38.2-3407.11:3 - Breast cancer underwriting and preexisting condition restrictions
§ 38.2-3407.11:3. Breast cancer underwriting and preexisting conditionrestrictions.
A. No (i) insurer proposing to issue group accident and sickness insurancepolicies or individual health insurance coverage providing hospital, medicaland surgical, major medical or cancer-only coverage on an expense-incurredbasis, and policies or contracts designed for issuance to persons eligiblefor coverage under Title XVIII of the Social Security Act, known as Medicare,or any other similar coverage under state or federal governmental plans; (ii)corporation providing individual or group accident and sickness subscriptioncontracts; or (iii) health maintenance organization providing a health careplan for health care services shall deny the issuance or renewal of, orcancel, a policy, subscription contract or plan or include any exception orexclusion of benefits in such policy, subscription contract or plan for thefollowing:
1. Solely because the insured has been diagnosed as having a fibrocysticcondition or a nonmalignant lesion, or solely due to the family history ofthe insured related to breast cancer, or solely due to any combination ofthese factors; or
2. Solely due to breast cancer, if the insured has been free from breastcancer for a period of five years or more prior to the date of applicationfor coverage. In the case of coverage subject to §§ 38.2-3432.3, 38.2-3514.1or § 38.2-3605, the provisions of those sections shall be controlling as tothe extent of any preexisting conditions period under such coverage.
Benefits provided under a policy, subscription contract or plan for suchinsureds shall be provided with durational limits, deductibles, coinsurancefactors, and copayments that are no less favorable than for physical illnessgenerally.
B. No (i) insurer proposing to issue group accident and sickness insurancepolicies or individual health insurance coverage providing hospital, medicaland surgical or major medical coverage on an expense-incurred basis, andpolicies or contracts designed for issuance to persons eligible for coverageunder Title XVIII of the Social Security Act, known as Medicare, or any othersimilar coverage under state or federal governmental plans; (ii) corporationproviding individual or group accident and sickness subscription contracts;or (iii) health maintenance organization providing a health care plan forhealth care services shall consider routine follow-up care, used to determinewhether a breast cancer has recurred in a person who has been previouslydetermined to be free of breast cancer as evidenced by negative follow-upcare for a period of at least five years following completion of local andadjuvant therapies, to constitute medical advice, diagnosis, care ortreatment for purposes of determining a preexisting condition unless evidenceof breast cancer is found during, or as a result of, the follow-up care.
C. The requirements of this section shall apply to all insurance policies,contracts and plans delivered, issued for delivery, reissued, renewed orextended or at any time when any term of any such policy, contract or plan ischanged or any premium adjustment is made. The provisions of this sectionshall not apply to short-term travel, accident-only, limited or specifieddisease policies except those providing coverage for cancer on anexpense-incurred basis, nor to short-term nonrenewable policies of not morethan six months' duration.
(2001, c. 242.)