
58-17-7      Documents forming part of policy--Setting forth in full, rates and classifications excepted.
58-17-8      Exceptions and reductions of coverage to be clearly set out.
58-17-9      Renewal of policy at option of insurer--Statement in policy so informing the policyholder.
58-17-10      Repealed.
58-17-10.1      Reduction of benefits because of increase in statutory disability benefits prohibited.
58-17-10.2      Individual policy for insured's spouse required in policies covering spouse--Eligibility--Coverage--Waiting periods.
58-17-11      Return of policy by purchaser--Refund of premium paid--Dissatisfaction with terms after examination.
58-17-11.1      Issuance of policies by insurance company, nonprofit hospital service plan, medical service corporation, or fraternal benefit society--Delivery receipts--Certificates of mailing--Term of retention.
58-17-12      Required provisions--Captions--Substitutes, approval by director.
58-17-13      Omission from policy of inapplicable provision--Approval of director--Modification of inconsistent provision.
58-17-14      Entire contract and change clauses required--Signed acceptance required for endorsements.
58-17-15      Time limit on certain defenses--Application of section.
58-17-16      Repealed.
58-17-17      Grace period on premiums required in policy.
58-17-18      Renewal of policy--Restriction on company's right to refuse.
58-17-19      Reinstatement when premium not paid within grace period.
58-17-20      Omission of provision as to application of premiums accepted in connection with reinstatement--Right of insured to continue policy in force by payment of premiums.
58-17-21      Notice of claim--Provision required in policy.
58-17-22      Notice of claim--Loss of time benefit--Optional provision, insertion by insurer.
58-17-23      Claim forms--Furnishing by insurer.


58-17-24      Proofs of loss--Provision required in policy.
58-17-25      Time of payment of claims--Provision required in policy.
58-17-26      Payment of claims--Persons to whom benefits payable--Provision required in policy.
58-17-27      Payment of claims--Optional provisions, insertion by insurer.
58-17-28      Physical examination of insured--Autopsy in death claims--Provision required in policy.
58-17-29      Action to recover under policy--Time for beginning.
58-17-30      Beneficiary--Changes reserved to insured.
58-17-30.1      Continuation of coverage for child with intellectual or physical disability--Proof of dependency.
58-17-30.2      Family coverage to include newborn or newly adopted children--Payment of claim not to be withheld during bonding period of adopted child.
58-17-30.3      Premature birth and congenital defects covered--Applicability.
58-17-30.4      Notice of birth or adoption required for continued coverage.
58-17-30.5      Coverage for inpatient alcoholism treatment required.
58-17-30.6      Alcoholism benefits provided--Days of care.
58-17-30.7      Policies excluded from alcoholism coverage requirements.
58-17-30.8      Exclusion of benefits for injury while under the influence of alcohol or drugs prohibited--Exception for sickness or injury caused in commission of felony.
58-17-30.9      Notice that dependent is no longer eligible for coverage--Premium adjustment.
58-17-31      Optional policy provisions.
58-17-32      Occupational change--Policy provision for adjustment of premium or benefits.
58-17-33      Misstatement of age--Policy provision for adjustment of benefits.
58-17-34      Earnings of insured--Policy provision for adjustment of benefits.
58-17-35      Earnings adjustment clause to be coupled with insured's right to continue policy in force.
58-17-36      Option of insurer to define "valid loss of time coverage".
58-17-37      Unpaid premiums--Deduction from benefits.
58-17-38      Conformity with state statutes of insured.
58-17-39      Illegal occupation of insured.
58-17-40      Renewal of policy at option of insurer.
58-17-41      Order of policy provisions.
58-17-42      Age limit in policy--Effect of acceptance of premiums or misstatement of age.
58-17-43      Third parties taking policy covering insured.
58-17-44      Foreign or alien insurer--Policy provision required by home state.
58-17-45      Policy of domestic insurer delivered in other state--Compliance with laws of other state.
58-17-46      Policy provisions not subject to chapter--Conforming to statute required.
58-17-47      Nonconforming and conflicting provisions construed in conformity with statute.
58-17-48      Liability and workers' compensation insurance--Inapplicability of health insurance provisions.
58-17-49      Health insurance provisions inapplicable to group or blanket policy.
58-17-50      Life insurance, endowment or annuity contracts not subject to health insurance provisions.
58-17-51      Health insurance provisions inapplicable to reinsurance.
58-17-52      Prior contracts or policies excepted.
58-17-53      Optometric services--Reimbursement, exceptions.
58-17-54      Reimbursement provisions applicable to all healing arts licensees--Self-insurance plans for public employees--Restrictions on policy limitations.
58-17-54.1      Copayment or coinsurance amounts for chiropractic, physical therapy, or occupational therapy services.
58-17-55      Reimbursement provisions applicable to licensed hospitals.
58-17-56      Reimbursement for service rendered or supervised by qualified mental health professional.
58-17-57      "Abuse of health insurance" defined--Violation as misdemeanor.
58-17-58      Waiver of required deductible or co-payment for charitable purposes permitted.
58-17-59      When waiver presumed.
58-17-60      Certain payments exempt.
58-17-61      Assignment of health insurance proceeds to certain hospitals authorized.
58-17-62      Coverage for phenylketonuria.
58-17-63      "Health benefit plan" defined.
58-17-64      Minimum loss ratio for individual health benefit plans.
58-17-65      Individual health insurance plan used in conjunction with managed care plan or utilization review organization.
58-17-66      Definitions for 58-17-66 to 58-17-87.
58-17-67      "Professional association" defined.
58-17-68      "Professional association plan" defined.
58-17-69      "Creditable coverage" defined.
58-17-70      Application of 58-17-66 to 58-17-87, inclusive.
58-17-71      Separate classes of individual business--Reasons--Number.
58-17-72      Transitional period when additional class of business acquired.
58-17-73      Director approval required to establish additional classes of business--Rates or rating methodologies.
58-17-74      Provisions for premium rates for individual health benefit plans.
58-17-74.1      Premium rate limitations.
58-17-75      Promulgation of rules for rates charged for individual health benefit plans.
58-17-76      Transfer into or out of class of business.
58-17-77      Temporary suspension of premium rates for individual health insurance--Reasons.
58-17-78      Required disclosure when offering individual health benefit plan.
58-17-79      Documentation of rating methods and practices.
58-17-80      Repealed.
58-17-81      Availability of information on rating methods and practices of carriers offering individual health benefit plans.
58-17-82      Renewal of individual health benefit plans--Exceptions.
58-17-83      Election not to renew individual health benefit plan--Future business restricted.
58-17-84      Provisions for carriers providing individual coverage other than excepted benefits.
58-17-84.1      Anesthesia and hospitalization for dental care to be provided certain covered persons.
58-17-85, 58-17-85.1. Repealed.
58-17-86      Repealed.
58-17-87      Director to promulgate rules for individual health insurance--Scope of rules.
58-17-88      Minimum inpatient care coverage following delivery.
58-17-89      Shorter hospital stay permitted--Follow-up visit within forty-eight hours required.
58-17-90      Notice to policyholders--Disclosures.
58-17-91 to 58-17-96.      Repealed.
58-17-97      Provisions covering preexisting conditions.
58-17-98      Health insurance policies to provide coverage for biologically-based mental illnesses.
58-17-99      Application of § 58-17-98--Exemptions.
58-17-100      Definitions.
58-17-101      Insurer may not exclude certain off-label uses of prescription drugs.
58-17-102      Exceptions.
58-17-103      Provisions limited to cancer or life threatening diseases.
58-17-104      Deductibles, copayments, and managed care review not affected.
58-17-105      Drugs used in research trials not covered.
58-17-106      No reduction or limitation of coverage otherwise required by law.
58-17-107      Health insurance policies to provide coverage for prostate cancer screening.
58-17-108      "Disability income insurance" defined.
58-17-109      Exclusion or reduction of benefits.
58-17-110      Commencement of loss.
58-17-111      Minimum standards--Exceptions.
58-17-112      Promulgation of rules regarding disability income policies--Content.
58-17-113, 58-17-114.      Repealed .
58-17-115      Repealed.
58-17-116      Repealed.
58-17-117, 58-17-118. Repealed.
58-17-119 to 58-17-124.      Repealed .
58-17-125      Repealed.
58-17-126      Repealed.
58-17-127 to 58-17-137. Repealed.
58-17-138      Repealed.
58-17-139 to 58-17-141. Repealed.
58-17-142      Maximum premium rates for plans issued prior to August 1, 2003--Rate provisions of § 58-17-75 to apply upon carrier's discontinuance of active marketing.
58-17-143      Repealed.
58-17-144, 58-17-145. Repealed.
58-17-145.1      Deadline for submission of health claim under risk pool.
58-17-146      Dental insurers prohibited from setting fees for noncovered service.
58-17-147      Elective abortion coverage prohibited in qualified health plan offered through health insurance exchange.
58-17-148      Qualified health plan sold through exchange to provide for placement through licensed insurance producer--Commissions.
58-17-149      Definitions regarding retrospective payment of clean claims for covered services provided during credentialing period.
58-17-150      Retrospective payment of clean claims for covered services provided by health care professional during credentialing period--Requirements.
58-17-151      Applications to be credentialed.
58-17-152      Application of §§ 58-17-149 to 58-17-151.
58-17-153      Coverage for treatment of hearing impairment for persons under age nineteen.
58-17-154      Definitions for §§ 58-17-155 to 58-17-162.
58-17-155      Exceptions to application of §§ 58-17-154 to 58-17-162.
58-17-156      Policies, contracts, certificates, and plans subject to §§ 58-17-154 to 58-17-162.
58-17-157      Coverage for applied behavior analysis for treatment of autism spectrum disorders.
58-17-158      Authorization, prior approval, and other care management requirements--Annual maximum benefit.
58-17-159      Qualifications of person performing applied behavior analysis (Effective until January 1, 2018).
58-17-159      Qualifications of person performing or supervising applied behavior analysis (Effective January 1, 2018).
58-17-160      Review of treatment.
58-17-161      Services under individualized service plan, family service plan, or education program.
58-17-162      Effective date of §§ 58-17-154 to 58-17-161.
58-17-163      Dental care insurers to honor assignment of benefits.
58-17-164      Revocation of assignment of dental insurance benefits.
58-17-165      Reimbursement of payment from insured following receipt of payment from insurer.
58-17-166      Scope of benefits not affected--Medical benefits not included.


     58-17-1.   Requirements for all health insurance policies delivered in state. No policy of health insurance may be delivered or issued for delivery to any person in this state unless it otherwise complies with this title, with §§ 58-17-1.1 to 58-17-11, inclusive, and with §§ 58-17-84.1 and 58-18-45.1.

Source: SL 1966, ch 111, ch 25, § 2; SL 1991, ch 400, § 1; SL 1999, ch 248, § 1.


     58-17-1.1.   Grandfathered plans required to cover low-dose mammography--Extent of coverage. Each policy of health insurance that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a policy that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening by low-dose mammography for the presence of occult breast cancer that is subject to the same dollar limits, deductibles, and coinsurance factors as for other radiological examinations. Coverage for the screening shall be provided as follows: ages thirty-five to thirty-nine, one baseline mammography; ages forty to forty-nine, a mammography every other year; and age fifty and older, a mammography every year.
     As used in this section, "low-dose mammography" means the X-ray examination of the breast using equipment dedicated specifically for mammography, including the X-ray tube, filter, compression device, screens, films and cassettes, with an average radiation exposure delivery of less than one rad midbreast, with two views for each breast and with interpretation by a qualified radiologist.
     The provisions of this section apply only to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§ 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147. (SL 2011, ch 216, § 19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.")

Source: SL 1990, ch 397, §§ 1, 2; SL 1991, ch 400, § 2; SL 2011, ch 216, § 1.


     58-17-1.2.   Policies to provide coverage for diabetes supplies, equipment and education--Exceptions--Conditions and limitations. Every policy of health insurance delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall provide, in writing, coverage for equipment, supplies, and self-management training and education, including medical nutrition therapy, for treatment of persons diagnosed with diabetes if prescribed by a physician or other licensed health care provider legally authorized to prescribe such treatment. Medical nutrition therapy does not include any food items or nonprescription drugs.
     Coverage for medically necessary equipment and supplies shall include blood glucose monitors, blood glucose monitors for the legally blind, test strips for glucose monitors, urine testing strips, insulin, injection aids, lancets, lancet devices, syringes, insulin pumps and all supplies for the pump, insulin infusion devices, prescribed oral agents for controlling blood sugars, glucose agents, glucagon kits, insulin measurement and administration aids for the visually impaired, and other medical devices for treatment of diabetes.
     Diabetes self-management training and education shall be covered if: (a) the service is provided by a physician, nurse, dietitian, pharmacist, or other licensed health care provider who satisfies the current academic eligibility requirements of the National Certification Board for Diabetic Educators and has completed a course in diabetes education and training or has been certified as a diabetes educator; and (b) the training and education is based upon a diabetes program recognized by the American Diabetes Association or a diabetes program with a curriculum approved by the American Diabetes Association or the South Dakota Department of Health.
     Coverage of diabetes self-management training is limited to (a) persons who are newly diagnosed with diabetes or have received no prior diabetes education; (b) persons who require a change in current therapy; (c) persons who have a co-morbid condition such as heart disease or renal failure; or (d) persons whose diabetes condition is unstable. Under these circumstances, no more than two comprehensive education programs per lifetime and up to eight follow-up visits per year need be covered. Coverage is limited to the closest available qualified education program that provides the necessary management training to accomplish the prescribed treatment.
     The benefits provided in this section are subject to the same dollar limits, deductibles, coinsurance, and other restrictions established for all other benefits covered in the policy.

Source: SL 1999, ch 252, § 1.


     58-17-1.3.   Diabetes coverage not required of certain plans and policies. The provisions of § 58-17-1.2 do not apply to any plan, policy, or contract that provides coverage only for:
             (1)      Specified disease;
             (2)      Hospital indemnity;
             (3)      Fixed indemnity;
             (4)      Accident-only;
             (5)      Credit;
             (6)      Dental;
             (7)      Vision;
             (8)      Prescription drug;
             (9)      Medicare supplement;
             (10)      Long-term care;
             (11)      Disability income insurance;
             (12)      Coverage issued as a supplement to liability insurance;
             (13)      Workers' compensation or similar insurance;
             (14)      Automobile medical payment insurance;
             (15)      Individual health benefit plans of six-months duration or less that are not renewable; or
             (16)      Individual nonmajor medical insurance.

Source: SL 1999, ch 252, § 2.


     58-17-1.4.   Policies required to cover occult breast cancer screening. Each policy of health insurance that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a policy that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening for the presence of occult breast cancer.
     The provisions of this section apply only to plans that are not grandfathered pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§ 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147. (SL 2011, ch 216, § 19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.")

Source: SL 2011, ch 216, § 13.


     58-17-2.   Persons covered by policy. A policy of health insurance shall purport to insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family, who shall be deemed the policyholder, any two or more eligible members of that family, including husband, wife, dependent children, or any children under a specified age which shall not exceed nineteen years and any other person dependent upon the policyholder or any other person related to and resident in the household of the insured.

Source: SL 1966, ch 111, ch 25, § 2 (3).


     58-17-2.1.   Health insurance on a franchise plan. Health insurance on a franchise plan is hereby declared to be that form of health insurance issued to:
             (1)      Three or more employees of any corporation, copartnership, or individual employer or any governmental corporation, agency, or department thereof; or
             (2)      Ten or more members of any trade, occupational, or professional association, or of a labor union, or of any other association having had an active existence for at least two years where such association or union has a constitution or bylaws and is formed in good faith for purposes other than that of obtaining insurance; where such persons, with or without their dependents, are issued the same form of an individual policy varying only as to amounts and kinds of coverage applied for by such persons, under an arrangement whereby the premiums on such policies may be paid to the insurer periodically by the employer, with or without payroll deductions, or by the association for its members, or by some designated person acting on behalf of such employer or association or by the insured directly to the insurer, if permitted by the insurer. The term, employees, as used in this section may be deemed to include the officers, managers, and employees and retired employees of the employer and the individual proprietor or partnership.
     Health insurance may be marketed on a franchise basis to members or employees of an employer, labor union, or association. Except as provided for by § 58-18B-2, health insurance marketed on a franchise basis may have the individual's premiums paid by the employer, labor union, or association. Marketing a policy on a franchise basis does not exempt any policy from any applicable requirement under this title except as provided in § 58-33-13.

Source: SL 1966, ch 111, ch 25, § 30 as added by SL 1968, ch 137; SL 2000, ch 241, §§ 1, 2.


     58-17-2.2.   Conversion privileges of insured's spouse upon divorce. No accident or health insurance policy providing coverage of hospital or medical expense which in addition to covering the insured also provides coverage to the spouse of the insured shall be issued without a provision that provides that upon divorce of the insured and the insured's spouse, the spouse is entitled to have issued to him or her, without evidence of insurability, upon application to the company within thirty days following the eligibility, and upon payment of the appropriate premium, an individual policy of accident or health insurance. Such policy shall provide the coverage then being issued by the insurer which is most nearly similar to the existing coverages. This obligation can be met by continuation of coverage for spouse under existing policy at the appropriate premium. Any and all probationary or waiting periods set forth in such policy shall be considered as being met to the extent coverage was in force under the prior policy.

Source: SL 1980, ch 354.


     58-17-2.3.   Dependent coverage termination--Age--Full-time students. No insurer or health carrier issuing health insurance coverage, other than excepted benefits, that provides dependent coverage for any qualifying child, as defined by rules promulgated pursuant to § 58-17-87, may terminate coverage due to attainment of a limiting age below age twenty-six. If the dependent remains a full-time student upon attaining the age of twenty-six, but not exceeding the age of twenty-nine, the insurer shall provide for the continuation of coverage for that dependent at the insured's option. However, the provisions of this section do not apply to any qualifying relative, as defined by rules promulgated pursuant to § 58-17-87, whose gross income is less than the exemption amount as prescribed by the director by rules promulgated pursuant to chapter 1-26. Continuation of coverage for full-time students attaining the age of twenty-four is not required if the dependent has other creditable coverage in force nor required for any full-time students who attained the age of twenty-four prior to July 1, 2007. (SL 2011, ch 216, § 19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.")

Source: SL 2005, ch 265, § 1; SL 2007, ch 288, § 1; SL 2011, ch 216, § 2.


     58-17-3.   Time of commencement and termination to be set out in policy. The time when the insurance takes effect and terminates shall be expressed in a policy of health insurance.

Source: SL 1966, ch 111, ch 25, § 2 (2).


     58-17-4.   Consideration for policy to be stated. The entire money and other considerations therefor shall be expressed in a policy of health insurance.

Source: SL 1966, ch 111, ch 25, § 2 (1).


     58-17-4.1.   Filing and approval of individual policy premium rates. Premium rates charged for any individual accident and health insurance policy issued pursuant to this chapter shall be filed with and are subject to the approval of the director. The rates shall be filed for approval, administered, and reviewed subject to all of the applicable procedures in accordance with §§ 58-11-64 to 58-11-76, inclusive. (SL 2011, ch 216, § 19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.")

Source: SL 1988, ch 399, § 1; SL 2006, ch 254, § 1; SL 2011, ch 216, § 3.


     58-17-4.2.   Premium rates required to be reasonable--Rules to establish minimum standards promulgated by director. Premium rates charged for any individual accident and health insurance policy pursuant to this chapter shall be reasonable in relation to the benefits available under the policy. The director shall promulgate rules pursuant to chapter 1-26 to establish minimum standards in accordance with accepted actuarial principles and practices, for loss ratios of individual accident and health insurance policies on the basis of incurred claims experience and earned premiums.

Source: SL 1988, ch 399, § 2.


     58-17-4.3.   Transferred to § 58-17-74.1 by SL 2005, ch 10, § 41.


     58-17-5.   Identification of forms, riders and endorsements--Form number, location. Each form for a policy of health insurance, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof.

Source: SL 1966, ch 111, ch 25, § 2 (6).


     58-17-6.   Style and arrangement of policy provisions--Printing, size of type. The style, arrangement, and overall appearance of a policy of health insurance shall give no undue prominence to any portion of the text, and every printed portion of the text of the policy and of any endorsements or attached papers shall be 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.

Source: SL 1966, ch 111, ch 25, § 2 (4).


     58-17-7.   Documents forming part of policy--Setting forth in full, rates and classifications excepted. A policy of health insurance shall contain no provision purporting to make any portion of the charter, rules, Constitution, or bylaws 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 director.

Source: SL 1966, ch 111, ch 25, § 2 (7).


     58-17-8.   Exceptions and reductions of coverage to be clearly set out. The exceptions and reductions of indemnity shall be set forth in a policy of health insurance and, other than those contained in §§ 58-17-14 to 58-17-39, inclusive, shall be 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," except 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.

Source: SL 1966, ch 111, ch 25, § 2 (5).


     58-17-9.   Renewal of policy at option of insurer--Statement in policy so informing the policyholder. In any case where a policy of health insurance is subject to renewal at the option of the insurer there shall be prominently printed both on the cover page and on the first page of such policy a statement so informing the policyholder.

Source: SL 1966, ch 111, ch 25, § 2 (9).


     58-17-10.   Repealed by SL 2006, ch 259, § 32.


     58-17-10.1.   Reduction of benefits because of increase in statutory disability benefits prohibited. No individual insurance policy for loss of time or disability benefits issued, amended, renewed, or delivered in this state shall contain any provision offsetting, or in any other manner reducing, any benefit under the policy by the amount of, or in proportion to, any increase in disability benefits received or receivable under the federal Social Security Act, the Railroad Retirement Act, any veteran's disability compensation and survivor benefits act, workers' compensation, or any similar federal or state law, as amended subsequent to the date of commencement of such benefit.

Source: SL 1976, ch 312.


     58-17-10.2.   Individual policy for insured's spouse required in policies covering spouse--Eligibility--Coverage--Waiting periods. No health insurance policy providing coverage of hospital or medical expense which in addition to covering the insured also provides coverage to the spouse of the insured shall be issued without a provision that provides that upon eligibility for medicare or social security disability benefits by one spouse the other spouse shall be entitled to have issued to him or her, without evidence of insurability, upon application to the company within sixty days following the eligibility, and upon payment of the appropriate premium, an individual policy of accident or health insurance. Such policy shall provide the coverage then being issued by the insurer which is most nearly similar to the existing coverages. This obligation can be met by continuation of coverage for spouse under existing policy at the appropriate premium. Any and all probationary or waiting periods set forth in such policy shall be considered as being met to the extent coverage was in force under the prior policy.

Source: SL 1979, ch 343.


     58-17-11.   Return of policy by purchaser--Refund of premium paid--Dissatisfaction with terms after examination. Every individual health insurance policy or contract, except single premium nonrenewable policies or contracts, issued for delivery in South Dakota on or after December 31, 1966, by an insurance company, nonprofit hospital service plan, or medical service corporation, shall have printed thereon or attached thereto a notice stating in substance that the person to whom the policy or contract is issued shall be permitted to return the policy or contract within ten days of its delivery to said purchaser and to have the premium paid refunded if, after examination of the policy or contract, the purchaser is not satisfied with it for any reason. If a policyholder or purchaser pursuant to such notice, returns the policy or contract to the company or association at its home or branch office or to the insurance producer through whom it was purchased, it is void from the beginning and the parties shall be in the same position as if no policy or contract had been issued.

Source: SL 1966, ch 111, ch 25, § 2 (8); SL 2001, ch 286, § 114.


     58-17-11.1.   Issuance of policies by insurance company, nonprofit hospital service plan, medical service corporation, or fraternal benefit society--Delivery receipts--Certificates of mailing--Term of retention. An insurance company, nonprofit hospital service plan, medical service corporation, health maintenance organization, or fraternal benefit society shall issue policies in this state for which an examination period is required in accordance with one of the following methods:
             (1)      If the policy is delivered by an insurance producer, a receipt shall be signed by the policyowner acknowledging delivery of the policy. The receipt shall include the policy number and the date of the delivery;
             (2)      If the policy is delivered by mail, it shall be sent by registered or certified mail, return receipt requested, or a certificate of mailing shall be obtained showing the date the policy was mailed to the policyowner. For policy issuances verified by a certificate of mailing, it is presumed that the policy is received by the policyowner ten days from the date of mailing.
     The receipts and the certificates of mailing described in this section shall be retained by the insurer for five years. If a producer obtains the delivery receipt, the producer shall forward the signed delivery receipt to the insurer.

Source: SL 1982, ch 28, § 18; SL 1987, ch 374, § 3; SL 2001, ch 286, § 115; SL 2002, ch 232, § 3.


     58-17-12.   Required provisions--Captions--Substitutes, approval by director. Except as provided in § 58-17-13, each policy of health insurance delivered or issued for delivery to any person in this state shall contain the provisions specified in §§ 58-17-14 to 58-17-29, inclusive, in the words in which the same appear; except, that the insurer may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the director which are in each instance not less favorable in any respect to the insured or the beneficiary. Each such provision shall be preceded individually by the applicable caption shown, or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the director may approve.

Source: SL 1966, ch 111, ch 25, § 3 (1).


     58-17-13.   Omission from policy of inapplicable provision--Approval of director--Modification of inconsistent provision. If any such provision 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 director shall omit from such policy any inapplicable provision or part of a provision and shall modify any inconsistent provision or part of a provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

Source: SL 1966, ch 111, ch 25, § 3 (2).


     58-17-14.   Entire contract and change clauses required--Signed acceptance required for endorsements. There shall be a provision as follows: "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 is valid until approved by an executive officer of the insurance company and unless such approval is endorsed or attached to this policy. No insurance producer has authority to change this policy or to waive any of its provisions."Any rider, endorsement, or application added to a policy, upon policy issuance, after the date of issue, or at reinstatement or renewal which reduces or eliminates benefits or coverage in the policy requires signed acceptance by the policyholder. After the date of policy issue, any rider or endorsement which increases benefits or coverage with an accompanying increase in premium during the policy term must be agreed to in writing signed by the insured, unless the increased benefits or coverage is required by law. Coverage as required by § 58-17-98 may be reduced or eliminated by a rider to, or an endorsement on, a new policy if the insurer would reject the application for the policy without the rider or endorsement based upon the applicant's preexisting condition of the type covered by § 58-17-98 and if there is signed acceptance by the policyholder.

Source: SL 1966, ch 111, ch 25, § 4; SL 1974, ch 315; SL 1982, ch 361; SL 2001, ch 286, § 116; SL 2002, ch 234, § 2; SL 2003, ch 247, § 1; SL 2010, ch 237, § 1.


     58-17-15.   Time limit on certain defenses--Application of section. There shall be a provision as follows: "Time limit on certain defenses: (1) 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 may not be construed 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 §§ 58-17-32 to 58-17-39, inclusive, in the event of misstatement with respect to age or occupation or other insurance. This section only applies to excepted benefits. This section does not apply to any long-term care insurance policy or certificate. (SL 2011, ch 216, § 19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.")

Source: SL 1966, ch 111, ch 25, § 5; SL 2011, ch 216, § 4.


     58-17-16.   Repealed by SL 2011, ch 216, § 5.


     58-17-17.   Grace period on premiums required in policy. There shall be a provision as follows: "Grace period: A grace period of __________ (insert a number not less than seven days for weekly premium policies, ten days for monthly premium policies and thirty-one days 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." If a claim arises under the policy during such period of grace the amount of any proportionate premium due or overdue for the grace period may be deducted from the policy proceeds but such deduction shall not renew the policy or further extend the grace period. Claims arising during a grace period shall be compensable whether or not a renewal premium has been tendered or accepted subject to any other policy defenses.
     A policy which gives the policyholder the right to select any one of two or more modes of premium payment by remitting an amount stated in the policy for that particular mode of payment, without requiring any formal request on the part of the policyholder for changing the mode of premium payment, shall provide a grace period of thirty-one days.

Source: SL 1966, ch 111, ch 25, § 6; SL 1977, ch 407, § 1.


     58-17-18.   Renewal of policy--Restriction on company's right to refuse. A policy in which the insurer reserves the right to refuse renewal shall have the following clause at the beginning of the provision in § 58-17-17,
     "Unless not less than thirty days prior to the premium due date the insurer has delivered to the insured or has mailed 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."

Source: SL 1966, ch 111, ch 25, § 6; SL 1977, ch 407, § 2.


     58-17-19.   Reinstatement when premium not paid within grace period. There shall be a provision as follows: "Reinstatement: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any insurance producer 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 insurance producer 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 a 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."

Source: SL 1966, ch 111, ch 25, § 7; SL 2001, ch 286, § 117.


     58-17-20.   Omission of provision as to application of premiums accepted in connection with reinstatement--Right of insured to continue policy in force by payment of premiums. The last sentence of the provision in § 58-17-19 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.

Source: SL 1966, ch 111, ch 25, § 7.


     58-17-21.   Notice of claim--Provision required in policy. There shall be a provision as follows: "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 insurance producer of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer."

Source: SL 1966, ch 111, ch 25, § 8; SL 2001, ch 286, § 118.


     58-17-22.   Notice of claim--Loss of time benefit--Optional provision, insertion by 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 provision in § 58-17-21: "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 the claim, give to the insurer notice of continuance of the 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."

Source: SL 1966, ch 111, ch 25, § 8.


     58-17-23.   Claim forms--Furnishing by insurer. There shall be a provision as follows: "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 the extent of the loss for which claim is made."

Source: SL 1966, ch 111, ch 25, § 9.


     58-17-24.   Proofs of loss--Provision required in policy. There shall be a provision as follows: "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 and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required."

Source: SL 1966, ch 111, ch 25, § 10.


     58-17-25.   Time of payment of claims--Provision required in policy. There shall be a provision as follows: "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 termination of liability will be paid immediately upon receipt of due written proof."

Source: SL 1966, ch 111, ch 25, § 11.


     58-17-26.   Payment of claims--Persons to whom benefits payable--Provision required in policy. There shall be a provision as follows: "Payment of claims: 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."

Source: SL 1966, ch 111, ch 25, § 12.


     58-17-27.   Payment of claims--Optional provisions, insertion by insurer. The following provisions, or either of them, may be included with the provision in § 58-17-26 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 proof 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."

Source: SL 1966, ch 111, ch 25, § 12.


     58-17-28.   Physical examination of insured--Autopsy in death claims--Provision required in policy. There shall be a provision as follows: "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."

Source: SL 1966, ch 111, ch 25, § 13.


     58-17-29.   Action to recover under policy--Time for beginning. There shall be a provision as follows: "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 written proof of loss is required to be furnished."

Source: SL 1966, ch 111, ch 25, § 14.


     58-17-30.   Beneficiary--Changes reserved to insured. There shall be a provision as follows: "Change of beneficiary: Unless the insured makes an irrevocable designation of beneficiary, the right to change a 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.

Source: SL 1966, ch 111, ch 25, § 15.


     58-17-30.1.   Continuation of coverage for child with intellectual or physical disability--Proof of dependency. An individual health insurance policy, which is delivered or issued for delivery in this state and which provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the policy, shall also provide that attainment of such limiting age shall not operate to terminate the coverage of such child while the child is and continues to be both (a) incapable of self-sustaining employment by reason of intellectual disability or physical disability and (b) chiefly dependent upon the policyholder for support and maintenance, provided proof of such incapacity and dependency is furnished to the insurer by the policyholder within thirty-one days of the child's attainment of the limiting age and subsequently as may be required by the insurer but not more frequently than annually after the two-year period following the child's attainment of the limiting age.

Source: SL 1969, ch 140; SL 2013, ch 125, § 18.


     58-17-30.2.   Family coverage to include newborn or newly adopted children--Payment of claim not to be withheld during bonding period of adopted child. Any individual health insurance policy and individual or indemnity type contract issued by a nonprofit corporation which offers coverage for a family member of an insured or subscriber shall provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber from the moment of birth or to a newly adopted child of the insured or subscriber from the beginning of the six-month adoption bonding period. The newly born or newly adopted child shall be added to the policy without underwriting and without the imposition of any preexisting waiting period. Any policy or contract issued before July 1, 1974, shall, upon its next anniversary date, also provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber from the moment of birth or to a newly adopted child of the insured or subscriber from the beginning of the six-month adoption bonding period. Payment of any valid insurance claim may not be withheld during the bonding period of an adopted child.

Source: SL 1974, ch 322; SL 1976, ch 313, § 1; SL 1977, ch 408; SL 1983, ch 375, § 1; SL 1988, ch 401; SL 1994, ch 387, § 5.


     58-17-30.3.   Premature birth and congenital defects covered--Applicability. The coverage for a newly born child from the moment of birth or for a newly adopted child, from the beginning of the six-month adoption bonding period, shall consist of coverage of injury or sickness including the necessary care and treatment of premature birth and medically diagnosed congenital defects and birth abnormalities. The provisions of §§ 58-17-30.2 to 58-17-30.4, inclusive, apply to any individually written health benefit plan issued or renewed by any health insurer, health carrier, health maintenance organization, fraternal benefit society, nonprofit medical and surgical plan, nonprofit hospital service plan, or other entity providing coverage through a health benefit plan subject to the provisions of this title.

Source: SL 1974, ch 322; SL 1976, ch 313, § 2; SL 1983, ch 375, § 2; SL 1984, ch 327, § 13; SL 2001, ch 274, § 1; SL 2015, ch 249, § 1.


     58-17-30.4.   Notice of birth or adoption required for continued coverage. An insurer may require notice that a newly born or newly adopted child is to be added to the policy or that coverage is to be changed from single or spousal coverage to family coverage. However, the insurer may not require notification sooner than the birth of the child or the start of the adoption bonding period. If the child is added or coverage changed to family coverage before the birth of the child or the start of the adoption bonding period, no additional premium may be charged by the insurer until the birth of the child or the start of the adoption bonding period. The insurer shall take reasonable steps to provide adequate notice to insureds of the need to alter coverage to ensure newborn or adopted children are covered and of the lack of premium adjustment until the birth of the child or the start of the adoption bonding period. An insurer is considered to have taken reasonable steps if prominent disclosure of the requirements of this section are included in a certificate, subscriber contract, evidence of coverage, or employee handbook if such are provided to all insureds.
     If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of a newly born child or notification of the start of the six-month adoption bonding period for an adopted child and payment of the required premium or fees be furnished to the insurer or nonprofit service or indemnity corporation within thirty-one days after the date of birth or start of the bonding period in order to have the coverage continued beyond the thirty-one day period.

Source: SL 1974, ch 322; SL 1983, ch 375, § 3; SL 1994, ch 387, § 6.


     58-17-30.5.   Coverage for inpatient alcoholism treatment required. Any insurer which delivers or issues for delivery in this state any insurance policy under this chapter which provides coverage on an expense incurred basis shall offer, in writing, to include in such policy or contract issued or renewed on or after July 1, 1979, coverage for the inpatient treatment of alcoholism in licensed hospitals and residential primary treatment facilities approved by the State of South Dakota which are carrying out an approved program pursuant to the diagnosis and recommendation of a doctor of medicine. When coverage for inpatient treatment is included in any policy, such coverage shall include inpatient treatment at any South Dakota approved inpatient alcoholism treatment facility.

Source: SL 1977, ch 410, § 2; SL 1979, ch 344, § 1.


     58-17-30.6.   Alcoholism benefits provided--Days of care. The alcoholism coverage to be offered shall provide benefits on the same basis as benefits provided for the treatment of other sicknesses covered under the policy; however, the coverage by the insurance carrier need not exceed thirty days' care in any six-month period, and the total days care per recipient need not exceed ninety days during the life of the contract.

Source: SL 1977, ch 410, § 3.


     58-17-30.7.   Policies excluded from alcoholism coverage requirements. Sections 58-17-30.5 and 58-17-30.6 do not apply to accident only, or limited or specified disease policies.

Source: SL 1977, ch 410, § 4; SL 1979, ch 344, § 2; SL 1982, ch 362; SL 1999, ch 249, § 1.


     58-17-30.8.   Exclusion of benefits for injury while under the influence of alcohol or drugs prohibited--Exception for sickness or injury caused in commission of felony. A policy or certificate of health insurance for an individual that is delivered, issued for delivery, or renewed in this state may not exclude the payment of benefits for injuries sustained by an insured person because the insured was under the influence of alcohol or drugs, as defined by § 32-23-1.
     Nothing in this section precludes a health insurer from excluding coverage for an insured for any sickness or injury caused in the commission of a felony.

Source: SL 1997, ch 290, §§ 1, 7.


     58-17-30.9.   Notice that dependent is no longer eligible for coverage--Premium adjustment. For any insurer that chooses to automatically cover any newborn or newly adopted child as a dependent without requiring the notice in § 58-17-30.4 and does not collect or track the demographic information on the dependent child, the insurer shall take reasonable steps to provide adequate notice of the insured's responsibility to advise the insurer when there is no longer any child eligible for dependent coverage. An insurer is considered to have taken reasonable steps if prominent disclosure of this responsibility is included in the policy or certificate, subscriber contract, evidence of coverage, or employee handbook if such are provided to all insureds and also provided to prospective insureds at the time of application for coverage. Upon receipt of a notice that a dependent is no longer eligible, the insurer shall adjust the coverage accordingly and, if applicable, return to the insured any unearned premium. This section applies to any policy or certificate subject to the provisions of chapters 58-17 and 58-18.

Source: SL 2013, ch 247, § 1.


     58-17-31.   Optional policy provisions. Except as provided in § 58-17-13, no policy of health insurance delivered or issued for delivery to any person in this state shall contain provisions respecting the matters set forth in §§ 58-17-32 to 58-17-40, inclusive, unless such provisions are in the words in which the same appear in the applicable section, except that the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the director 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 applicable caption or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the director may approve.

Source: SL 1966, ch 111, ch 25, § 16.


     58-17-32.   Occupational change--Policy provision for adjustment of premium or benefits. There may be a provision as follows: "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 prorata 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."

Source: SL 1966, ch 111, ch 25, § 17.


     58-17-33.   Misstatement of age--Policy provision for adjustment of benefits. There may be a provision as follows: "Misstatement of age: If the age of the insured has been misstated all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age."

Source: SL 1966, ch 111, ch 25, § 18.


     58-17-34.   Earnings of insured--Policy provision for adjustment of benefits. There may be a provision as follows: "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 only for 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 prorata 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."

Source: SL 1966, ch 111, ch 25, § 19 (1).


     58-17-35.   Earnings adjustment clause to be coupled with insured's right to continue policy in force. The policy provision in § 58-17-34 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.

Source: SL 1966, ch 111, ch 25, § 19 (2).


     58-17-36.   Option of insurer to define "valid loss of time coverage". The insurer may, at its option, include in the provision in § 58-17-34 a definition of "valid loss of time coverage," approved as to form by the director, which definition shall be limited in subject matter to coverage provided by governmental agencies or 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, or to any other coverage the inclusion of which may be approved by the director 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.

Source: SL 1966, ch 111, ch 25, § 19 (2).


     58-17-37.   Unpaid premiums--Deduction from benefits. There may be a provision as follows: "Unpaid premiums: 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."

Source: SL 1966, ch 111, ch 25, § 20.


     58-17-38.   Conformity with state statutes of insured. There may be a provision as follows: "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."

Source: SL 1966, ch 111, ch 25, § 21.


     58-17-39.   Illegal occupation of insured. There may be a provision as follows: "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."

Source: SL 1966, ch 111, ch 25, § 22.


     58-17-40.   Renewal of policy at option of insurer. Health insurance policies, other than accident insurance only policies, in which the insurer reserves the right to refuse renewal on an individual basis, shall provide in substance in a provision thereof or in an endorsement thereon or rider attached thereto that subject to the right to terminate the policy upon nonpayment of premium when due, such right to refuse renewal may not be exercised so as to take effect before the renewal date occurring on, or after and nearest, each policy anniversary, or in the case of lapse and reinstatement, at the renewal date occurring on, or after and nearest, each anniversary of the last reinstatement, and that any refusal of renewal shall be without prejudice to any claim originating while the policy is in force. The clause making reference to lapse and reinstatement may be omitted at the insurer's option.

Source: SL 1966, ch 111, ch 25, § 23.


     58-17-41.   Order of policy provisions. The provisions which are the subject of §§ 58-17-14 to 58-17-39, inclusive, or any corresponding provisions which are used in lieu thereof in accordance with such sections, shall be printed in the consecutive order of the provisions in such sections 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 that 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.

Source: SL 1966, ch 111, ch 25, § 24.


     58-17-42.   Age limit in policy--Effect of acceptance of premiums or misstatement of age. If any policy of health insurance 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 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.

Source: SL 1966, ch 111, ch 25, § 28.


     58-17-43.   Third parties taking policy covering insured. The word "insured," as used in this chapter, 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.

Source: SL 1966, ch 111, ch 25, § 25.


     58-17-44.   Foreign or alien insurer--Policy provision required by home state. Any policy of a foreign or alien insurer, when delivered or issued for delivery to any person in this state, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of this chapter and which is prescribed or required by the law of the state or country under which the insurer is organized.

Source: SL 1966, ch 111, ch 25, § 26 (1).


     58-17-45.   Policy of domestic insurer delivered in other state--Compliance with laws of other state. Any policy of a domestic insurer may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.

Source: SL 1966, ch 111, ch 25, § 26 (2).


     58-17-46.   Policy provisions not subject to chapter--Conforming to statute required. No policy provision which is not subject to this chapter shall make a policy, or any portion thereof, less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to this chapter.

Source: SL 1966, ch 111, ch 25, § 27 (1).


     58-17-47.   Nonconforming and conflicting provisions construed in conformity with statute. A policy delivered or issued for delivery to any person in this state in violation of this chapter shall be held valid but shall be construed as provided in this chapter. When any provision in a policy subject to this chapter is in conflict with any provision of this chapter, the rights, duties, and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of this chapter.

Source: SL 1966, ch 111, ch 25, § 27 (2).


     58-17-48.   Liability and workers' compensation insurance--Inapplicability of health insurance provisions. Nothing in §§ 58-17-1 to 58-17-47, inclusive, shall apply to or affect any policy of liability or workers' compensation and employers liability insurance.

Source: SL 1966, ch 111, ch 25, § 1 (1).


     58-17-49.   Health insurance provisions inapplicable to group or blanket policy. Nothing in §§ 58-17-1 to 58-17-47, inclusive, shall apply to or affect any group or blanket policy.

Source: SL 1966, ch 111, ch 25, § 1 (2).


     58-17-50.   Life insurance, endowment or annuity contracts not subject to health insurance provisions. Nothing in §§ 58-17-1 to 58-17-47, inclusive, shall apply to or affect life insurance, endowment, or annuity contracts, or contracts supplemental thereto which contain only such provisions relating to health insurance as:
             (1)      Provide additional benefits in case of dismemberment or loss of sight, or of death by accident or accidental means, or as
             (2)      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 becomes totally and permanently disabled, as defined by the contract or supplemental contract.

Source: SL 1966, ch 111, ch 25, § 1 (3).


     58-17-51.   Health insurance provisions inapplicable to reinsurance. Nothing in §§ 58-17-1 to 58-17-47, inclusive, shall apply to or affect reinsurance.

Source: SL 1966, ch 111, ch 25, § 1 (4).


     58-17-52.   Prior contracts or policies excepted. The provisions of §§ 58-17-1 to 58-17-51, inclusive, shall not apply to any contracts or policies entered into or issued prior to February 8, 1966, nor to any extensions, renewals, or modifications thereof or amendments thereto whenever made.

Source: SL 1966, ch 111, ch 25, § 29.


     58-17-53.   Optometric services--Reimbursement, exceptions. If an insurer provides by contract, policy, certificate, or any other means whatever, for a service, or for the partial or total reimbursement, payment, or cost of a service to or on behalf of any of its policyholders, group policyholders, subscribers, or group subscribers, or any other person or groups of persons, which service is within the lawful scope of practice of a licensed optometrist, the person rendering the service or the policyholder, subscriber, or other person is entitled to partial or total reimbursement, payment, or cost of that service, whether the service is performed by a licensed physician or by a licensed optometrist. Unless the contract, policy, certificate, or other means employed otherwise provides, there is no reimbursement of payment for ophthalmic materials, lenses, spectacles, eyeglasses, or appurtenances thereto. Reimbursement may be denied to a policyholder treating himself or any member of his family residing in his household, provided, however, that reimbursement for durable medical equipment, pharmaceuticals, and prosthetic devices may not be denied where within policy coverages.

Source: SL 1966, ch 111, ch 32, § 8; SL 1982, ch 363, § 1.


     58-17-54.   Reimbursement provisions applicable to all healing arts licensees--Self-insurance plans for public employees--Restrictions on policy limitations. Notwithstanding any provision of any policy of insurance subject to the general provisions of this title, if a policy or contract provides for reimbursement for any service which may be legally performed by a person licensed in this state for the practice of medicine, surgery, anesthesia by a certified registered nurse anesthetist licensed under chapter 36-9, psychology, dentistry, osteopathy, social work by an independent social worker licensed under § 36-26-17, optometry, chiropractic, or podiatry, the reimbursement under that policy or contract may not be denied if the service is rendered by a person so licensed. The provisions of this section apply to all practitioners licensed pursuant to chapters 36-4A and 36-9A after July 1, 1980, and to any plan of self-insurance for public employees. Reimbursement may be denied to a policyholder treating himself or any member of his family residing in his household. However, reimbursement for durable medical equipment, pharmaceuticals, and prosthetic devices may not be denied if within policy coverages.
     No policy, certificate, or contract may exclude or limit reimbursement for any lawful diagnostic or treatment service by a licensee under chapter 36-5 if the exclusion or limitation is based wholly or in part on any requirement that the service be performed in a place of service not normally used by the licensee.
     A policy, certificate, or contract may only limit or make optional the reimbursement for any lawful diagnostic or treatment service by a licensee under chapters 36-4 and 36-5 if the limitation is based on a rational basis which is not solely related to the license under, or practices authorized by, chapter 36-5 or is not dependent upon a method of classification, categorization or description based directly or indirectly upon differences in terminology used by different licensees in describing human ailments or in the diagnosis or treatment of human ailments.
     This section does not require reimbursement for any method or service not necessary, not reasonable or not generally accepted by the peers of the particular licensed health care provider.

Source: SL 1970, ch 273; SL 1980, ch 355, § 2; SL 1981, ch 24, § 6; SL 1982, ch 363, § 2; SL 1986, ch 419, § 1; SL 1988, ch 402; SL 1989, ch 427; SL 1993, ch 360.


     58-17-54.1.   Copayment or coinsurance amounts for chiropractic, physical therapy, or occupational therapy services. No health insurer may impose any copayment or coinsurance amount on an insured for services rendered by a doctor of chiropractic licensed pursuant to chapter 36-5, an occupational therapist licensed pursuant to chapter 36-31, or a physical therapist licensed pursuant to chapter 36-10 that is greater than the copayment or coinsurance amount imposed on the insured for the services of a primary care physician or practitioner for the same or a similar diagnosed condition even if a different nomenclature is used to describe a condition.

Source: SL 2011, ch 217, § 1; SL 2012, ch 244, § 1.


     58-17-55.   Reimbursement provisions applicable to licensed hospitals. Notwithstanding any provision of any policy of insurance subject to the general provisions of this title, whenever such policy or contract provides for reimbursement for any service which may be legally performed by a hospital licensed in this state which has an organized medical staff with permanent facilities including inpatient beds and which is primarily engaged in providing diagnostic or therapeutic services for medical diagnosis, treatment, or care of injured and disabled, rehabilitation services for the physical rehabilitation of the injured and disabled, either on its premises or in facilities under the supervision of physicians on a pre-arranged basis to inpatients, reimbursement for coverage provided under such policy or contracts shall not be denied.

Source: SL 1977, ch 409.


     58-17-56.   Reimbursement for service rendered or supervised by qualified mental health professional. Notwithstanding any provision of any policy of insurance subject to the general provisions of this title, whenever such policy or contract provides for reimbursement for any service rendered by or directly supervised by a qualified mental health professional as defined in § 27A-1-3, which may be legally performed by a mental health center as defined by § 27A-1-1, reimbursement for coverage provided under such policy or contracts may not be denied. However, the provisions of this section only apply to the services defined in § 58-17-98.

Source: SL 1987, ch 377; SL 1991, ch 220, §§ 1 and 2; SL 2003, ch 152, § 2.


     58-17-57.   "Abuse of health insurance" defined--Violation as misdemeanor. A person who provides health care commits abuse of health insurance, if, as a regular business practice, he knowingly accepts from any third-party payor, as payment in full for services rendered, the amount the third-party payor covers, or submits a fee to a third-party payor which is higher than the fee he has agreed to accept from the insured with the understanding of waiving the required deductible or co-payment, if the effect of either business practice is to eliminate the need for payment by the insured of any required deductible or co-payment applicable in the insured's health benefit plan. Abuse of health insurance is a Class 1 misdemeanor.

Source: SL 1989, ch 429, § 1.


     58-17-58.   Waiver of required deductible or co-payment for charitable purposes permitted. However, a person may waive any required deductible or co-payment for charitable purposes if:
             (1)      The person who provides the health care determines that the services are necessary for the immediate health and welfare of the insured;
             (2)      The waiver is made on a case-by-case basis and the person who provides the health care determines that payment of the deductible or co-payment would create a substantial financial hardship for the insured; and
             (3)      The waiver is not a regular business practice of the person who provides the health care.

Source: SL 1989, ch 429, § 2.


     58-17-59.   When waiver presumed. Any person who provides health care and who waives the deductible or co-payment for more than one-fourth of his patients during any calendar year, excluding waivers under § 58-17-58, or who advertises that he will accept from any third-party payor, as payment in full for services rendered, the amount the third-party payor covers, is presumed to be waiving the deductible or co-payment as a regular business practice.

Source: SL 1989, ch 429, § 3.


     58-17-60.   Certain payments exempt. Payments made pursuant to federal medicare laws or payments made to the health-care provider according to a contract or agreement between an employer and employee which requires a third-party payor to pay the full amount for health-care services are exempt from §§ 58-17-57 to 58-17-60, inclusive.

Source: SL 1989, ch 429, § 4.


     58-17-61.   Assignment of health insurance proceeds to certain hospitals authorized. Any person insured by a health insurance company, health maintenance organization, preferred provider organization, individual practice association, or nonprofit hospital service corporation may assign in writing benefits from such policy, contract, or certificate to a hospital licensed pursuant to chapter 34-12. If such assignment is executed and written notice thereof is given, the insurance company, health maintenance organization, preferred provider organization, individual practice association, or nonprofit hospital service corporation shall pay the benefits directly to the hospital.
     Nothing in this section modifies the scope of coverage or the amount of benefits payable under a health insurance policy, contract, or certificate.

Source: SL 1989, ch 430.


     58-17-62.   Coverage for phenylketonuria. Every policy of health insurance that is delivered, issued for delivery or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall offer coverage for testing, diagnosis, and treatment of phenylketonuria including dietary management, formulas, case management, intake and screening, assessment, comprehensive care planning, and service referral.

Source: SL 1992, ch 348, § 1.


     58-17-63.   "Health benefit plan" defined. For the purposes of §§ 58-17-64, 58-18-63, 58-38-36, and 58-40-33, a health benefit plan is any hospital or medical policy or certificate, hospital or medical service plan, or health maintenance organization subscriber contract. The term does not include specified disease, hospital indemnity, fixed indemnity, fixed duration of one year or less, accident-only, credit, dental, vision, medicare supplement, long-term care, or disability income insurance, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, or automobile medical payment insurance.

Source: SL 1994, ch 381, § 3.


     58-17-64.   Minimum loss ratio for individual health benefit plans. Premium rates for individual health benefit plans shall produce a minimum lifetime loss ratio of not less than sixty-five percent. The director may promulgate rules pursuant to chapter 1-26 which modify the minimum loss ratio required based on the specific design of the product or other objective and pertinent criteria.

Source: SL 1994, ch 381, § 4.


     58-17-65.   Individual health insurance plan used in conjunction with managed care plan or utilization review organization. If a managed care plan or utilization review organization is used in conjunction with an individual health insurance plan, it shall follow the provisions of §§ 58-18-64 to 58-18-75, inclusive, in the same manner as a managed care plan or utilization review organization subject to chapter 58-18.

Source: SL 1996, ch 296, § 7.


     58-17-66.   Definitions for 58-17-66 to 58-17-87. Terms used in §§ 58-17-66 to 58-17-87, inclusive, mean:
             (1)      "Actuarial certification," any written statement by a member of the American Academy of Actuaries or other person approved by the director that a carrier is in compliance with the provisions of §§ 58-17-66 to 58-17-87, inclusive, based upon the person's examination and a review of the appropriate records and the actuarial assumptions and methods used by the carrier in establishing premium rates for applicable individual health benefit plans;
             (2)      "Affiliate" or "affiliated," any person who, directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, any other specified person;
             (3)      "Base premium rate," the lowest premium rate charged or which could have been charged for each class of business for a rating period under a rating system for that class of business, by the carrier to individuals with similar case characteristics for health benefit plans with the same or similar coverage;
             (4)      "Carrier," any person that provides individual health insurance in the state, includes an insurance company, a prepaid hospital or medical service plan, a health maintenance organization, a multiple employer welfare arrangement, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation;
             (5)      "Church plan," a church plan as defined in section 3(33) of the Employee Retirement Income Security Act of 1974 as adopted by the director pursuant to chapter 1-26;
             (6)      "Class of business," all or a separate grouping of persons established pursuant to §§ 58-17-66 to 58-17-87, inclusive;
             (7)      "Dependent," any spouse, an unmarried child under the age of nineteen years, an unmarried child who is a full-time student under the age of twenty-three and who is financially dependent upon the parent, and any other person who qualifies as a dependent under this title;
             (8)      "Director," the director of the Division of Insurance;
             (9)      "Health benefit plan," any hospital or medical policy or certificate, hospital or medical service plan, or health maintenance organization subscriber contract of more than six-month duration. The term does not include, unless otherwise provided, specified disease, hospital indemnity, fixed indemnity, accident-only, credit, dental, vision, medicare supplement, long-term care, or disability income insurance; coverage issued as a supplement to liability insurance, worker's compensation or similar insurance; or automobile medical payment insurance;
             (10)      "Index rate," the arithmetic average of the applicable base premium rate and the corresponding highest premium rate for each class of business for persons with similar case characteristics;
             (11)      "New business premium rate," the premium rate charged or offered by an individual carrier to persons with similar case characteristics for newly issued health benefit plans with the same or similar coverage for each class of business for a rating period;
             (12)      "Rating characteristics," the demographic characteristics of individuals which are considered by the carrier in the determination of premium rates for the individuals; and
             (13)      "Rating period," the calendar period for which premium rates established by a carrier are assumed to be in effect.

Source: SL 1996, ch 286, § 1; SL 1997, ch 289, § 1.


     58-17-67.   "Professional association" defined. For purposes of §§ 58-17-66 to 58-17-87, inclusive, the term, professional association, means any association that meets all of the following criteria:
             (1)      Serves a single profession that requires a significant amount of education, training, or experience or a license or certificate from a state authority to practice the profession;
             (2)      Has been actively in existence for five years;
             (3)      Has a constitution and by-laws or other analogous governing documents;
             (4)      Has been formed and maintained in good faith for purposes other than obtaining insurance;
             (5)      Is not owned or controlled by a carrier or affiliated with a carrier;
             (6)      Does not condition membership in the association on health status of claims experience;
             (7)      Has at least one thousand members if it is a national association; five hundred members if it is a state association; or two hundred members if it is a local association;
             (8)      All members and dependents of members are eligible for coverage regardless of health status or claims experience;
             (9)      Is governed by a board of directors and sponsors annual meetings of its members; and
             (10)      Does not allow producers to market association memberships, accept applications for memberships, or sign up members.

Source: SL 1996, ch 286, § 2.


     58-17-68.   "Professional association plan" defined. For purposes of §§ 58-17-66 to 58-17-87, inclusive, the term, professional association plan, means a health benefit plan offered through a professional association that covers members of a professional association and their dependents, and not others, in this state regardless of the situs of delivery of the policy or contract and which meets all the following criteria:
             (1)      Conforms with all the provisions of the rate requirements of §§ 58-17-66 to 58-17-87, inclusive;
             (2)      Provides renewability of coverage for the members and dependents of members of the professional association that meets the renewability requirements of §§ 58-17-66 to 58-17-87, inclusive;
             (3)      Provides availability of coverage for the members and dependents of members of the professional association without regard to health status; and
             (4)      Is offered by a carrier that offers health benefit plan coverage to any professional association seeking health benefit plan coverage from the carrier.

Source: SL 1996, ch 286, § 3; SL 2003 (SS), ch 1, § 28.


     58-17-69.   "Creditable coverage" defined. For purposes of §§ 58-17-66 to 58-17-87, inclusive, the term, creditable coverage, means benefits or coverage provided under:
             (1)      An employer-based health insurance or health benefit arrangement that provides benefits similar to or exceeding benefits provided under the basic health benefit plan or an employee welfare benefit plan as defined in section 3(1) of the Employee Retirement Income Security Act of 1974 as adopted by the director pursuant to chapter 1-26, to the extent that the plan provides directly or through insurance, reimbursement or otherwise to employees or their dependents medical care for the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body and amounts paid for the transportation primarily for and essential to medical care;
             (2)      An individual health benefit plan, including coverage issued by any health maintenance organization or pre-paid hospital or medical services plan that provides benefits similar to or exceeding the benefits provided under the basic health benefit plan as approved pursuant to chapter 1-26, but excluding limited benefit plans and dread disease plans;
             (3)      Medicare or medicaid;
             (4)      Chapter 55 of Title 10, United States Code;
             (5)      A medical care program of the Indian Health Service or of a tribal organization;
             (6)      A state health benefits risk pool;
             (7)      A health plan offered under Chapter 89 of Title 5, United States Code;
             (8)      A public health plan;
             (9)      A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. 2504(e));
             (10)      A church plan;
             (11)      A college plan;
             (12)      A short term or limited duration plan; or
             (13)      An individual health benefit plan, including coverage issued by any health maintenance organization or pre-paid hospital or medical services plan that provided benefits less than the benefits provided under the basic health benefit plan as approved pursuant to chapter 1-26, but excluding the following excepted benefits:
             (a)      Coverage only for accident including accidental death and dismemberment;
             (b)      Disability income insurance;
             (c)      Liability insurance including general liability insurance and automobile liability insurance;
             (d)      Coverage issued as a supplement to liability insurance;
             (e)      Workers' compensation or similar insurance;
             (f)      Automobile medical payment insurance;
             (g)      Credit only insurance including mortgage insurance;
             (h)      Coverage for on-site medical clinics; and
             (i)      Limited scope dental and long-term care insurance, if provided under a separate policy, certificate, or contract of insurance, or not otherwise an integral part of a plan.

Source: SL 1996, ch 286, § 4; SL 1997, ch 289, § 2; SL 1998, ch 289, § 1; SL 1999, ch 250, § 1; SL 2001, ch 275, § 1; SL 2004, ch 301, § 1.


     58-17-70.   Application of 58-17-66 to 58-17-87, inclusive. Sections 58-17-66 to 58-17-87, inclusive, apply to any individual health benefit plan or certificate delivered or issued for delivery in the state. Sections 58-17-66 to 58-17-87, inclusive, apply to any certificate issued to an eligible person that evidences coverage under a policy or contract issued to a trust or association or other similar grouping of persons, regardless of the situs of delivery of the policy or contract, if the eligible person pays the premium and is not being covered under the policy or contract pursuant to continuation of benefit provisions applicable under federal or state law. The following are not subject to the provisions of §§ 58-17-66 to 58-17-87, inclusive:
             (1)      Any medicare supplement policy;
             (2)      Any long-term care policy;
             (3)      Any contract or certificate marketed on a group basis that is subject to regulation under chapter 58-18B or §§ 58-18-42 to 58-18-51.1, inclusive;
             (4)      Any certificate issued to an eligible person that evidences coverage under a professional association plan;
             (5)      Any policy or certificate of specified disease, short-term hospital-surgical care of six months or less duration, hospital confinement indemnity, limited benefit health insurance, or other policy or certificate that provide benefits less than as provided for under subdivision 58-17-69(2) if the carrier offering the policy or certificate at the time of filing for policy form approval, submits a statement certifying that policies or certificates described in this section are being offered and marketed as supplemental health insurance or as individual health benefit plans of six-month duration or less and not renewable, and not as a substitute for hospital or medical expense insurance or major medical insurance. For policy forms approved prior to July 1, 1996, the carrier shall submit such a statement with the director. If such a statement certifying that the policies or certificates are being offered as supplemental health insurance and not as a substitute for major medical insurance is either not filed or is withdrawn, the carrier offering such coverage shall, in addition to the policy or certificate providing coverage that is less than major medical, offer and actively market an individual major medical policy to any person who is solicited for coverage for the nonmajor medical products it offers.

Source: SL 1996, ch 286, § 5; SL 1998, ch 289, § 2; SL 2003 (SS), ch 1, § 29.


     58-17-71.   Separate classes of individual business--Reasons--Number. A carrier may establish a separate class of individual business only to reflect substantial differences in expected claims experience or administrative costs related to the following reasons:
             (1)      The carrier used more than one type of system for the marketing and sale of health benefit plans to individuals; or
             (2)      The carrier has acquired a class of business from another carrier.
     A carrier may establish up to three separate classes of individual business under this section.

Source: SL 1996, ch 286, § 6.


     58-17-72.   Transitional period when additional class of business acquired. The director may provide for a period of transition in order for a carrier to come into compliance with § 58-17-71 in the instance of acquisition of an additional class of business from another carrier.

Source: SL 1996, ch 286, § 7.


     58-17-73.   Director approval required to establish additional classes of business--Rates or rating methodologies. The director may approve the establishment of additional classes of business upon application to the director and a finding by the director that such action would enhance the efficiency and fairness of the individual marketplace. Nothing in §§ 58-17-66 to 58-17-87, inclusive, requires a carrier to change any of its rates or rating methodologies for any business other than the individual business subject to the provisions of §§ 58-17-66 to 58-17-87, inclusive.

Source: SL 1996, ch 286, § 8.


     58-17-74.   Provisions for premium rates for individual health benefit plans. Premium rates for individual health benefit plans subject to §§ 58-17-66 to 58-17-87, inclusive, are subject to the following provisions:
             (1)      Any new policy issued after the effective date of §§ 58-17-66 to 58-17-87, inclusive, is subject to the provisions of §§ 58-17-66 to 58-17-87, inclusive;
             (2)      The index rate for a rating period for any class of individual business may not exceed the index rate for any other class of individual business by more than twenty percent;
             (3)      For a class of business, the premium rates charged during a rating period to individuals with similar case characteristics for the same or similar coverage, or the rates that could be charged to such individuals under the rating system for that class of business, may not vary from the index rate by more than thirty percent of the index rate;
             (4)      An adjustment applied to a single block of business may not exceed the adjustment applied to all blocks of business by more than fifteen percent due to the claim experience or health status of that block of business;
             (5)      Any adjustment in rates for claim experience and duration of coverage may not be charged to specific individual policyholders. Any such adjustment shall be applied uniformly to the rates charged for any person and dependents of the person within each class of business;
             (6)      Premium rates for individual health benefit plans shall comply with the requirements of §§ 58-17-66 to 58-17-87, inclusive;
             (7)      Each carrier shall apply rating factors consistently with respect to all persons in a class of business. Rating factors shall produce premiums for identical persons which differ only by the amounts attributable to plan design;
             (8)      No carrier may use characteristics other than age, gender, lifestyle, family composition, and geographic area without prior approval of the director. The maximum rating differential based solely on age may not exceed a factor of 5:1; and
             (9)      All rate adjustments based on geographic area shall reflect actual differences in the health care costs of the respective areas.
     The rating provisions of subdivisions (1), (2), (3), (4), and (6) of this section do not apply to individual health benefit plans issued by a carrier to qualifying individuals on a guaranteed issue basis. However, the rate for any individual covered on a guaranteed issue basis may not exceed two and one half times the base rate of the class of business with the lowest index rate.

Source: SL 1996, ch 286, § 9; SL 2008, ch 263, § 1.


     58-17-74.1.   Premium rate limitations. Any health benefit plan issued before July 1, 1996, is subject to the rating limitations provided in this section. For a class of business, the premium rates charged during a rating period to individuals with similar case characteristics for the same or similar coverage, or the rates that could be charged to such individuals under the rating system for that class of business, may not exceed three times the base premium rate after July 1, 2001, two and one-half times the base premium rate after July 1, 2003, and two times the base premium rate after July 1, 2005.

Source: SL 2000, ch 240, § 1; SDCL § 58-17-4.3; SL 2005, ch 10, § 41.


     58-17-75.   Promulgation of rules for rates charged for individual health benefit plans. The director shall promulgate rules pursuant to chapter 1-26 to ensure that rating practices used by carriers are consistent with the purposes of §§ 58-17-66 to 58-17-87, inclusive, including rules that ensure that differences in rates charged for individual health benefit plans by carriers are reasonable, and reflect objective differences in plan design, age, and gender of the insured.

Source: SL 1996, ch 286, § 10.


     58-17-76.   Transfer into or out of class of business. No carrier may transfer a person involuntarily into or out of a class of business. No carrier may offer to transfer a person into or out of a class of business unless such an offer is made to transfer all persons in the class of business without regard to claim experience or duration of coverage since issue.

Source: SL 1996, ch 286, § 11.


     58-17-77.   Temporary suspension of premium rates for individual health insurance--Reasons. The director may suspend for a specified period the application of subdivision 58-17-74(2) as to the premium rates for one or more rating periods upon a filing by the carrier and a finding by the director either that the suspension is reasonable in light of the financial condition of the carrier or that the suspension would enhance the efficiency and fairness of the marketplace for individual health insurance.

Source: SL 1996, ch 286, § 12.


     58-17-78.   Required disclosure when offering individual health benefit plan. In connection with the offering for sale of any individual health benefit plan to a person, a carrier shall make a reasonable disclosure, as part of its solicitation and sales materials, of:
             (1)      The extent to which premium rates for a specified person are established or adjusted based upon age and gender;
             (2)      The provisions of the individual health benefit plan concerning the carrier's right to change premium rates and the factors that affect changes in premium rates;
             (3)      The provisions relating to renewability of policies and contracts; and
             (4)      The provisions relating to any preexisting condition provision.

Source: SL 1996, ch 286, § 13.


     58-17-79.   Documentation of rating methods and practices. Each carrier shall maintain at its principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation that demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.

Source: SL 1996, ch 286, § 14.


     58-17-80.   Repealed by SL 2009, ch 262, § 1.


     58-17-81.   Availability of information on rating methods and practices of carriers offering individual health benefit plans. A carrier shall make the information and documentation described in § 58-17-79 available to the director upon request. Except in cases of violations of §§ 58-17-66 to 58-17-87, inclusive, the information is proprietary and trade secret information and may not be disclosed by the director to persons outside of the division, except in the case of an administrative proceeding, to the Office of Hearing Examiners or the court in question or except as agreed to by the carrier or as ordered by a court of competent jurisdiction.

Source: SL 1996, ch 286, § 16.


     58-17-82.   Renewal of individual health benefit plans--Exceptions. An individual health benefit plan subject to §§ 58-17-66 to 58-17-87, inclusive, is renewable with respect to any person or dependent at the option of the person and may not be terminated by the insurer at any time, except as provided in § 58-17-15 or in any of the following cases:
             (1)      The individual has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the insurer has not received timely premium payments;
             (2)      Fraud or intentional misrepresentation of material fact by the person;
             (3)      In the case of a health insurance issuer that offers health insurance coverage in the market through a network plan, there are no longer any enrollees in connection with the plan who live, reside, or work in the service area of the issuer or in the area for which the issuer is authorized to do business and the issuer would deny enrollment with respect to the plan as provided for in § 58-18B-37;
             (4)      Election by the carrier not to renew all of its individual health benefit plans delivered or issued for delivery to persons in the state. In such a case, the carrier shall provide advance notice of its decision under this subdivision to the director in each state in which it is licensed and provide notice of the decision not to renew coverage to all affected individuals and to the director in each state in which an affected insured individual is known to reside at least one hundred eighty days before the nonrenewal of any individual health benefit plans by the carrier. Notice to the director under this subdivision shall be provided at least three working days before the notice to the affected individuals. In such instances, the director shall assist the affected persons in finding replacement coverage;
             (5)      In the case of health insurance coverage that is made available only through one or more bona fide associations, the membership of an employer in the association (on the basis of which the coverage is provided) ceases but only if the coverage is terminated uniformly without regard to any health status-related factor relating to any covered individual; or
             (6)      The insured individual becomes eligible for medicare coverage under Title XVIII of the Social Security Act, unless federal law requires that medicare coverage under Title XVIII be excluded as a reason for renewability of coverage;
             (7)      If the issuer decides to discontinue offering a particular type of individual health insurance offered in the individual market, coverage of such type may be discontinued if:
             (a)      The issuer provides notice to each insured provided coverage of this type in such market (and any participant and beneficiary covered under such coverage) of the discontinuation at least ninety days prior to the date of the discontinuation of the coverage;
             (b)      The issuer offers to each insured provided coverage of this type in such market, the option to purchase all other health insurance coverage currently being offered by the issuer to an individual health plan in such market; or
             (c)      In exercising the option to discontinue coverage of this type and in offering the option of coverage under subsection (b), the issuer acts uniformly without regard to the claims experience of those insured or any health status-related factor relating to any participant or beneficiary covered or any new participant or beneficiary who may become eligible for such coverage.

Source: SL 1996, ch 286, § 17; SL 1997, ch 289, § 3; SL 2003, ch 248, § 1.


     58-17-83.   Election not to renew individual health benefit plan--Future business restricted. No carrier that elects not to renew an individual health benefit plan under subdivision 58-17-82(4) may write new business in the individual health benefit plan market in the state for a period of five years from the date of notice to the director.

Source: SL 1996, ch 286, § 18.


     58-17-84.   Provisions for carriers providing individual coverage other than excepted benefits. Any health carrier providing individual coverage, other than excepted benefits, shall comply with the following provisions:
             (1)      No individual coverage may deny, exclude, or limit benefits for a covered individual for claims incurred more than twelve months following the effective date of the person's coverage due to a preexisting condition. No policy may define a preexisting condition more restrictively than:
             (a)      A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment during the twelve months immediately preceding the effective date of coverage;
             (b)      A condition for which medical advice, diagnosis, care, or treatment was recommended or received during the twelve months immediately preceding the effective date of coverage; or
             (c)      A pregnancy existing on the effective date of coverage;
             (2)      The health carrier shall waive any time period applicable to a preexisting condition exclusion or limitation period with respect to particular services for the aggregate period of time a person was previously covered by creditable coverage, excluding limited benefit plans and dread disease plans that provided benefits with respect to such services, if the creditable coverage was continuous to a date not more than sixty-three days before the application for the new coverage. A period of time a person was previously covered may not be aggregated if there was a break in coverage of sixty-three days or more. The coverage shall count a period of creditable coverage without regard to the specific benefits covered under the policy, unless the health carrier elects to credit it based on coverage of benefits within several classes or categories of benefits specified in rules adopted pursuant to chapter 1-26, by the director;
             (3)      A health maintenance organization which does not utilize a preexisting waiting period may use an affiliation period in lieu of a preexisting waiting period. No affiliation period may exceed two months in length. No premium may be charged for any portion of the affiliation period. If the health maintenance organization utilizes neither a preexisting waiting period nor an affiliation period, the health maintenance organization may use other criteria designed to avoid adverse selection provided that those criteria are approved by the director;
             (4)      Genetic information may not be treated as a condition for which a preexisting condition exclusion may be imposed in the absence of a diagnosis of the condition related to such information; and
             (5)      A condition may not be defined or considered as preexisting if the condition arose after a person began creditable coverage and if there was not a break in coverage which exceeded sixty-three days.
     For purposes of this section, the effective date of coverage is the first day the person became covered for either accidents or sicknesses. Except for plans grandfathered pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§ 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147, no covered person under the age of nineteen is subject to a preexisting condition limitation or exclusion for any plan year beginning on or after September 23, 2010. Excepted benefits are subject to the provisions of § 58-17-97. (SL 2011, ch 216, § 19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.")

Source: SL 1996, ch 286, § 19; SL 1997, ch 289, § 4; SL 2001, ch 275, § 2; SL 2003, ch 248, § 2; SL 2011, ch 216, § 6.


     58-17-84.1.   (Text of section effective until the first plan year, policy year, or renewal date on or after January 1, 2019) Anesthesia and hospitalization for dental care to be provided certain covered persons. Any health benefit plan as defined by § 58-17-63 shall cover anesthesia and hospital charges for dental care provided to a covered person who:
             (1)      Is a child under age five; or
             (2)      Is severely disabled or otherwise suffers from a developmental disability as determined by a licensed physician which places such person at serious risk.
     Such coverage applies regardless of whether the services are provided in a hospital or a dental office. A health carrier may require prior authorization of hospitalization for dental care procedures in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions.
     (Text of section effective the first plan year, policy year, or renewal date on or after January 1, 2019) Anesthesia and hospital or ambulatory surgery center charges for dental care to be covered for certain persons. Any health benefit plan as defined by § 58-17-63 shall cover anesthesia and hospital or ambulatory surgery center charges for dental care provided to a covered person who:
             (1)      Is a child under age five; or
             (2)      If determined by a licensed physician, is severely disabled, has a developmental disability, or otherwise has a medical condition that places the person at serious medical risk.
     The coverage applies regardless of whether the services are provided in a hospital, ambulatory surgery center, or a dental office. A health carrier may require prior authorization in the same manner that prior authorization is required for other covered diseases or conditions.

Source: SL 1999, ch 248, § 2; SL 2018, ch 279, § 1, eff. Jan. 1, 2019.


     58-17-85, 58-17-85.1.   Repealed by SL 2015, ch 249, §§ 2, 3.


     58-17-86.   Repealed by SL 2003 (SS) ch 1, § 33


     58-17-87.   Director to promulgate rules for individual health insurance--Scope of rules. The director shall promulgate rules pursuant to chapter 1-26 to cover:
             (1)      Terms or renewability;
             (2)      Conditions of eligibility;
             (3)      Benefit limitations, exceptions, and reductions;
             (4)      Definition of terms;
             (5)      Filing requirements for forms, rates, and rate schedules;
             (6)      Marketing practices;
             (7)      Reporting practices;
             (8)      Compensation arrangements between insurers or other entities and their agents, representatives, or producers;
             (9)      Suitability and appropriateness of the policy sold;
             (10)      Certificates of coverage;
             (11)      Determinations with regard to waiting periods;
             (12)      College plans;
             (13)      Creditable coverages;
             (14)      Breaks in coverage;
             (15)      The application of waiting periods; and
             (16)      Risk spreading mechanisms.
     The director shall promulgate rules pursuant to chapter 1-26 that specify prohibited policy or certificate provisions not otherwise specifically authorized by statute which, in the opinion of the director, are unjust, unfair, or unfairly discriminatory to any person insured or proposed for coverage under an individual policy or certificate. The director shall also promulgate rules pursuant to chapter 1-26 assuring public access to rate and form information and establishing procedures for rate and form approvals and disapprovals. If any federal standards are in place which would require additional steps to meet those standards beyond what is required by this chapter, the director shall promulgate rules to require the offering of health insurance plans, in addition to those specifically required by § 58-17-85, the underwriting and coverage criteria that may be utilized for such health insurance plans, and other requirements related to the coverage criteria and availability of health insurance to individuals in this state in order to minimally meet the federal standards.

Source: SL 1996, ch 286, § 22; SL 1997, ch 289, § 6; SL 1998, ch 289, § 4.


     58-17-88.   Minimum inpatient care coverage following delivery. If a health insurance policy that is issued or renewed on or after July 1, 1996, provides maternity coverage, the policy shall provide coverage for a minimum of forty-eight hours of inpatient care following a vaginal delivery and a minimum of ninety-six hours of inpatient care following delivery by cesarean section for a mother and her newborn child in a health care facility licensed pursuant to chapter 34-12, except as otherwise provided in § 58-17-89. Any policy that provides coverage for complications of pregnancy, and does not provide other maternity benefits, is not required to comply with this section.

Source: SL 1996, ch 292, § 1; SL 1998, ch 290, § 1.


     58-17-89.   Shorter hospital stay permitted--Follow-up visit within forty-eight hours required. If the treating physician determines that the mother and the newborn meet medical criteria contained in Guidelines for Perinatal Care, Third Edition, of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists as in effect on January 1, 1996, a health insurance policy may provide coverage for a shorter length of hospital inpatient stay for services related to maternity and newborn care than is required in § 58-17-88 if the coverage includes one follow-up visit in the first forty-eight hours after discharge to verify the condition of the mother and newborn.

Source: SL 1996, ch 292, § 2.


     58-17-90.   Notice to policyholders--Disclosures. The health insurer shall provide notice to policyholders regarding the coverage required by §§ 58-17-88 and 58-17-89 in accordance with rules adopted by the director of the Division of Insurance pursuant to chapter 1-26. The notice shall be in writing and prominently positioned in any literature or correspondence. The notice shall be transmitted to policyholders in the next mailing to policyholders, in the yearly informational packet sent to policyholders, or by January 1, 1997, whichever is earliest.

Source: SL 1996, ch 292, § 3.


     58-17-91 to 58-17-96.   Repealed by SL 2000, ch 243, §§ 16 to 21


     58-17-97.   Provisions covering preexisting conditions. Any accident and sickness policy or certificate subject to the provisions of this chapter, other than credit health insurance as defined in subdivision 58-19-2(1) and a health benefit plan as defined in § 58-17-66, shall comply with the following provisions:
             (1)      No policy or certificate may deny, exclude, or limit benefits for a covered individual for claims incurred more than twelve months following the effective date of the person's coverage due to a preexisting condition;
             (2)      No policy or certificate may define a preexisting condition more restrictively than:
             (a)      A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment during the twelve months immediately preceding the effective date of coverage;
             (b)      A condition for which medical advice, diagnosis, care, or treatment was recommended or received during the twelve months immediately preceding the effective date of coverage; or
             (c)      A pregnancy existing on the effective date of coverage.

Source: SL 1997, ch 288, § 2; SL 2001, ch 275, § 4; SL 2013, ch 248, § 1.


     58-17-98.   Health insurance policies to provide coverage for biologically-based mental illnesses. Every policy of health insurance that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall provide, in writing, coverage for the treatment and diagnosis of biologically-based mental illnesses with the same dollar limits, deductibles, coinsurance factors, and restrictions as for other covered illnesses.
     The term, biologically-based mental illness, means schizophrenia and other psychotic disorders, bipolar disorder, major depression, and obsessive-compulsive disorder.

Source: SL 1998, ch 291, § 1; SL 1999, ch 251, § 1.


     58-17-99.   Application of § 58-17-98--Exemptions. The provisions of § 58-17-98 do not apply to any plan, policy, or contract that provides coverage only for:
             (1)      Specified disease;
             (2)      Hospital indemnity;
             (3)      Fixed indemnity;
             (4)      Accident-only;
             (5)      Credit;
             (6)      Dental;
             (7)      Vision;
             (8)      Prescription drug;
             (9)      Medicare supplement;
             (10)      Long-term care;
             (11)      Disability income insurance;
             (12)      Coverage issued as a supplement to liability insurance;
             (13)      Workers' compensation or similar insurance;
             (14)      Automobile medical payment insurance; or
             (15)      Individual health benefit plans of six-months duration or less that are not renewable.

Source: SL 1998, ch 291, § 7.


     58-17-100.   Definitions. Terms used in §§ 58-17-100 to 58-17-106, inclusive, mean:
             (1)      "FDA," the federal Food and Drug Administration;
             (2)      "Health insurer," any person who provides health insurance in this state. The term includes a licensed insurance company, a prepaid hospital or medical service plan, a health maintenance organization, a multiple employer welfare arrangement, or any person providing a plan of health insurance subject to state insurance regulation;
             (3)      "Life threatening," either or both of the following:
             (a)      A disease or condition where the likelihood of death is high, unless the course of the disease is interrupted; or
             (b)      A disease or condition with potentially fatal outcomes where the end point of clinical intervention is survival;
             (4)      "Medical literature," a published scientific study in a journal or other publication in which original manuscripts have been published only after critical review for scientific accuracy, validity, and reliability by unbiased independent experts and a determination by the International Committee of Medical Journal Editors that it meets the Uniform Requirements for Manuscripts submitted to biomedical journals. The term, medical literature, does not include a publication or a supplement to a publication that is sponsored to a significant extent by a pharmaceutical manufacturing company or health carrier;
             (5)      "Standard reference compendia," one of the following:
             (a)      The United States Pharmacopeia Drug Information;
             (b)      DRUGDEX; or
             (c)      The American Hospital Formulary Service Drug Information;
             (6)      "Off-label," the use of an FDA approved drug for an indication that is not included in the approved labeling;
             (7)      "Drug," any substance prescribed by a licensed health care provider acting within the scope of the provider's license and that is intended for use in the diagnosis, mitigation, treatment, or prevention of disease and is taken by mouth; injected into a muscle, the skin, a blood vessel, or cavity of the body; applied to the skin; or otherwise assimilated by the body. The term, drug, includes only those substances that are approved by the FDA for at least one indication.

Source: SL 2000, ch 242, § 1.


     58-17-101.   Insurer may not exclude certain off-label uses of prescription drugs. No health insurer issuing a policy which provides coverage for prescription drugs may exclude coverage of any drug used for the treatment of cancer or life threatening conditions on the grounds that the drug has not been approved by the FDA for that indication if that drug is recognized for treatment of such indication in one of the standard reference compendia or in the medical literature. The prescribing physician shall submit documentation supporting the proposed off-label use or uses to the insurer, if requested. Any coverage of a drug that serves as the primary treatment required by §§ 58-17-100 to 58-17-106, inclusive, shall also include medically necessary services associated with the administration of the drug.

Source: SL 2000, ch 242, § 2.


     58-17-102.   Exceptions. No coverage is required under §§ 58-17-100 to 58-17-106, inclusive, for the following:
             (1)      Any drug that has not been fully licensed or approved by the FDA;
             (2)      The use of any drug if the FDA has determined that use to be contraindicated; or
             (3)      Any experimental drug not otherwise approved for any indication by the FDA.

Source: SL 2000, ch 242, § 3.


     58-17-103.   Provisions limited to cancer or life threatening diseases. The provisions of §§ 58-17-100 to 58-17-106, inclusive, apply to drugs used in the treatment for cancer or life threatening diseases only, and nothing in §§ 58-17-100 to 58-17-106, inclusive, may be construed to create, impair, alter, limit, modify, enlarge, abrogate, or prohibit reimbursement for medications used in the treatment of any other disease or condition.

Source: SL 2000, ch 242, § 4.


     58-17-104.   Deductibles, copayments, and managed care review not affected. Nothing in §§ 58-17-100 to 58-17-106, inclusive, may be construed to prevent the application of contractual deductibles or copayment provisions or managed care review.

Source: SL 2000, ch 242, § 5.


     58-17-105.   Drugs used in research trials not covered. The following drugs or services are not subject to coverage under § 58-17-101:
             (1)      Any drug that is used in research trials sponsored by the manufacturer of that drug or a governmental entity; or
             (2)      Any drug or service furnished in a research trial, if the sponsor of the research trial furnishes the drug or service without charge to any participant in the research trial.

Source: SL 2000, ch 242, § 6.


     58-17-106.   No reduction or limitation of coverage otherwise required by law. Sections 58-17-100 to 58-17-106, inclusive, may not be used to reduce or limit coverage for off-label use of drugs otherwise required by law or contract.

Source: SL 2000, ch 242, § 7.


     58-17-107.   Health insurance policies to provide coverage for prostate cancer screening. Every policy of health insurance that covers a male and that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall provide the following coverage for diagnostic screening for prostate cancer:
             (1)      An annual medically recognized diagnostic examination, including a digital rectal examination and a prostate-specific antigen test, as follows:
             (a)      For asymptomatic men aged fifty and over; and
             (b)      For men aged forty-five and over at high risk for prostate cancer; and
             (2)      For males of any age who have a prior history of prostate cancer, medically indicated diagnostic testing at intervals recommended by a physician, including the digital rectal examination, prostate-specific antigen test, and bone scan.

Source: SL 2001, ch 277, § 1.


     58-17-108.   "Disability income insurance" defined. For the purposes of §§ 58-17-108 to 58-17-112, inclusive, the term, disability income insurance, means a policy or certificate of insurance that primarily provides payment to or for the benefit of the policyholder or certificate holder based, in whole or in part, upon lost wages or other earned income or business or financial losses as a result of an inability to work due to sickness, injury, or a combination of sickness and injury.

Source: SL 2001, ch 276, § 1.


     58-17-109.   Exclusion or reduction of benefits. Any disability income insurance policy may include provisions that exclude or reduce benefits if the insured is collecting other benefits under a government program or is eligible to receive benefits under other insurance coverage. If the insured subsequently receives other benefits for a period for which the insurer paid benefits, the insurer may require reimbursement from the insured for any benefits already paid that otherwise would not have been paid. If the insured fails to make timely application for any other insurance coverage or governmental program for which that insured may be eligible, fails to actively and in good faith pursue all appeals procedures if benefits under other insurance or governmental program have been denied, or fails to produce satisfactory evidence that the applications have been made and the appeals pursued, benefits may be reduced or withheld.

Source: SL 2001, ch 276, § 2.


     58-17-110.   Commencement of loss. No disability income insurance policy may require the loss to commence less than thirty days after the date of the accident.

Source: SL 2001, ch 276, § 3.


     58-17-111.   Minimum standards--Exceptions. Except for overhead expense, buy-sell coverage, or other similar business disability income insurance coverage, a disability income insurance policy shall meet the following minimum standards:
             (1)      Provide that periodic payments that are payable at ages after sixty-two and reduced solely on the basis of age are at least fifty percent of the amounts payable immediately prior to age sixty-two or in the case of an employer group plan that has twenty or more employees, that periodic payments are actuarially equivalent regardless of age;
             (2)      Contain an elimination period no greater than:
             (a)      Ninety days in the case of coverage providing a benefit of one year or less;
             (b)      One hundred eighty days in the case of coverage providing a benefit of more than one year but not greater than two years;
             (c)      Three hundred sixty-five days in the case of coverage providing a benefit of more than two years but not greater than five years; or
             (d)      Seven hundred thirty days in the case of coverage providing a benefit greater than five years resulting from sickness or injury;
             (3)      Provide a maximum benefit period of at least six months for long-term disability income insurance and at least twelve weeks for short-term disability income insurance. However, in the case of a policy covering disability arising out of pregnancy, childbirth, or miscarriage, the maximum benefit period may be one month, except if the plan is an employer plan with fifteen or more employees, then the maximum benefit period for pregnancy, childbirth, or miscarriage may not be less than the maximum benefit period for other covered disabilities;
             (4)      Include no reduction in benefits because of any cost of living increase in social security or similar benefits during a benefit period;
             (5)      Require only one elimination period if a policy provides total disability income benefits and partial disability income benefits.
     A long-term disability income insurance policy may have longer elimination periods if the policy is issued in conjunction with or supplemental to a limited duration self-insured or other short-term disability income policy. The provisions of this section do not apply to an employer plan if at least fifty percent of the covered employee's disability income benefits are subject to federal income taxes.

Source: SL 2001, ch 276, § 4.


     58-17-112.   Promulgation of rules regarding disability income policies--Content. The director may promulgate rules pursuant to chapter 1-26 to protect the insurance-buying public with regard to disability income policies. However, the director shall take into account the effect any such rule may have on the availability of coverage. The rules may include:
             (1)      Definition of terms;
             (2)      Permissible exclusions;
             (3)      Return of premium provisions;
             (4)      Terms of renewability;
             (5)      Disclosure requirements;
             (6)      Benefit triggers, if such rules permit the use of activities of daily living as an acceptable benefit trigger; and
             (7)      Limitations, exceptions, and reductions.

Source: SL 2001, ch 276, § 5.


     58-17-113, 58-17-114.   Repealed by SL 2015, ch 249, § 36, eff. Jan. 1, 2017.


     58-17-115.   Repealed by SL 2015, ch 249, § 5.


     58-17-116.   Repealed by SL 2015, ch 249, § 36, eff. Jan. 1, 2017.


     58-17-117, 58-17-118.   Repealed by SL 2015, ch 249, §§ 6, 7.


     58-17-119 to 58-17-124.   Repealed by SL 2015, ch 249, § 36, eff. Jan. 1, 2017.


     58-17-125.   Repealed by SL 2015, ch 249, § 10.


     58-17-126.   Repealed by SL 2015, ch 249, § 36, eff. Jan. 1, 2017.


     58-17-127 to 58-17-137.   Repealed by SL 2015, ch 249, §§ 12 to 22.


     58-17-138.   Repealed by SL 2015, ch 249, § 36, eff. Jan. 1, 2017.


     58-17-139 to 58-17-141.   Repealed by SL 2015, ch 249, §§ 24 to 26.


     58-17-142.   Maximum premium rates for plans issued prior to August 1, 2003--Rate provisions of § 58-17-75 to apply upon carrier's discontinuance of active marketing. Any carrier of any in force individual health benefit plan issued guarantee issued policies prior to August 1, 2003, for which rates are established pursuant to § 58-17-75, may set and charge a maximum premium rate of not more than two and two-tenths times the base premium rate until January 1, 2005, and may set and charge a maximum premium rate of not more than two and one-half times the base premium rate for each year thereafter, if the carrier actively markets individual major medical policies in this state during the entire year of 2003 and each year thereafter. If, in any year after 2003, the carrier discontinues actively marketing individual health benefit plans in this state, the premium rate provisions of § 58-17-75 apply to those policies in force issued guarantee issued policies from the date of the carrier's discontinuance of active marketing.
     The provisions of this section apply only to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§ 54 and 602, as of January 1, 2015, and 29 C.F.R. § 2590, as of January 1, 2015, and 45 C.F.R. § 147, as of January 1, 2015.

Source: SL 2003 (SS), ch 2, § 1, eff. Sept. 26, 2003; SL 2015, ch 249, § 27.


     58-17-143.   Repealed by SL 2015, ch 249, § 36, eff. Jan. 1, 2017.


     58-17-144, 58-17-145.   Repealed by SL 2015, ch 249, §§ 28, 29.


     58-17-145.1.   Deadline for submission of health claim under risk pool. Any person covered under a risk pool established pursuant to the provisions of § 58-17-113 in the State of South Dakota may submit a health claim within six months from June 30, 2015. Each claim shall be submitted in writing to the Bureau of Human Resources. A claim shall be paid in accordance with the South Dakota risk pool plan document in effect July 1, 2014, through June 30, 2015, inclusive.

Source: SL 2015, ch 249, § 30.


     58-17-146.   Dental insurers prohibited from setting fees for noncovered service. No contract between an insurer and a dentist may require a dentist to provide services for an insured at a fee set by the contract unless the services are covered services under the terms of the insured's plan or policy. For the purposes of this section, the term, covered services, means services reimbursable under the plan, policy, or contract, subject to such contractual limitations on benefits as may apply, including deductibles, waiting periods, frequency limitations, or charges over the benefit maximum.

Source: SL 2010, ch 239, § 1.


     58-17-147.   Elective abortion coverage prohibited in qualified health plan offered through health insurance exchange. Pursuant to the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, no qualified health plan offered through a health insurance exchange established in the state may include elective abortion coverage.
     For the purposes of this section, an elective abortion is an abortion performed for any reason other than a medical emergency as set forth in subdivision 34-23A-1(5).

Source: SL 2012, ch 245, §§ 1, 2.


     58-17-148.   Qualified health plan sold through exchange to provide for placement through licensed insurance producer--Commissions. Any qualified health plan as defined by the Patient Protection and Affordable Care Act of 2010 sold in South Dakota through a public health care exchange, as mandated by the Patient Protection and Affordable Care Act of 2010, shall provide for placement through a licensed insurance producer upon enrollment. Any commission paid by a health insurance carrier for the sale of a qualified health plan through a public health exchange shall be the same as a commission paid by the same health insurance carrier outside the public exchange for a similar plan.

Source: SL 2013, ch 249, § 1.


     58-17-149.   Definitions regarding retrospective payment of clean claims for covered services provided during credentialing period. Terms used in §§ 58-17-149 to 58-17-152, inclusive, mean:
             (1)      "Application date," the date on which a health insurer or other entity responsible for the credentialing of health care professionals on behalf of the health insurer receives the health care professional's completed application for credentialing or change request;
             (2)      "Clean claim," as defined in § 58-12-19;
             (3)      "Health care professional," as defined in subdivision 58-17F-1(8);
             (4)      "Health insurer," as defined in subdivision 58-17-100(2);
             (5)      "Special Review," a supplemental review of a health care professional's completed application for credentialing or change request by a health insurer or other entity responsible for credentialing of health care professionals necessitated by credible evidence received by a health insurer or other entity responsible for credentialing of health care professionals as it relates to investigation of the following: action taken against the applicant's licensure status, action taken against the applicant's professional society status, verified complaints to facilities, or licensing agency regarding the applicant; the applicant's non-completion of training programs; a criminal proceeding brought against the applicant a malpractice claim brought against the applicant; loss of a Drug Enforcement Administration certificate or state-controlled substance certificate; loss of a Medicare or Medicaid certification status; or involuntary termination of credentialing by a different health insurer.

Source: SL 2014, ch 236, § 1.


     58-17-150.   Retrospective payment of clean claims for covered services provided by health care professional during credentialing period--Requirements. A health insurer shall make retrospective payment for all clean claims submitted by a health care professional after the credentialing period for covered services provided by the health care professional during the credentialing period subject to all of the following:
             (1)      The credentialing period begins on the application date and ends on the date that the health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer has made a final determination approving the health care professional's application to be credentialed and notice has been sent;
             (2)      The health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer shall, electronically or in writing, notify an applicant of its determination regarding a properly completed application for credentialing within ninety days of receipt of an application containing all information required by the health insurer's credentialing form:
             (a)      If an incomplete application is received, the health insurer or other entity responsible for credentialing of health care professionals on behalf of the insurer shall notify the health care professional of the incomplete application as soon as possible, but no more than thirty days after receipt of the application. The notification shall itemize all documentation or other information that the insurer or entity must receive to complete the application. The health insurer or other entity responsible for credentialing of health care professionals on behalf of the insurer may request additional information if the information provided by the health care professional to the insurer or other entity responsible for credentialing of health care professionals on behalf of the insurer pursuant to this subsection is inaccurate, incomplete, or unclear;
             (b)      A health insurer or other entity responsible for credentialing of health care professionals may take additional time beyond the ninety days if a special review is required;
             (3)      The health care professional may not submit any claim to the health insurer during the credentialing period;
             (4)      A health insurer may not be required to pay any claim submitted by a health care professional during the credentialing period;
             (5)      The health insurer's time period for timely submission of claims may not begin until the credentialing period has ended. The health insurer's rules pertaining to timely submission may not be used to deny payment of any clean claim for medical services provided by a health care professional during the credentialing period, so long as the health care professional submits all such claims within the time period required by the health insurer's rules beginning on the date the health care professional receives notice that the healthcare professional is credentialed;
             (6)      Unless otherwise prohibited by law, after the health care professional is credentialed, the health care professional shall submit all claims to the health insurer for covered services provided by the health care professional during the credentialing period;
             (7)      After the health care professional is credentialed, a health insurer shall pay or deny all clean claims submitted by the health care professional for covered services provided by the health care professional during the credentialing period.

Source: SL 2014, ch 236, § 2.


     58-17-151.   Applications to be credentialed. Within ten business days of receiving a request for an application to be credentialed by a health care professional, a health insurer or other entity responsible for the credentialing of health care professionals on behalf of the health insurer shall send an application form to the professional, unless the application to be credentialed is available electronically on a public website. The application form shall identify and itemize all documentation and other information that the insurer or entity must receive in order for an application to be complete.

Source: SL 2014, ch 236, § 3.


     58-17-152.   Application of §§ 58-17-149 to 58-17-151. Nothing in §§ 58-17-149 to 58-17-151, inclusive, applies to services provided by a health care professional that are covered by Medicaid, Medicare, TRICARE, or other health care benefit program subject to federal regulations regarding eligibility and provider payments. Nothing in §§ 58-17-149 to 58-17-151, inclusive, requires a health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer to take any action in violation of the requirements of the National Committee for Quality Assurance (NCQA) or Utilization Review Accreditation Commission (URAC).
     Nothing in §§ 58-17-149 to 58-17-151, inclusive, requires a health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer to credential a health care professional or to permit a non-credentialed health care professional to participate in the health insurer's provider network.

Source: SL 2014, ch 236, § 4.


     58-17-153.   Coverage for treatment of hearing impairment for persons under age nineteen. Any qualified health plan issued on or after January 1, 2015, that offers coverage for professional audiology services shall include coverage for medically necessary physician services appropriate for the treatment of hearing impairment to a person under the age of nineteen. This shall include professional services rendered by an audiologist licensed pursuant to chapter 36-24.
     The benefits provided shall be subject to the same dollar limits, deductibles, coinsurance and other limitations provided for other covered benefits in the policy.
     Nothing in this section requires the payment by the health plan of hearing aids, devices, or equipment to correct hearing impairment or loss.

Source: SL 2014, ch 237, § 1.


     58-17-154.   Definitions for §§ 58-17-155 to 58-17-162. Terms used in §§ 58-17-155 to 58-17-162, inclusive, mean:
             (1)      "Applied behavior analysis," the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior;
             (2)      "Autism spectrum disorder," a complex neurodevelopmental medical disorder characterized by social impairment, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior;
             (3)      "Behavioral health treatment," evidence-based interventions that:
             (a)      Achieve specific improvements in functional capacity of a person; and
             (b)      Are provided or supervised by a licensed practitioner as provided in § 58-17-159;
             (4)      "Treatment," evidence-based care which is prescribed or ordered for a person diagnosed with an autism spectrum disorder by a licensed physician or psychologist, including:
             (a)      Behavioral health treatment;
             (b)      Pharmacy care; and
             (c)      Therapeutic care.

Source: SL 2015, ch 250, § 1; SL 2017, ch 212, § 1, eff. Jan. 1, 2018.


     58-17-155.   Exceptions to application of §§ 58-17-154 to 58-17-162. Nothing in §§ 58-17-154 to 58-17-162, inclusive, applies to nongrandfathered plans in the individual and small group markets that are required to include essential health benefits under the federal Patient Protection and Affordable Care Act of 2010, as in effect on January 1, 2015, or to Medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, major medical policies with a limited duration of less than twelve months, or other limited benefit hospital insurance policies, or any plan or coverage exempted from state regulation by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 18, as in effect on January 1, 2015.

Source: SL 2015, ch 250, § 2.


     58-17-156.   Policies, contracts, certificates, and plans subject to §§ 58-17-154 to 58-17-162. Except as provided in § 58-17-155, §§ 58-17-154 to 58-17-162, inclusive, apply to all individual and group health insurance policies, contracts, and certificates issued by health carriers as defined in subdivision 58-17H-1(19) and self-funded nonfederal governmental plans with the exception of the state employee health plan sponsored by the State of South Dakota.

Source: SL 2015, ch 250, § 3.


     58-17-157.   Coverage for applied behavior analysis for treatment of autism spectrum disorders. Every policy, contract, certificate, or plan subject to the provisions of §§ 58-17-154 to 58-17-162, inclusive, shall provide coverage for applied behavior analysis for the treatment of autism spectrum disorders consistent with §§ 58-17-154 to 58-17-162, inclusive.

Source: SL 2015, ch 250, § 4.


     58-17-158.   Authorization, prior approval, and other care management requirements--Annual maximum benefit. Coverage for an applied behavior analysis may be subject to pre-authorization, prior approval, and other care management requirements including limits on the number of individual visits a person may make for applied behavior analysis subject to the general care management provisions of the plan, and may be subject to dollar limits, deductibles, copayments, or coinsurance provisions that apply to other medical or surgical services covered under the policy. The coverage for applied behavior analysis shall provide an annual maximum benefit that may not be less than the following:
             (1)      Through age 6 $36,000
             (2)      Age 7 through age 13 $25,000
             (3)      Age 14 through age 18 $12,500

Source: SL 2015, ch 250, § 5.


     58-17-159.   Qualifications of person performing or supervising applied behavior analysis. Any person who performs or supervises applied behavior analysis shall:
             (1)      Be licensed by the South Dakota Board of Medical and Osteopathic Examiners or the Board of Examiners of Psychologists and have documented training and competence in applied behavior analysis; or
             (2)      Be licensed by the South Dakota Board of Social Workers as a licensed behavior analyst.

Source: SL 2015, ch 250, § 6; SL 2017, ch 212, § 2, eff. Jan. 1, 2018.


     58-17-160.   Review of treatment. A health carrier or plan provider subject to §§ 58-17-154 to 58-17-162, inclusive, shall have the right to request a review of the treatment that a person is receiving not more than once every three months unless the insurer and the person's licensed physician or licensed psychologist execute an agreement that a more frequent review is necessary. Any agreement regarding the right to review a treatment plan more frequently applies only to a particular person receiving applied behavior analysis and may not apply to all persons receiving applied behavior analysis by a licensed physician, licensed psychologist, or licensed behavior analyst. The cost of obtaining a review under this section shall be paid by the health carrier or plan.

Source: SL 2015, ch 250, § 7; SL 2017, ch 212, § 3, eff. Jan. 1, 2018.


     58-17-161.   Services under individualized service plan, family service plan, or education program. Nothing in §§ 58-17-154 to 58-17-162, inclusive, may be construed to affect any obligation to provide services to a person under an individualized family service plan, an individualized education program, or an individualized service plan.

Source: SL 2015, ch 250, § 8.


     58-17-162.   Effective date of §§ 58-17-154 to 58-17-161. The effective date of §§ 58-17-154 to 58-17-161, inclusive, is the first plan year, policy year, or renewal date on or after January 1, 2016.

Source: SL 2015, ch 250, § 9.


     58-17-163.   Dental care insurers to honor assignment of benefits. Any insurer that provides dental care insurance to a person shall honor an assignment, made in writing by the person insured under the policy, of payments due under the policy to a dentist or a dental corporation for dental care services provided to the person that is insured under the policy. Upon notice of the assignment, the insurer shall make payments directly to the dentist or dental corporation providing the dental care services. A dentist or dental corporation with a valid assignment may bill the insurer and notify the insurer of the assignment. Upon request of the insurer, the dentist or dental corporation shall provide a copy of the assignment to the insurer.

Source: SL 2017, ch 213, § 1.


     58-17-164.   Revocation of assignment of dental insurance benefits. A person may revoke an assignment made pursuant to § 58-17-163 with or without the consent of the dentist or dental corporation. The revocation shall be in writing. The person shall provide notice of the revocation to the insurer. The insurer shall send a copy of the revocation notice to the dentist or dental corporation subject to the assignment. The revocation is effective when both the insurer and the dentist or dental corporation have received a copy of the revocation notice. The revocation is only effective for any charges incurred after both parties have received the revocation notice.

Source: SL 2017, ch 213, § 2.


     58-17-165.   Reimbursement of payment from insured following receipt of payment from insurer. If, under an assignment authorized in § 58-17-163, a dentist or dental corporation collects payment from a person and subsequently receives payment from the insurer, the dentist or dental corporation shall reimburse the person, less any applicable copayments, deductibles, or coinsurance amounts, within forty-five days.

Source: SL 2017, ch 213, § 3.


     58-17-166.   Scope of benefits not affected--Medical benefits not included . Nothing in §§ 58-17-163 to 58-17-165, inclusive, limits an insurer's ability to determine the scope of the insurer's benefits, services, or any other terms of the insurer's policies or to negotiate any contract with a licensed health care provider regarding reimbursement rates or any other lawful provisions.
     The provisions of §§ 58-17-163 to 58-17-166, inclusive, apply only to any policy of insurance insuring dental care services. The provisions of §§ 58-17-163 to 58-17-166, inclusive, do not apply to any service payable as a medical benefit pursuant to a health benefit plan as defined in subdivision 58-17-66(9).

Source: SL 2017, ch 213, § 4.


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