CA PPO Affidavit – Maternity Coverage

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Maternity Services

Incorporated by Reference in 28 US Code § 1746

Patient/Multiple Patients:         DOS:

I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Insurer or Contracted Entity has met the provisions of Cal. Ins. Code §10123.87(a) which states, in pertinent part:

(a) No individual or group policy of disability insurance that provides coverage for hospital, medical, and surgical benefits that is issued, amended, renewed, or delivered on or after the effective date of the act adding this section, that provides maternity coverage, shall do any of the following:

(1) Restrict benefits for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery and less than 96 hours following a delivery by caesarean section.  However, coverage for inpatient hospital care may be for a time period less than 48 or 96 hours if both of the following conditions are met:

(A) The decision to discharge the mother and newborn before the 48- or 96-hour time period is made by the treating physicians in consultation with the mother.

(2) Reduce or limit the reimbursement of the attending provider for providing care to an individual insured in accordance with the coverage requirements.

(7) Require the treating physician to obtain authorization from the insurer prior to prescribing any services covered by this section.

I fully understand that this affidavit constitutes an official statement under penalty of perjury under the laws of the United States subject to possible audit and investigation by the State of California.


Health Insurer:



Health Insurer Representative Signature:



Health Insurer Representative Title:





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