District Of Columbia § 31-3407 - Requirements for group contract, individual contract, and evidence of coverage.
Full text of District Of Columbia D.C. Code § 31-3407 — Requirements for group contract, individual contract, and evidence of coverage., with citation guidance and answers to common questions.
§ 31-3407. Requirements for group contract, individual contract, and evidence of coverage.
31-3407Every group and individual contract holder is entitled to a group or individual contract.
The contract shall not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation.
The contract shall contain a clear statement of the following:
Name and address of the health maintenance organization;
Eligibility requirements;
Covered services within the service area;
Covered emergency care benefits and services;
Out of area covered benefits and services, if any;
Copayments, deductibles, or other out-of-pocket expenses;
Limitations and exclusions;
Enrollee termination;
Enrollee reinstatement, if any;
Claims procedures;
Repealed.
Continuation of coverage, if any;
Conversion;
Extension of benefits if any;
Coordination of benefits, if applicable;
Subrogation, if any;
Description of the service area;
Entire contract provision;
Term of coverage;
Cancellation of group or individual contract holder;
Renewal;
Reinstatement of group or individual contract holder, if any;
Grace period;
Conformity with District of Columbia law; and
Payment provisions.
An evidence of coverage may be filed as part of the group contract to describe the provisions required in paragraph (2)(A) through (Q) of this subsection.
In addition to the requirements of subsection (a)(2)(A) through (Y) of this section, an individual contract shall provide for a 10-day period to examine and return the contract and have the dues refunded. If services were received during the 10-day period and the person returns the contract to receive a refund of the dues paid, the person must pay for such services.
Every enrollee shall receive an evidence of coverage from the group contract holder or the health maintenance organization.
The evidence of coverage shall not contain provisions or statements which are unfair, unjust, inequitable, misleading, or deceptive.
The evidence of coverage shall contain a clear statement of the requirements in subsection (a)(2)(A) through (Q) of this section.
The Commissioner may adopt regulations establishing readability standards for individual contract, group contract, and evidence of coverage forms.
No group or individual contract, evidence of coverage, or amendment thereto shall be delivered or issued for delivery in the District unless its form has been filed with and approved by the Commissioner pursuant to subsections (f) and (g) of this section.
If an evidence of coverage issued pursuant to a contract issued in the District is intended for delivery in the District, the evidence of coverage must be submitted to and approved by the Commissioner in accordance with subsection (g) of this section.
If an evidence of coverage issued pursuant to a contract issued in Virginia or Maryland is intended for delivery in the District, the evidence of coverage shall be deemed approved if it has been filed and approved by the appropriate regulatory authority of Virginia or Maryland, as applicable.
If an evidence of coverage issued pursuant to a contract issued in another state, excepting Virginia and Maryland as described in paragraph (1) of this subsection, is intended for delivery in the District, the evidence of coverage must be submitted to and approved by the Commissioner in accordance with subsection (g) of this section.
Every form required by this section shall be filed with the Commissioner not less than 30 days prior to delivery or issue for delivery in the District. At any time during the initial 30-day period, the Commissioner may extend the period for review for an additional 30 days. Notice of an extension shall be in writing. At the end of the review period, the form is deemed approved if the Commissioner has taken no action. The filer shall notify the Commissioner in writing prior to using a form that is deemed approved.
At any time, after 30-days notice and for cause shown, the Commissioner may withdraw approval of any form effective at the end of the 30 days if the form would violate a statute or regulation of the District. For group and individual contracts and evidence of coverages which have already been issued and delivered, the effective date shall not occur until the next anniversary date of the group or individual contract unless the Commissioner requires that the effective date shall be earlier. In such case, the health maintenance organization may revise its dues and other terms contained in the contract or evidence of coverage to reflect any changes required as a result of the Commissioner’s withdrawal of approval.
When a filing is disapproved or approval of a form is withdrawn, the Commissioner shall give the health maintenance organization written notice of the reasons for disapproval and in the notice shall inform the health maintenance organization that within 30 days of receipt of the notice the health maintenance organization may request a hearing. A hearing will be conducted within 30 days after the Commissioner has received the request for a hearing.
The Commissioner may require the submission of any relevant information the Commissioner deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.
Annotations
Source: official District Of Columbia text · Last verified 2026-08-27
Frequently Asked Questions About District Of Columbia § 31-3407
What does D.C. Code § 31-3407 cover?
Section 31-3407 ("Requirements for group contract, individual contract, and evidence of coverage.") is part of the D.C. Code, the codified statutory law of District Of Columbia. It sets out the legal rule or procedure described in the text above. Statutes are amended regularly, so always verify against the official source.
How do I cite District Of Columbia § 31-3407?
A common citation format is "D.C. Code § 31-3407" (District Of Columbia). Legal writing may require the code abbreviation, section number, and year or edition. Match the style required by your court, professor, or publisher.
Is this the official text of District Of Columbia law?
No. This page is for research and education and may not include the most recent amendments. For official current law, check the District Of Columbia official source linked on this page or consult a licensed District Of Columbia attorney.
How does District Of Columbia § 31-3407 apply to my situation?
Statutes are interpreted in context, and application depends on your specific facts. Only a licensed attorney in District Of Columbia can advise on how this section applies to you. Contact your state or local bar association for a referral.
Sources & Verification
Not legal advice. Verify against the official source and consult a licensed attorney in District Of Columbia.