A converted policy may provide that an insurer may at any time request information of an insured policyholder with respect to any person covered thereunder as to whether he is covered for the similar benefits described in N.C. Gen. Stat. § 58-53-70(1)a or is or could be covered for the similar benefits described in N.C. Gen. Stat. § 58-53-70(1)b and 58-53-70(1)c. The converted policy may provide that as of any premium due date an insurer may refuse to renew the policy or the coverage of any insured person for the following reasons only:

(1)        Either those similar benefits for which such person is or could be covered, together with the converted policy’s benefits, would result in overinsurance according to the insurer’s standards for overinsurance, or the policyholder of the converted policy fails to provide the requested information;

(2)        Fraud or material misrepresentation in applying for any benefits under the converted policy;

(3)        Eligibility of any insured person for coverage under Medicare, or under any other State or federal law providing benefits substantially similar to those provided by the converted policy; or

(4)        Termination of an enrollee’s enrollment in a health maintenance organization for cause in accord with the terms of the enrollee’s evidence of coverage or the health maintenance organization’s contract with the group. (1981, c. 706, s. 1; 1991, c. 195, s. 3.)

Terms Used In North Carolina General Statutes 58-53-75

  • Contract: A legal written agreement that becomes binding when signed.
  • converted policy: means an individual health insurance policy issued by an insurance company or an individual contract issued by a service corporation or health maintenance organization or similar corporation or organization. See North Carolina General Statutes 58-53-1
  • 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.
  • following: when used by way of reference to any section of a statute, shall be construed to mean the section next preceding or next following that in which such reference is made; unless when some other section is expressly designated in such reference. See North Carolina General Statutes 12-3
  • Fraud: Intentional deception resulting in injury to another.
  • insured: refer to coverage under a group policy, individual policy or converted policy on a premium-paying basis, and do not include coverage provided by reason of a disability extension. See North Carolina General Statutes 58-53-1
  • Insurer: means the entity issuing a group policy or an individual or converted policy. See North Carolina General Statutes 58-53-1
  • Medicare: means Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded. See North Carolina General Statutes 58-53-1
  • Premium: includes any premium or other consideration payable for coverage under a group or individual policy. See North Carolina General Statutes 58-53-1
  • state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories, so called; and the words "United States" shall be construed to include the said district and territories and all dependencies. See North Carolina General Statutes 12-3