CHAPTER 369
H.P. 1036 - L.D. 1453
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24 MRSA �2316, as amended by PL 1981, c. 205, �1, is further amended to read:
�2316. Certificates or contracts; approval by superintendent
No A nonprofit hospital and medical service organization shall may not issue or deliver in this State any certificate or other evidence of any contract unless and until the form thereof used, together with the form of application and all riders or endorsements for use in connection therewith, shall with the certificate or other evidence of a contract, have been filed with and approved by the superintendent and approved by him as conforming to reasonable rules and regulations from time to time made by him the superintendent and as not inconsistent consistent with any other provisions of law applicable thereto. The superintendent shall, within a reasonable time after the filing of any such form, notify the organization filing the same form either of his the approval or of his the disapproval of such the form. The superintendent may approve any such form which that in his the superintendent's opinion contains provisions on any one or more of the several requirements made by him which the superintendent that are more favorable to the subscribers than the one or ones so required. The superintendent shall have power, from time to time, is authorized to make, alter and supersede reasonable regulations prescribing the required, optional and prohibited provisions in such any contracts, and such regulations shall must conform, as far as practicable, to Title 24-A, chapters 33 and 35. Where If the superintendent deems determines those chapters to be inapplicable, either in part or in their entirety, the foregoing chapters, he the superintendent may prescribe the portions or summary thereof of the contract to be printed on the certificate issued to the subscriber. No contracts A contract may not be delivered or issued for delivery in this State unless they meet it meets the requirements of Title 24-A, sections 2438 to 2445, section 2729-A and section 2747. Any filing made hereunder shall be in accordance with this section is deemed approved unless disapproved within 60 days from the date of such the filing.
Sec. 2. 24-A MRSA �2910-A is enacted to read:
�2910-A. Subrogation; medical payments coverage
1. Policy requirements. A casualty insurance policy subject to this chapter may not provide for subrogation or priority over the insured of payment for any hospital, nursing, medical or surgical services or of any expenses paid or reimbursed under the medical payments coverage in the policy in the event the insured is entitled to receive payment or reimbursement from any other person as a result of legal action or claim, except as provided in this section.
The coverage may contain a provision that allows the payments if that provision is approved by the superintendent and if that provision required the prior written approval of the insured and provides that the insurer's subrogation right is subject to subtraction to account for the pro rata share of the insured's attorney's fees incurred in obtaining the recovery from another source.
2. Dispute resolution. In the event of a dispute as to the application of any such provision or the amount available for payment to those claiming payment for services or reimbursement, that dispute must be determined, if the action is pending, before the court in which it is pending; or if no action is pending, by filing an action in any court for determination of the dispute.
3. Exception. Nothing in this section prevents an insurer from exercising its subrogation rights directly against any person legally responsible for the insured's injury. In the event that the insurer pursues its subrogation rights directly against such a person, the insurer's subrogation right is not subject to any subtraction to account for attorney's fees and the insurer is entitled to full recovery.
Sec. 3. 24-A MRSA �4243 is enacted to read:
�4243. Limits on priority liens; subrogation
An individual or group contract subject to this chapter may not provide for subrogation or priority over the enrollee of payment for any hospital, nursing, medical or surgical services or of any expenses paid or reimbursed under the coverage, in the event the enrollee is entitled to receive payment or reimbursement from any other person as a result of legal action or claim, except as provided in this section.
The coverage may contain a provision that allows the payments, if that provision is approved by the superintendent and if that provision required the prior written approval of the insured and allows such payments only on a just and equitable basis and not on the basis of a priority lien. A "just and equitable basis" means that any factors that diminish the potential value of the enrollee's claim may likewise reduce the share in the claim for those claiming payment for services or reimbursement. Such factors include, but are not limited to:
1. Legal defenses. Questions of liability and comparative negligence or other legal defenses;
2. Exigencies of trial. Exigencies of trial that reduce a settlement or award in order to resolve the claim; and
3. Limits of coverage. Limits on the amount of applicable insurance coverage that reduce the claim to an amount recoverable by the insured.
In the event of a dispute as to the application of any such provision or the amount available for payment to those claiming payment for services or reimbursement, that dispute must be determined, if the action is pending, before the court in which it is pending; or if no action is pending, by filing an action in any court for determination of the dispute.
Effective September 19, 1997, unless otherwise indicated.
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