                                 CODE OF VIRGINIA

CLAIMS EXPERIENCE (§ 38.2-3540.1)

A. Each group accident and sickness insurance policy and health care plan shall
contain a provision which provides that the insurer, upon request, shall provide
a policyholder that employed an average of at least 100 individuals who were
insureds, subscribers, or enrollees on business days during the preceding
12-month period with a complete record of the policyholder&#8217;s medical
claims experience or medical costs incurred under the group policy, contract or
plan. This record shall include all claims incurred for the lesser of (i) the
period of time since the policy, contract or plan was issued or issued for
delivery or (ii) the period of time since the policy, contract, or plan was last
renewed, reissued or extended, if already issued. This record shall be made
available promptly to the policyholder upon request made not less than 30 days
prior to the date upon which the premiums or contractual terms of the policy,
contract or plan may be amended. Nothing in this section shall require the
disclosure of personal or privileged information about an individual that is
protected from disclosure under Chapter 6 (&#xA7; 38.2-600 et seq.) of this
title, or under any other applicable federal or state law or regulation. No
policyholder shall be required to pay for information requested pursuant to this
section.

B. A policyholder that employed an average of at least 100 individuals who were
insureds, subscribers or enrollees on business days during the preceding
12-month period shall receive from its insurer, upon request, at the time that
the insurer provides a record of medical claims experience or medical costs
under subsection A of this section (i) a summary of medical claims charges or
medical costs incurred and the amount paid with respect to those claims for the
most recently available 24-month period; (ii) a listing of the number of
insured, subscribers or enrollees for whom combined medical claims payments or
medical costs exceed $100,000 for the most recently available 12-month period,
and for the preceding 12 months if not previously provided, with information as
to whether these enrollees from the most recently available 12-month period
remain enrolled under the policy, and provided that a policyholder and insurer
may agree by contract to provide the listing for amounts less than $100,000; and
(iii) total enrollment in each membership type as of the end of the most
recently available 12-month period. This record shall be made available to the
policyholder within 20 business days upon written request made not less than 45
days prior to the date upon which the premiums or contractual terms of the
policy may be amended. Nothing in this section shall require the disclosure of
personal or privileged information about an individual that is protected from
disclosure under Chapter 6 (&#xA7; 38.2-600 et seq.) of this title, or under any
other applicable federal or state law or regulation. No policyholder shall be
required to pay for information requested pursuant to this section.

C. With respect to group accident and sickness insurance policies, the
requirements of this section shall apply to all policies, contracts, and plans
delivered, issued for delivery, reissued or extended on and after July 1, 2003,
or at any time after the effective date hereof when any term of any such policy,
contract or plan is changed or any premium adjustment is made. With respect to
health care plans, the requirements of this section shall apply to all contracts
delivered, issued for delivery, reissued or extended on and after January 1,
2005, or at any time after the effective date hereof when any term of any such
contract or plan is changed or any premium adjustment is made.

HISTORY: 1992, c. 800; 1999, c. 116; 2003, c. 654; 2004, c. 772.