Tennessee Code Annotated

Title 56: Insurance

Chapter 7: Policies and Policyholders

Part 23: Mandated Insurer or Plan Coverage

TCA 56-7-2302: Dependent children under hospital or medical expense policies -- Coverage -- Services by charitable research hospitals.

(a)  (1)  An individual hospital or medical expense insurance policy or contract, as provided under chapter 26, 28 or 29 of this title, delivered or issued for delivery in this state, or that is amended or renewed by agreement or otherwise, on or after August 13, 1986, and that 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 the limiting age not be earlier than twenty-four (24) years for those dependent children who are unmarried and dependent on the insured for support and maintenance. This subdivision (a)(1) shall not be construed to require coverage for a dependent child under the policy of insurance, if the dependent child would be otherwise ineligible for the coverage either by the terms of the policy of insurance or other provisions of this title, except those relating to the limiting age for the dependent child stated in this subdivision (a)(1).

     (2)  A group hospital or medical expense insurance policy or contract, as provided under chapter 26, 28 or 29 of this title, delivered or issued for delivery in this state, or that is amended or renewed by agreement or otherwise, on or after August 13, 1986, and that 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 the limiting age not be earlier than twenty-four (24) years for those dependent children who are unmarried and dependent on the insured for support and maintenance. This subdivision (a)(2) shall not be construed to require coverage for a dependent child under the policy of insurance if the dependent child would be otherwise ineligible for the coverage either by the terms of the policy of insurance or other provisions of this title, except those relating to the limiting age for the dependent child stated in this subdivision (a)(2).

(b)  (1)  An individual hospital or medical expense insurance policy or contract, as provided under chapter 26, 28 or 29 of this title, delivered or issued for delivery in this state more than one hundred twenty (120) days after May 7, 1969, that 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 in substance that attainment of the limiting age shall not operate to terminate the coverage of the child while the child is and continues to be both:

          (A)  Incapable of self-sustaining employment by reason of mental retardation or physical handicap; and

          (B)  Chiefly dependent upon the policyholder for support and maintenance, provided proof of the incapacity and dependency is furnished to the insurer by the policyholder within thirty-one (31) 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.

     (2)  A group hospital or medical expense insurance policy or contract, as provided under chapter 26, 28 or 29 of this title, delivered or issued for delivery in this state more than one hundred twenty (120) days after May 7, 1969, that provides that coverage of a dependent child of an employee or other member of the covered group shall terminate upon attainment of the limiting age for dependent children specified in the policy, shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child while the child is and continues to be both:

          (A)  Incapable of self-sustaining employment by reason of mental retardation or physical handicap; and

          (B)  Chiefly dependent upon the employee or member for support and maintenance, provided proof of the incapacity and dependency is furnished to the insurer by the employee or member within thirty-one (31) 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.

     (3)  Any group hospital or medical expense insurance policy or contract that is issued to replace an existing group policy or contract shall continue the coverage for those handicapped dependents covered under the prior group insurance policy or contract, regardless of age, in the manner specified in subdivisions (a)(1) and (2). The handicapped dependents covered under the prior plan on the date of discontinuance who would be eligible for coverage in accordance with the succeeding carrier's plan of benefits, except for the fact that they have attained the limiting age, shall be covered under the succeeding carrier's plan on its effective date so long as they are handicapped and dependent under the definitions in subdivisions (b)(1) and (2).

(c)  (1)   Notwithstanding any other law to the contrary, no insurer, or employer or other entity that administers health, medical, or surgical insurance or that has an insurance company administering its health services program, and no individual, blanket or group policy of insurance issued pursuant to this title, that is entered into, amended, delivered, issued for delivery, or renewed by agreement or otherwise, on or after March 17, 1982, shall deny, for the reason that the insured or the covered dependent incurred no expense, charge, or obligation, a claim for expenses incurred in connection with the patient's hospitalization for hospital, medical or surgical services rendered by a non-governmental, charitable research hospital that bills all patients for services rendered but does not enforce by judicial proceedings payment from an individual patient in the absence of insurance coverage.

     (2)  No expense incurred, individual or group hospital, medical or surgical policy issued, delivered, amended or renewed on or after March 17, 1982, or employer or other entity that administers health, medical, or surgical insurance or that has an insurance company administering its health services program, shall except, limit, or reduce benefits or otherwise fail to pay for services rendered by a non-governmental charitable research hospital because it bills patients for services rendered, but does not enforce by judicial proceedings collection from individual patients in the absence of insurance coverage.

(d)  (1)  All policies or contracts as described in subdivisions (a)(1) and (2), and all ERISA group health plans and health maintenance organizations, are prohibited from denying coverage to a child because the child was born out of wedlock, was not claimed as a dependent on the parent's income tax return, or does not reside with the parent or in the service area of the entity providing health insurance or coverage.

     (2)  Should health insurance or coverage be ordered by a court of law or administrative order and the parent so ordered is eligible for coverage, the insurer, the employer or the ERISA group health plan administrator, nonprofit hospital and medical service plan or health maintenance organization of the parent so ordered must permit enrollment of the child who is otherwise eligible, without regard to any enrollment season restriction. The entity providing health insurance or coverage must accept the applications for coverage of the child made by either the child's other parent or the state agency administering Title XIX of the Social Security Act, compiled in 42 U.S.C. § 1396 et seq. or the Title IV-D child support enforcement program, compiled in 42 U.S.C. §§ 661-669.

     (3)  No entity providing health care benefits may disenroll or eliminate coverage under subdivision (d)(2) without satisfactory written evidence that the court or administrative order is no longer in effect or that there is written evidence that the child will be enrolled in comparable health coverage through another insurer that will take effect not later than the effective date of the disenrollment or, in the case of an employer, where the employer has eliminated family health coverage for all of its employees.

     (4)  No entity providing health care benefits may impose different requirements on a state, as assignee of the rights of a covered individual who is enrolled in any insurance program offered in the state, that differ from requirements imposed on agents or assignees of any other covered individual.

     (5)  In cases where the noncustodial parent is providing coverage, all entities providing the coverage must provide information to the custodial parent, or provider, with the custodial parent's approval, that is necessary for the child to obtain benefits, though that coverage must permit the custodial parent or the provider with approval of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent, and must make payment of the claims directly to the custodial parent, the provider, the state agency administering Title XIX or IV-D of the Social Security Act or any contractor who has contracted with the state to provide medicaid services.

     (6)  The commissioner is authorized to adopt rules and standards establishing reasonable procedures for use by group health plans to determine whether a child is covered under a qualified medical support order.

(e)  All policies and contracts as described in subdivision (a)(2), all ERISA group health plans and health maintenance organizations must provide the same coverage to adopted children under eighteen (18) years of age as of the date of placement for adoption or adoption as for natural children effective upon placement of the children, regardless of whether the adoption has become final. No preexisting conditions of an adopted child may be used to deny coverage if the adoption or placement for adoption occurs while the parent is eligible for coverage.

History: [Acts 1969, ch. 230, § 1; T.C.A., § 56-1160; Acts 1982, ch. 596, § 1; 1985, ch. 206, § 1; 1986, ch. 773, § 1; 1992, ch. 984, § 1; T.C.A., § 56-7-1005; Acts 1994, ch. 881, § 1.]