CurrentNorth Dakota Insurance DepartmentPolicy N/A

Advisory Bulletin Regarding Workmen's Compensation Exclusions in Health Insurance Policies and Contracts

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Directs insurers and hospital and medical service plan corporations in North Dakota to administer workmen's compensation exclusions consistently with Section 65-05-15. Charges attributable to aggravation of a prior injury or disease should not be excluded, while policy terms and lawful defenses remain preserved.

Policy Summary

PayerNorth Dakota Insurance Department

PolicyAdvisory Bulletin Regarding Workmen's Compensation Exclusions in Health Insurance Policies and Contracts

Policy CodePolicy N/A

Change TypeAdministrative guidance

Effective DateApril 3, 1970

Next Review DateN/A

Key ActionAssess whether each claim involves aggravation of a prior injury or disease under Section 65-05-15 before applying a workmen's compensation exclusion.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

§ 65-05-15Governing provision

$10/weekMinimum weekly compensation

Medical careCharges protected from exclusion

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CurrentNorth Dakota Insurance DepartmentPolicy N/A

Advisory Bulletin Regarding Workmen's Compensation Exclusions in Health Insurance Policies and Contracts

Customize your policy alerts

Sign up for all North Dakota Insurance Department policy alerts

Know when North Dakota Insurance Department releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerNorth Dakota Insurance Department

PolicyAdvisory Bulletin Regarding Workmen's Compensation Exclusions in Health Insurance Policies and Contracts

Policy CodePolicy N/A

Change TypeAdministrative guidance

Effective DateApril 3, 1970

Next Review DateN/A

Key ActionAssess whether each claim involves aggravation of a prior injury or disease under Section 65-05-15 before applying a workmen's compensation exclusion.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

§ 65-05-15Governing provision

$10/weekMinimum weekly compensation

Medical careCharges protected from exclusion

Workmen’s Compensation Exclusion Administration

When administering occupational health insurance policies or nonprofit hospital and medical service corporation contracts delivered or issued for delivery in North Dakota, apply the aggravation-of-injury rule under North Dakota Century Code § 65-05-15 before applying a Workmen’s Compensation exclusion.

ALL of the following

The claim is being administered under an insurance policy or nonprofit hospital and medical service corporation contract delivered or issued for delivery in North Dakota that provides occupational coverage.
Claims departments should specifically review the claim for application of the Workmen’s Compensation exclusion and the aggravation-of-injury rule.
The claim involves aggravation of an injury or disease that existed before the compensable injury, within the context of North Dakota Century Code § 65-05-15.
Particular care is required to determine whether the claim involves aggravation of a prior injury or disease.
Apply the statutory apportionment: compensation, medical, hospital, or funeral expenses, or death benefits are allowed by the bureau and paid from the fund only for the portion of the disability, death benefit, or expense arising from aggravation of the prior disease or injury that is reasonably attributable to the compensable injury.
Do not use the Workmen’s Compensation exclusion to exclude the portion of hospital and medical care and treatment charges attributable to the prior injury or disease when § 65-05-15 applies to the aggravation.
The exclusion must not operate to exclude that attributable portion of charges.
Compensation paid on the basis of aggravation must not be less than $10 per week, unless the claimant’s actual wages are less than $10 per week; in that event, actual wages are paid as compensation.
This statutory minimum applies to compensation paid on the basis of aggravation.
The administration of the claim does not extend liability beyond the terms of the applicable policy or contract, constitute a bar or waiver of any lawful defense, or abrogate any provision of the policy or contract.
The Bulletin addresses administration of the Workmen’s Compensation exclusion when § 65-05-15 applies and does not otherwise expand coverage.

Claim Administration Requirements

Documentation Required

Evaluate Aggravation Claims

Before applying a Workmen’s Compensation exclusion, determine whether the claim involves aggravation of a prior injury or disease within the meaning of North Dakota Century Code Section 65-05-15.

Billing Rule

Preserve Attributable Charges

When Section 65-05-15 applies, do not exclude the portion of hospital and medical care and treatment charges reasonably attributable to the aggravation of the prior injury or disease.

Aggravation of Injury or Disease

Aggravation of Injury or Disease Under Section 65-05-15

Statutory provisionSection 65-05-15, “Aggravation of Injury or Disease” under the North Dakota Workmen’s Compensation Act.

When it appliesA pre-existing injury or disease is aggravated by a compensable injury.

Compensation and benefitsCompensation, medical, hospital, funeral expenses, and death benefits are allowed only for the portion reasonably attributable to the compensable aggravation.

Minimum weekly compensationCompensation based on aggravation must be at least $10 per week unless the claimant’s actual wages are less than $10, in which case actual wages are paid.