31.12.04.09

.09 Contract Forms.

A. The dental plan organization:

(1) Shall provide a written dental benefit contract to each group contract holder;

(2) Shall provide a written evidence of coverage to each individual covered under a group dental benefit contract;

(3) Shall provide a written dental benefit contract to each individual who applies for individual dental coverage;

(4) Shall execute a written provider contract with each of the dental plan organization's plan dentists;

(5) May not deliver or issue for delivery in this State any of the following forms unless the form has been filed with and approved by the Insurance Commissioner:

(a) Dental benefit contract,

(b) Evidence of coverage,

(c) Provider contract,

(d) Application form, and

(e) Riders or endorsement forms.

B. The Commissioner shall disapprove any form filed, or withdraw any previous approval, if the form:

(1) Contains or incorporates by reference, when the incorporation is otherwise permissible, any inconsistent, ambiguous, or misleading clauses, or exceptions and conditions which deceptively affect the risk purported to be assumed in the general coverage of the contract;

(2) Has any title, heading, or other indication of its provisions which is likely to mislead the contract holder or individual;

(3) Contains an inequitable provision or a provision without substantial benefit to the contract holder;

(4) Is printed or otherwise reproduced in a manner as to render any provision of the form substantially illegible;

(5) Includes benefit provisions which are unreasonable in relation to the premium or subscription fee charged; or

(6) Is a provider contract which does not provide for the rendering of covered services in a reasonable manner.