Untrue or Misleading Statements; Deceptive Evidence of Coverage; Cancellation or Nonrenewal of Enrollees

  1. Law
  2. Georgia Code
  3. Insurance
  4. Health Maintenance Organizations
  5. Untrue or Misleading Statements; Deceptive Evidence of Coverage; Cancellation or Nonrenewal of Enrollees

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  1. No health maintenance organization or representative of a health maintenance organization may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this Code section:
    1. A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a health benefits plan;
    2. A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information may be reasonably understood by a reasonable person not possessing special knowledge regarding health care coverage as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health benefits plan, if the benefit or advantage or absence of limitation, exclusion, or disadvantage does not in fact exist; and
    3. An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person not possessing special knowledge regarding health benefits plans and evidences of coverage for the health benefits plan to expect benefits, services, charges, or other advantages which the evidence of coverage does not provide or which the health benefits plan issuing the evidence of coverage does not regularly make available for enrollees covered under evidence of coverage.
  2. The provisions of Chapter 6 of this title applicable to insurers shall apply to health maintenance organizations in this chapter and, for the purpose of determining whether a violation of Chapter 6 of this title has occurred, an "enrollee" as defined in this chapter shall be deemed to be an insured or a policyholder as used in Chapter 6 of this title, whichever is applicable.
  3. An enrollee may not be canceled or nonrenewed except for the failure to pay the charge for such coverage or for such other reasons as may be promulgated by the Commissioner.

(Code 1933, § 56-3613, enacted by Ga. L. 1979, p. 1148, § 1; Ga. L. 1986, p. 676, § 12.)


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