New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT
25 BEAVER STREET
NEW YORK, NEW YORK 10004

George E. Pataki
Governor

Gregory V. Serio
Superintendent

The Office of General Counsel issued the following informal opinion on December 6, 2002, representing the position of the New York State Insurance Department.

Explanation of Benefits Form

Question Presented:

At the request of an insured or a subscriber, may an insurer provide the insured or subscriber with an explanation of benefits form, other than by mailing it to the insured or subscriber’s home address?

Conclusion:

Yes. N.Y. Ins. Law §§ 3234, 3235 (McKinney 2000) do not require that the insurer mail the explanation of benefits form to the insured or subscriber’s home address.

Facts:

No facts were provided. The inquiry was general in nature.

Analysis:

N.Y. Ins. Law § 3234 (McKinney 2000) provides in pertinent part:

(a) Every insurer, including health maintenance organizations operating under article forty-four of the public health law or article forty-three of this chapter and any other corporation operating under article forty-three of this chapter, is required to provide the insured or subscriber with an explanation of benefits form in response to the filing of any claim under a policy or certificate providing coverage for hospital or medical expenses, including policies and certificates providing nursing home expense or home care expense benefits.

(b) The explanation of benefits form must include at least the following: (1) the name of the provider of service the admission or financial control number, if applicable; (2) the date of service; (3) an identification of the service for which the claim is made; (4) the provider`s charge or rate; (5) the amount or percentage payable under the policy or certificate after deductibles, co-payments, and any other reduction of the amount claimed; (6) a specific explanation of any denial, reduction, or other reason, including any other third-party payor coverage, for not providing full reimbursement for the amount claimed; and (7) a telephone number or address where an insured or subscriber may obtain clarification of the explanation of benefits, as well as a description of the time limit, place and manner in which an appeal of a denial of benefits must be brought under the policy or certificate and a notification that failure to comply with such requirements may lead to forfeiture of a consumer`s right to challenge a denial or rejection, even when a request for clarification has been made.

There is a similar provision relating to claims under medicare supplemental insurance policies and limited benefits health insurance policies or certificates designed primarily to supplement medicare benefits. N.Y. Ins. Law § 3235 (McKinney 2000).

Both these sections require that the insurer provide the insured or subscriber with an explanation of benefits form. There is no requirement that it be sent to the insured or subscriber’s home address. Accordingly, the insurer would be in compliance with the statute if, upon the insured or subscriber’s request, it made alternate arrangements to provide the insured or subscriber with the explanation of benefits form.

For further information you may contact Supervising Attorney Joan Siegel at the New York City Office.