CHAPTER 370

FORMERLY

SENATE SUBSTITUTE NO. 1

FOR

SENATE BILL NO. 194 AS AMENDED BY SENATE AMENDMENT NO. 1

AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO HEALTH INSURANCE CONTRACTS.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE:

Section 1. Amend §3339 of Title 18, Delaware Code, by designating the current Section as Subsection "(a)", and by adding new subsections as follows:

"(b) An insurer that proposes to terminate or not renew a contract with a professional health care Provider shall give a minimum of 60 days' written notice thereof to the Provider prior to the effective date of the termination of the contract. This notice shall include a statement of the Provider's right to request a written explanation and to request an internal administrative review within 20 days. For purposes of this Section, "Provider" shall mean a health care professional licensed pursuant to Title 24 of the Delaware Code.

(c) Upon the request of a Provider who has. received notice pursuant to Subsection (b) hereof, an insurer shall provide written explanation by certified or registered mail of the reasons for the proposed termination or nonrenewal (unless such explanation has already been provided), and an opportunity for an internal administrative review of the decision to terminate. The provider's request for written explanation and administrative review must be made within 20 days' after receipt of the insurer's notice of termination or nonrenewal. The insurer shall provide the written explanation and administrative review not less than 20 days after receipt of the Provider's request for same.

() A Provider who reasonably believes than an insurer's decision to terminate or not renew a contract was solely based on reasons prohibited pursuant to Subsection (a) of this Section. may request that this concern be addressed in the written explanation and administrative review provided by the insurer. Upon request, such a Provider shall submit to the insurer a list of the insurer's enrollees with whom the Provider has communicated and upon whom the Provider relies to support his belief and a statement of the nature of the information provided to each enrollee that is protected by this Section.

(a) If an insurer collects and maintains professional profiling data and the written explanation provided pursuant to Subsection (c) states that the insurer used such data to evaluate the performance or practice of the Provider, this data shall be provided to the Provider and be discussed during the administrative review pursuant to Subsection (c). Data provided by an insurer pursuant to this Section shall be confidential and shall not be disclosed by a Provider or an insurer to third parties without the consent of the other party, except such data may be disclosed to a party's attorney or as otherwise required by law.

(f) This Section shall not apply to a decision by an insurer to terminate or renew a Provider's contract because of breach of contract, loss of professional liability insurance, indictment or arrest or conviction for a felony or crime or moral turpitude, final internal disciplinary action (excluding judicial appeals) by a hospital, licensing board or other governmental agency that impairs the Provider's ability to practice or clinical privileges,

failure to meet the minimum requirements for participation in the insurer's plan, as previously disclosed to the Provider, adjudication of fraud or in cases involving imminent harm to patient care.

(g) Nothing in this Section shall be construed to prohibit an insurer from terminating or not renewing a Provider's contract with or without cause for economic reasons or any other reason not prohibited by Subsection (a), but a written explanation of the reasons for the proposed termination or nonrenewal must be provided pursuant to the provisions of Subsection (c).

() This Section shall not be deemed to create a private cause of action as a result of an insurer's termination or nonrenewal of a provider's contract. This Subsection shall not abrogate any cause of action or remedy to which a provider may have a right pursuant to contract.

(a) Any insurer who violates the provisions of this section may be subject to the administrative orders and penalties imposable for a violation of Chapter 23 of this Title as specified in 18 Del. C. §2308(a)(1) and (a)(2).

(b) Providers, insurers and their respective employees, agents, attorneys and other representatives who have acted in good faith while participating in the written explanation or administrative review provided pursuant to Subsection (c), shall have immunity and shall not be held liable as a result of any such participation in a case alleging slander, libel, defamation or in any other private cause of action. Such persons shall be presumed to have acted in good faith in the absence of evidence of malice or willful misconduct."

Section 2. The provisions of this Act shall also apply to Health Service corporations, and to policies delivered or issued for delivery in this State by Health Service Corporations.

Approved July 7, 1998.