31.11.01.04

.04 Conversion Privilege.

A. All group policies, as defined in this chapter, shall contain a provision stating that an insured person who has been continuously covered under the group policy and under any group policy providing similar benefits which it replaces for at least 3 months and whose coverage is terminated for any reason other than the reasons described in §D of this regulation, shall have issued to him without evidence of insurability a converted policy providing benefits not less than the minimum benefits required by this chapter.

B. A carrier shall include a notice of the right of conversion in each certificate of coverage provided to individuals covered under group policies.

C. Termination.

(1) Termination of coverage shall include, but not be limited to, termination by reason of discontinuance of the group policy in its entirety or with respect to an insured class, or termination by reason of the individual's no longer meeting the definition of a dependent contained in the group policy, or by reason of no longer meeting the definition in the policy of an employee or member, or by reason of the individual's retirement.

(2) The following are intended as illustrations of terminations by reason of no longer meeting the definition of dependent:

(a) A surviving spouse, whose coverage under the group policy terminates at the death of the employee or member;

(b) A spouse whose coverage under the group policy terminates by reason of divorce or legal separation;

(c) A child whose coverage under the group policy terminates at the death of an employee or member;

(d) A child whose coverage under the group policy terminates by reason of his reaching a limiting age specified in the group policy.

(3) If a group policy provides that a retired employee may continue to be covered under the group policy, the employee shall be given the option of electing the same conversion rights that would apply if the employee's insurance under the group policy had terminated at retirement.

D. Exceptions.

(1) The carrier is not required to issue a converted policy if the insured person is enrolled in a health maintenance organization, or is covered or eligible for coverage under another group policy which provides benefits substantially equal to the minimum benefits required by these regulations, or if the provisions of Regulation .06H(1) of this chapter would be applicable.

(2) The carrier is not required to issue a converted policy to a person eligible for Medicare.

(3) The carrier is not required to issue a converted policy if termination under the group policy occurred because:

(a) The employee, member, or dependent performed an act or practice that constitutes fraud in connection with the coverage;

(b) The employee, member, or dependent made an intentional misrepresentation of a material fact under the terms of coverage; or

(c) The terminated coverage under the group policy was replaced by similar coverage within 31 days after the date of termination of the group policy.

(4) The carrier is not required to issue a converted policy if the individual's coverage under the group policy terminated due to the insured person's failure to pay a required premium.