§ 4320. Limitations on administrative services and stop-loss coverage.
No insurer, subsidiary of an insurer, or controlled person of a holding
company system may act as an administrator or claims paying agent, as
opposed to an insurer, on behalf of a group which denies or limits
benefits for a specific disease or condition or for a procedure or
treatment unique to a specific disease or condition in a manner which
would be inconsistent with this chapter or regulations promulgated by
the superintendent had the group purchased insurance. No insurer,
subsidiary of an insurer, or controlled person of a holding company may
provide stop loss, catastrophic or reinsurance coverage to groups which
deny or limit benefits for a specific disease or condition or for a
procedure or treatment unique to a specific disease or condition in a
manner which would be inconsistent with this chapter or regulations
promulgated by the superintendent had the group purchased insurance. A
limit, maximum, or other mechanism that controls total coverage without
regard to a specific disease or condition shall not be deemed one that
denies or limits benefits for a specific disease or condition, or for a
procedure or treatment unique to a specific disease or condition.
Nothing herein shall be construed to mandate the inclusion of specified
benefits in an employer group plan, if such plan is not subject to the
provisions of this chapter.