.03 Summary Form.

A. An insurer which provides benefits for inpatient hospitalization or outpatient surgical care on an expense-incurred basis shall provide claimants annually a consolidated summary explanation regarding benefits claimed for those services during each calendar year.

B. The summary shall identify the provider by name and shall state the:

(1) Date of the service;

(2) Amount claimed;

(3) Amount which was paid or is payable by the insurer on claims processed during the year; and

(4) Balance to be paid by the covered individual, if the balance is determinable from the claim forms submitted.

C. The summary referred to in §B of this regulation shall be provided by insurers to claimants between January 1 and February 15 for claims made during the preceding calendar year.

D. At the insurer's option, the summary may include information pertaining to benefits other than those specified in §A of this regulation.