Maine Revised Statutes Title 24-A Sec. 4212 – Prohibited practices
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1. No health maintenance organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this chapter:
A. A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a health maintenance organization; [PL 1975, c. 503 (NEW).]
B. A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which such statement is made or such item of information is communicated, such statement or item of information may be reasonably understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health maintenance organization, if such benefit or advantage or absence of limitation, exclusion or disadvantage does not in fact exist; [PL 1975, c. 503 (NEW).]
C. An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person, not possessing special knowledge regarding health maintenance organizations and evidences of coverage therefor, to expect benefits, services, charges or other advantages which the evidence of coverage does not provide or which the health maintenance organization issuing such evidence of coverage does not regularly make available for enrollees covered under such evidence of coverage. [PL 1975, c. 503 (NEW).]
[PL 1975, c. 503 (NEW).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 4212
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Enrollee: means an individual who is enrolled in a health maintenance organization. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Evidence of coverage: means any certificate, agreement or contract issued to a group contract holder or an enrollee setting out the coverage to which an enrollee is entitled. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Health maintenance organization: means a public or private organization that is organized under the laws of the Federal Government, this State, another state or the District of Columbia or a component of such an organization, and that:
A. See Maine Revised Statutes Title 24-A Sec. 4202-APerson: means an individual, firm, partnership, corporation, association, syndicate, organization, society, business trust, attorney-in-fact or any legal entity. See Maine Revised Statutes Title 24-A Sec. 4202-A Superintendent: means the Superintendent of Insurance. See Maine Revised Statutes Title 24-A Sec. 4202-A
2. An enrollee may not be cancelled nor denied renewal except for the following:
A. Fraud or material misrepresentation; [PL 1995, c. 332, Pt. O, §6 (NEW).]
B. Failure to pay the charge for coverage; [PL 1995, c. 332, Pt. O, §6 (NEW).]
C. When the provisions of the State’s community rating law are applicable, as provided by section 2736?C, subsection 3, paragraph B and section 2808?B, subsection 4, paragraph B; or [PL 1995, c. 332, Pt. O, §6 (NEW).]
D. Other reasons promulgated by the superintendent. [PL 1995, c. 332, Pt. O, §6 (NEW).]
[PL 1995, c. 332, Pt. O, §6 (RPR).]
3. No health maintenance organization, unless licensed as an insurer, may use in its name, contracts or literature any of the words “insurance”, “casualty”, “surety”, “mutual” or any other words descriptive of the insurance, casualty or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in this State.
[PL 1975, c. 503 (NEW).]
SECTION HISTORY
PL 1975, c. 503 (NEW). PL 1995, c. 332, §O6 (AMD).