17:48E-32. Continuation of coverage for totally disabled
A group contract or individual group certificate delivered or issued for delivery in this State which covers employees or members and their dependents for health services on an expense incurred or service basis, other than for specific diseases or for accidental injuries only, shall provide that employees or members, whose coverage under the group contract or individual group certificate would otherwise terminate because of termination of employment or membership due to total disability of the employee or member, shall be entitled to continue their health services coverage under that group contract or individual group certificate for themselves and their eligible dependents, subject to all of the group contract’s or individual group certificate’s terms and conditions applicable to that coverage and subject to the following conditions:
a. Continuation shall only be available to any employee or member who has been continuously covered under the group contract or individual group certificate during the entire three month period ending with the termination.
b. Continuation shall be available for any person who is covered by or eligible for Medicare, subject to any nonduplication of benefits provisions of the group contract or individual group certificate.
C. In addition to hospital, medical-surgical, or major medical benefits, continuation shall include any other health care expense benefits, including dental, vision care, or prescription drug benefits, available through the insured group.
d. An employee or member electing continuation shall pay to the group contract holder or his employer, on a monthly basis in advance, the amount of contribution required by the contract holder or employer, but not more than the group rate for the coverage being continued under the group contract or individual group certificate on the due date of each payment. The employee’s or member’s written election for continuation, together with the first contribution required to establish contributions on a monthly basis in advance, shall be given to the contract holder or employer within 31 days of the date the employee’s or member’s coverage would otherwise terminate.
e. Continuation of coverage under the group contract or individual group certificate for any person shall terminate at the first to occur of the following:
(1) Failure of the former employee or member to make timely payment of a required contribution. Termination shall occur at the end of the period for which contributions were made.
(2) The date the employee again becomes employed and eligible for benefits under another group plan providing health care expense benefits, or in the case of a qualified eligible dependent, the date the dependent becomes employed and eligible for those benefitS.
(3) The date on which the group contract or individual group certificate is terminated or, in the case of any employee, the date his employer terminates participation under the group contract or individual group certificate; except that: (a) The employee or member shall have the right to become covered under any new group contract or individual group certificate contracted for by the employer, for the balance of the period that he would have remained covered under the prior group certificate in accordance with this act had a termination of a group not occurred;
(b) The minimum level of benefits to be provided by the other group contract or individual group certificate shall be the applicable level of benefits of the prior group contract or individual group certificate reduced by any benefits payable under that prior group contract or individual group certificate; and
(c) The prior group contract or individual group certificate shall continue to provide benefits to the extent of its accrued liability and extension of benefits, but only when replacement occurred.
f. A notification of the continuation privilege shall be included in any individual group certificate or employee booklet.
g. For the purposes of this section, “total disability of an employee or member” exists only while the employee or member (1) is not engaged in and (2) is completely unable, due to sickness or injury or both, to engage in any and every gainful occupation for which the person is reasonably fitted by education, training or experience.
L. 1985, C. 236, S.32, eff. July 15, 1985.
Original Text maintained by the State of New Jersey:
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