IMPORTANT NOTICE FOR NEW YORK VICTIMS OF DOMESTIC VIOLENCE AND ENDANGERED INDIVIDUALS
American National Life Insurance Company of New York
Farm Family Casualty Insurance Company
Garden State Life Insurance Company
United Farm Family Insurance Company
(each and together “us”)
New York Insurance Law § 2612 and Insurance Regulation 168 govern confidentiality protocols for victims of domestic violence and endangered individuals. The regulation states that if any person covered by an insurance policy issued to another person who is the policyholder or if any person covered under a group policy delivers to the insurer that issued the policy, a valid order of protection against the policyholder or other person, then the insurer is prohibited for the duration of the order from disclosing to the policyholder or other person the address and telephone number of the insured, or of any person or entity providing covered services to the insured.
Insurance Law § 2612 also requires a health insurer to accommodate a reasonable request made by a person covered by a policy of accident and health insurance to receive communications of claim-related information by alternative means or at alternative locations if the person clearly states that disclosure of the information could endanger the person. Except with the express consent of the person making the request, the insurer shall not disclose to the policyholder (i) the address, telephone number, or any other personally identifying information of the person who made the request or child for whose benefit a request was made; (ii) the nature of the health care services provided; or (iii) the name or address of the provider of the covered services. If a child is the covered person, then this right may be asserted by the child’s parent or guardian.
PROCEDURE TO MAKE A REQUEST AND/OR TO PROVIDE ALTERNATE CONTACT INFORMATION
If you (i) are covered by a policy issued by us in the state of New York, (ii) have been the victim of domestic violence and, (iii) have obtained a valid order of protection against a policyholder or other person insured by us, you may make a request by contacting us at 1-800-933-5954, LIA.Compliance@americannational.com, or by mailing a written request to:
American National Administrative Office-LIA
Compliance PO Box 1890
Galveston, TX 77553.
Please be advised that the requester will be required to provide a valid order of protection and an alternate method of contact.
If you are covered under a policy of disability income insurance or health insurance issued in the State of New York by American National Life Insurance Company of New York and you are a victim of domestic violence, you may make a request to receive communications of claim related information by alternative means or at alternate locations by completing the Confidential Communication Request Form on the following page and mailing or emailing it to the address indicated above. If you would like to revoke your request, you must do so in writing to the address or email address indicated above.
For additional help, you may also want to contact the New York State Domestic and Sexual Violence Hotline at 1-800-942-6906
This form is for use by a person who is covered by policy of disability income insurance or health insurance issued in the state of New York by American National Life Insurance Company of New York and wishes to make a reasonable request to receive communications of claim-related information by alternative means or at alternative locations if disclosing claim-related information could endanger the person.