§ 2232.34. Insurance with Other Insurers.

OPTIONAL UNIFORM PROVISIONS

Form A.

Reduced Hospital Benefits in Case of Coverage Under the California Unemployment Insurance Code. The hospital benefits otherwise payable to insured employees hereunder shall be reduced by the amounts of additional benefits during hospital confinement to which such employees shall become entitled pursuant to the California Unemployment Insurance Code or any voluntary plan approved thereunder which is specifically identified in this policy or in the application therefor or in a rider attached to this policy specifically referring to this provision, as such plan is constituted on the effective date of this policy or such rider, as the case may be.

Instructions for Use of Form A

1. The insurer may use this provision only in a policy providing hospital benefits.

2. In lieu of incorporating this uniform provision in the policy, the insurer may, at its option, incorporate the substance or effect thereof, or a provision more favorable to insured employees, in the statement of hospital benefits of the policy by way of an affirmative statement of the benefits applicable to those employees who are also entitled to additional benefits during hospital confinement under the California Unemployment Insurance Code or an existing voluntary plan proved pursuant thereto, or applicable to a period of time for which such additional benefits are payable, or to both. Such affirmative statement of benefits may specifically eliminate or reduce hospital benefits because, or by the amount of the benefits on account of hospitalization to which the employee is entitled as state plan benefits under the California Unemployment Insurance Code to make such equitable adjustment of premium and premium rate for the policy as will after giving effect to the changes in the benefits of the policy resulting from the amendments of the California Unemployment Insurance Code, make such premium and premium rate thereafter commensurate with the premium and premium rate for the benefits theretofore provided by the policy.

Form B. Insurance With Other Insurers, Expense Incurred Basis.

If there be other valid coverage, not with this insurer, on any individual with respect to whom coverage is provided by this policy, providing benefits for the same loss on a provision of service basis or an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of the loss, then the only liability under an expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total like amount under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of each portion of the premium paid as shall exceed the prorated portion of the amount of benefits so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the “like amount” of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.

Instructions for Use of Form B

(1) The insurer may include Form B in any policy providing benefits upon an expense incurred basis. The insurer may, at its option, include in this provision a definition of “other valid coverage” approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, or by hospital or medical service organizations, and to any other coverage, the inclusion of which may be approved by the commissioner. In the absence of such definition, such term shall not include individual insurance, automobile medical payment insurance or coverage provided by hospital or medical service organizations, or by union welfare plans or employer or employee benefit organizations. For the purpose of applying this provision with respect to any person with respect to whom insurance coverage is provided, any amount of benefit provided for such person pursuant to any compulsory benefit statute (including any workmen's compensation, or employers' liability statute) whether provided by a government agency or otherwise shall in all cases be deemed to be “other valid coverage” of which the insurer has had notice. In applying this provision no third party liability coverage shall be included as “other valid coverage.” The insurer may restrict the applicability of this provision by the definition of “other valid coverage” to other group insurance benefits.

Instructions Applicable to Form A and Form B

Except as may be herein otherwise provided, the proration of benefits of a group disability policy because of other insurance covering the same loss is not appropriate to or applicable for use in group disability policies providing benefits other than benefits upon an expense incurred basis, except to the extent that Form A above is used in accordance with the instructions for its use, and no other such provision may be used. (Ins. C. 10369.5 and 10369.6.)