Section 2232.55 - Definitions(a) "Plan" means any plan providing benefits or services for or by reason of medical or dental care or treatment, which benefits or services are provided by: (1) group, blanket or franchise insurance coverage,(2) service plan contracts, group practice, individual practice and other prepayment coverage,(3) any coverage under labor-management trusteed plans, union welfare plans, employer organization plans, or employee benefit organization plans, and(4) any coverage under governmental programs, and any coverage required or provided by any statute. The term "Plan" shall be construed separately with respect to each policy, contract, or other arrangement for benefits or services and separately with respect to that portion of any such policy, contract, or other arrangement which reserves the right to take the benefits or services of other Plans into consideration in determining its benefits and that portion which does not.
(b) "This Plan" means that portion of this policy which provides the benefits that are subject to this provision.(c) "Allowable Expense" means any necessary, reasonable, and customary item of expense at least a portion of which is covered under at least one of the Plans covering the person for whom claim is made. When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered shall be deemed to be both an Allowable Expense and a benefit paid.
(d) "Claim Determination Period" means a calendar year.Instructions
The definition of a "Plan" within the COB provision of group contracts enumerates the types of coverage which the insurer may consider in determining whether overinsurance exists with respect to a specific claim. Such definition:
(a) May not include individual or family policies or individual or family subscriber contracts, except as otherwise provided in this special instruction.(b) May include all group policies, group subscriber contracts, selected group disability insurance contracts issued pursuant to Section 10270.97 of the Insurance Code and blanket insurance contracts, except blanket insurance contracts issued pursuant to Section 10270.2(b) or (e) which contain nonduplication of benefits or excess policy provisions.(c) May not include to any extent whatever any entitlements to Medi-Cal benefits under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14500) or Part 3 of Division 9 of the Welfare and Institutions Code, or benefits under the California Crippled Children Services program under Section 10020 of the Welfare and Institutions Code or any other coverage provided for or required by law when, by law, its benefits are excess to any private insurance or other non-governmental program.(d) May not include the medical payment benefits customarily included in the traditional automobile contracts.(e) May include "Medicare" or any other similar governmental benefits so long as it does not expand the definition of "Allowable Expenses" beyond the hospital, medical and surgical benefits as may be provided by the government program and so long as such benefits are not by law excess to this Plan.Cal. Code Regs. Tit. 10, § 2232.55
1. Amendment filed 1-8-86; effective thirtieth day thereafter (Register 86, No. 2). Note: Authority cited: Sections 10270.94, 10270.98, 11515 and 11515.5, Insurance Code. Reference: Sections 10270.98 and 11515.5, Insurance Code.
1. Amendment filed 1-8-86; effective thirtieth day thereafter (Register 86, No. 2).