806 KAR 17:030. Surgical schedule.

 

      RELATES TO: KRS 304.17-030

      STATUTORY AUTHORITY: KRS 304.2-110

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110 provides that the Executive Director of Insurance may make reasonable rules and administrative regulations necessary for or as an aid to the effectuation of any provision of the Kentucky Insurance Code. This administrative regulation provides certain inclusions in health insurance contracts where surgical care and indemnification is provided.

 

      Section 1. A health policy, or rider attached, or to be attached thereto, providing identification for surgical care through the means of an operation or surgical schedule will not be approved for use in Kentucky unless it complies with the following:

      (1) Where the indemnity is limited to the listed operation(s), the policy or rider shall indicate in unequivocal language that indemnity will be paid only for listed operations; and

      (2) If the company is to determine the amount to be paid for any unlisted operation, the policy must provide that the amount will be determined:

      (a) On a basis of comparative severity or original difficulty with operations listed in the schedule of operations;

      (b) On the basis of usual and customary charges in the community by accredited physicians for comparable services; or

      (c) On some other basis as may be approved by the executive director. (I-17.02; 1 Ky.R. 1083; eff. 7-2-75; TAm eff. 8-9-2007.)