Introduction to EOC Evidence of Coverage

So many questions are answered right in the Full Policy the evidence of coverage – EOC, in

• PLAIN English, as mandated by law.
• Along with your duty to read the policy!

Sure beats reading the law and then trying to see for sure if the law applies to you.   When you have your actual EOC, a couple of  easy ways to find stuff in the policy is the bookmarks, table of contents and the search feature.

The Evidence of Coverage (EOC) is a document that describes in detail the health care benefits covered by the health plan. It provides documentation of what that plan covers and how it works, including how much you pay. The EOC can also refer to a certificate or contract provided to a health plan member that contains information about coverage and other rights.  ^{National Disability Rights} *

Here’s where to find your  EOC Evidence of Coverage for:

• Individual & Family Plans
  • Sample EOC 2024 Blue Shield PPO
• Employer Group Plans
  • Sample 
• Medi-Cal
  • HMO – Managed Care Providers follow the links to get EOC
• Medicare Advantage Co Ordination Plan –
  • Medicare & Medi-Cal
• Email us if you are in CA and have any questions.

Must #read your policy

A court “must hold the insured bound by clear and conspicuous provisions in the policy even if evidence suggests that the insured did not read or understand them.”

• property casualty 360.com/is-there-a-duty-to-read-insurance-contracts
• IRMI duty to read
• Is there a duty to read?  Hastings College of Law
• Fordham Law Review Duty to read a changing concept 1974
• Kenny & Sams Law Firm 

 (NASE’s prior Carrier, as pointed out by UICI’s to Steve Shorr personally  4/6/2006 letter)  This case shows that one must read the ACTUAL policy and can’t rely on Agent’s statements or brochures.  There are some exceptions…  This doesn’t just apply to NASE, but to ANY Insurance Contract.  See attorney Keler.com for more explanation.

Plain Language – Read Policy THREE times

The

doctrine of privity in contract law

provides that a contract cannot confer rights or impose obligations arising under it on any person or agent except the parties to it.

The premise is that only parties to contracts should be able to sue to enforce their rights or claim damages as such. However, the doctrine has proven problematic due to its implications upon contracts made for the benefit of third parties who are unable to enforce the obligations of the contracting parties. en.wikipedia.org

 In tort law, a duty of care is a legal obligation imposed on an individual requiring that they adhere to a standard of reasonable care while performing any acts that could foreseeably harm others. It is the first element that must be established to proceed with an action in negligence. The plaintiff must be able to show a duty of care imposed by law which the defendant has breached. In turn, breaching a duty may subject an individual to liability in tort. The duty of care may be imposed by operation of law between individuals with no current direct relationship (familial or contractual or otherwise), but eventually become related in some manner, as defined by common law (meaning case law). wikipedia.org/

Elements

Free Look Period #view FULL Policy – E O C (Evidence of Coverage) when you purchase Health Insurance and full return privileges’

California Insurance Code §10276.

Every individual accident and health policy or contract, except single premium nonrenewable policies or contracts, issued for delivery in this state on or after July 1, 1962, by an insurance company, nonprofit hospital service plan or medical service corporation, shall have printed thereon or attached thereto a notice stating that the person to whom the policy or contract is issued shall be permitted to return the policy or contract after its delivery to the purchaser and to have the premium paid refunded if, after examination of the policy or contract, the purchaser is not satisfied with it for any reason.

The period time set forth by the insurer, nonprofit hospital service plan or medical service corporation for return of the policy or contract shall be clearly stated on the notice and such period shall not be less than 10 days nor more than 30 days. The policyholder or purchaser may return the policy or contract to the insurer, plan or corporation at any time during the period specified in the notice. If a policyholder or purchaser pursuant to such notice, returns the policy or contract to the company or association at its home or branch office or to the agent through whom it was purchased, it shall be void from the beginning and the parties shall be in the same position as if no policy or contract had been issued.  ^{California Insurance Code §10276.} 

Check your evidence of coverage for the exact provisions!

Covered CA has a different Opinion.  IMHO they are in violation of law!

See  § 155.430  *   Termination of Exchange  enrollment or coverage  

(b)Termination events –

(1)Enrollee-initiated terminations.

(i) The Exchange must permit an enrollee to terminate his or her coverage or enrollment in a QHP through the Exchange, including as a result of the enrollee obtaining other minimum essential coverage. To the extent the enrollee has the right to terminate the coverage under applicable State laws, including “free look” cancellation laws, the enrollee may do so, in accordance with such laws.