F. Prohibited Policy Provisions and
Practices.
(1) No policy shall contain
provisions establishing a probationary or waiting period during which no
coverage is provided under the policy subject to the further exception that a
policy may specify a probationary or waiting period not to exceed six (6)
months for specified diseases or conditions and losses resulting therefrom for
hernia, disorder of reproduction organs, varicose veins, adenoids, appendix,
tonsils, hemorrhoids and piles. However, the permissible six (6) months
exception shall not be applicable where such specified diseases or conditions
are treated on an emergency basis and if there is no previous medical history
of the condition which predates the policy. Accident policies shall not contain
probationary or waiting periods.
(2) No policy or rider for additional
coverage may be issued as a dividend unless an equivalent cash payment or
reduction in premium is offered to the policyholder as an alternative to such
dividend policy or rider. No such dividend policy or rider shall be issued for
an initial term of less than 6 months. This provision shall not be so construed
as to prevent an insurer from voluntarily endorsing a policy so as to increase
all future benefits without an increase in premium.
The initial renewal subsequent to the issuance of any policy or
rider as a dividend shall clearly disclose that the policyholder is renewing
the coverage that was provided as a dividend for the previous term and that
such renewal is optional with the policyholder.
(3) A policy which is non-cancellable or
guaranteed renewable may contain a "return of premium" or "cash value" benefit
so long as: (1) such return of premium or cash value benefit is not reduced by
an amount greater than the aggregate of any claims paid under the policy; and
(2) the insurer demonstrates that the reserve basis for such policies is
adequate. No other policy shall provide a return of premium or cash value
benefit, except return of unearned premium upon termination or suspension of
coverage, retroactive waiver of premium paid during disability, payment of
dividends on participating policies, or experience rating refunds.
(4) Notwithstanding the permissible
definition of hospital in Section E(2)(b)4., a hospital confinement indemnity
policy shall not exclude coverage merely because of confinement in any
government related hospital.
(5) A
policy issued to a person eligible for Medicare by reason of age may not have
limitations or exclusions more restrictive than those of Medicare for any type
of coverage under such policies.
(6) No policy shall limit or exclude coverage
by type of illness, accident, treatment, or medical condition more stringent
than the following:
(a) Pre-existing
conditions or diseases, except for congenital anomalies of a covered dependent
child;
(b) mental or emotional
disorders, alcoholism and drug addiction;
(c) normal pregnancy and childbirth except
for Disability Income policies defined in section G(6) of this
regulation;
(d) illness, accident,
treatment or medical condition arising out of:
1. war or act of war (whether declared or
undeclared); participation in a felony, riot or insurrection; service in the
armed forces or units auxiliary thereto,
2. suicide, sane or insane, attempted suicide
or intentionally self-inflicted injury,
3. aviation,
4. with respect to short-term nonrenewable
policies, interscholastic sports;
(e) cosmetic surgery, except that "cosmetic
surgery" shall not include reconstructive surgery when such service is
incidental to or follows surgery resulting from trauma, infection or other
diseases of the involved part, and reconstructive surgery because of congenital
disease or anomaly of a covered dependent child which has resulted in a
functional defect;
(f) foot care in
connection with corns, calluses, flat feet, fallen arches, weak feet, chronic
foot strain, or symptomatic complaints of the feet;
(g) care in connection with the detection and
correction by manual or mechanical means of structural imbalance, distortion,
or subluxation in the human body for purposes of removing nerve interference
and the effects thereof, where such interference is the result of or related to
distortion, misalignment or subluxation of, or in the vertebral
column;
(h) treatment provided in a
government hospital (except a hospital confinement policy); benefits provided
under Medicare or other governmental program (except Medicaid), any state or
federal workmen's compensation, employers liability or occupational disease
law, any motor vehicle no-fault law; services rendered by employees of
hospitals, laboratories or other institutions; services performed by a member
of the covered person's immediate family; and services for which no charge is
normally made in the absence of insurance;
(i) dental care or treatment
(j) eye glasses, hearing aids and examination
for the prescription or fitting thereof;
(k) rest cures, custodial care,
transportation and routine physical examinations;
(l) territorial limitations.
(7) Other provisions of this
regulation shall not impair or limit the use of waivers to exclude, limit or
reduce coverage or benefits for specifically named or described pre-existing
diseases, physical condition or extra hazardous activity. Where waivers are
required as a condition of insurance, renewal or reinstatement, signed
acceptance by the insured is required unless on initial issuance the full text
of the waiver is contained either on the first page or specification page of
the policy or unless notice of the waiver appears on the first page or
specification page.
(8) Policy
provisions precluded in this section shall not be construed as a limitation on
the authority of the Commissioner to disapprove other policy provisions in
accordance with Section
38-71-530(b)
which, in the opinion of the Commissioner,
are unjust, unfair, misleading, or unfairly discriminatory to the policyholder,
beneficiary, or any person insured under the policy.
(9) No policy shall include a provision which
gives the insurer an unconditional right of non-renewal.
(10) No policy shall exclude coverage for a
loss due to a pre-existing condition for a period greater than 12 months
following policy issue where the application for such insurance does not seek
disclosure of prior illness, disease or physical conditions or prior medical
care and treatment and such pre-existing condition is not specifically excluded
by the terms of the policy.
G. Accident and Health Minimum Standards for
Benefits.
The following minimum standards for benefits are prescribed for
the categories of coverage noted in the following subsections. No individual
policy of accident and health insurance or non-profit hospital, medical or
dental service corporation contract shall be delivered or issued for delivery
in this state which does not meet the required minimum standards for the
specified categories unless the Commissioner finds that such policies or
contracts serve a valid economic and social purpose and are approvable as
Limited Benefit Health Insurance and the Outline of Coverage complies with the
appropriate outline in section H(11) of this Regulation. Each such policy shall
contain the words "LIMITED BENEFITS" or "LIMITED OR SUPPLEMENTAL BENEFITS"
prominently displayed on the first page of the policy in boldface type or
contrasting color.
Nothing in this section shall preclude the issuance of any policy
or contract combining two or more categories of coverage set forth in Section
38-71-540(a).
(1) General Rules
(a) A "noncancellable," "guaranteed
renewable," or "noncancellable and guaranteed renewable" policy shall not
provide for termination of coverage of the spouse solely because of the
occurrence of an event specified for termination of coverage of the insured,
other than nonpayment of premium. The policy shall provide that in the event of
the insured's death the spouse of the insured, if covered under the policy,
shall have the right to continue coverage previously afforded by the policy and
exercise any rights previously vested in the insured.
(b) "Guaranteed renewable insurance" means
all individual insurance which grants an insured the right to continue the
policy in force by the timely payment of premiums until at least age 65 or to
eligibility for Medicare during which period the insurer has no right to make
unilaterally any change in any provision of the policy while the policy is in
force, except that the insurer may make changes in premium rates by classes
except that the Commissioner may disapprove such increase in rates if he
determines that the benefits provided in such policies are unreasonable in
relation to the premium to be charged after the increase.
(c) "Noncancellable insurance" or
"noncancellable and guaranteed renewable insurance" means all individual
insurance which gives the insured the right to continue the insurance in force
by the timely payment of premiums set forth in the policy until at least age 65
or to eligibility for Medicare during which period the insurer has no right to
make unilaterally any change in any provision of the policy while it is in
force.
(d) "Nonrenewable for stated
reasons only" or "Conditionally Renewable" means all individual insurance which
limits the insurer's right of nonrenewal to reasons stated in the policy. The
following are acceptable reasons, except that reasons 2 and 3 shall not be
included in the same policy:
1. overinsurance
in accordance with insurer's standards on file with the Commissioner;
2. discontinuance of all policies in the same
class;
3. discontinuance of all
policies issued on the same form in this State;
4. change of the insured's occupation to an
occupation classified as more hazardous than the original occupation.
5. any other factor which would qualify as a
valid and generally accepted insurance underwriting basis.
(e) In a policy covering both husband and
wife the age of the younger spouse must be used as the basis for meeting the
age and durational requirements of the definitions of "noncancellable" or
"guaranteed renewable." However, this requirement shall not prevent termination
of coverage of the older spouse upon attainment of the stated age limit (e.g.,
age 65) so long as the policy may be continued in force as to the younger
spouse to the age or for the durational period as specified in said
definition.
(f) When accidental
death and dismemberment coverage is part of the insurance coverage offered
under the contract, the insured shall have the option to include all insureds
under such coverage and not just the principal insured.
(g) If a policy contains a status type
military service exclusion or a provision which suspends coverage during
military service, the policy shall provide, upon receipt of written request,
for refund of premiums as applicable to such persons on a pro rata
basis.
(h) In the event the insurer
cancels, or refuses to renew, policies providing pregnancy benefits, the policy
shall provide for an extension of benefits as to pregnancy commencing while the
policy is in force and for which benefits would have been payable had the
policy remained in force.
(i)
Policies providing convalescent or extended care benefits following
hospitalization shall not condition such benefits upon admission to the
convalescent or extended care facility within a period of less than fourteen
(14) days after discharge from the hospital.
(j) Family coverage shall continue for any
dependent child who is incapable of self sustaining employment due to
intellectual disability or physical handicap on the date that such child's
coverage would otherwise terminate under the policy due to the attainment of a
specified age limit for children and is chiefly dependent on the insured for
support and maintenance. The policy may require that within 31 days of such
date the company receive due proof of such incapacity in order for the insured
to elect to continue the policy in force with respect to such child, or that a
separate converted policy be issued at the option of the insured or
policyholder.
(k) Any policy
providing medical expense coverage for the recipient in a transplant operation
shall also provide reimbursement of any medical expenses of a live donor to the
extent that benefits remain and are available under the recipient's policy,
after benefits for the recipient's own expenses have been paid.
(l) A policy may contain a provision relating
to recurrent disabilities; provided however, that no such provision shall
specify that a recurrent disability be separated by a period greater than six
(6) months.
(m) Accidental death
and dismemberment benefits shall be payable if the loss occurs within ninety
(90) days from the date of the accident, irrespective of total disability.
Disability income benefits due to accident, if provided, shall not require the
loss to commence less than thirty (30) days after the date of accident, nor
shall any policy which the insurer cancels or refuses to renew require that it
be in force at the time disability commences if the accident occurred while the
policy was in force.
(n) Specific
dismemberment benefits shall not be in lieu of other benefits unless the
specific benefit equals or exceeds the other benefits.
(o) A company may not refuse to refund
unearned premiums during a term for which premiums are paid. It may, however,
base the amount of refund on a mode of premium payment more frequent than that
of the term paid.
(p) Any
accident-only policy providing benefits which vary according to the type of
accidental cause shall prominently set forth in the outline of coverage the
circumstances under which benefits are payable which are lesser than the
maximum amount payable under the policy.
(q) Termination of the policy shall be
without prejudice to losses incurred for "one period of confinement", as
defined, or to any continuous loss which commenced while the policy was in
force, but the extension of benefits beyond the period the policy was in force
may be predicated upon the continuous disability of the insured, limited to the
duration of the policy benefit period, if any, or payment of the maximum
benefits.
(2) Basic
Hospital Expense Coverage: "Basic Hospital Expense Coverage" is a policy of
accident and health insurance which provides coverage for a period of not less
than thirty-one (31) days during any continuous hospital confinement for each
person insured under the policy, for expense incurred for necessary treatment
and services rendered as a result of accident or sickness for at least the
following:
(a) daily hospital room and board
in an amount not less than the lesser of 80% of the charges for semi-private
room accommodations or $30.00 per day;
(b) miscellaneous hospital services for
expenses incurred for the charges made by the hospital for services and
supplies which are customarily rendered by the hospital and provided for use
only during any one period of confinement in an amount not less than the lesser
of (i) 80% of the charges incurred up to at least $1,000.00 or (ii) ten times
the daily hospital room and board benefits;
(c) hospital outpatient services consisting
of hospital services on the day surgery is performed, hospital services
rendered within 72 hours after accidental injury, in an amount not less than
$50, and X-ray and laboratory tests to the extent that benefits for such
services would have been provided if rendered to an in-patient of the hospital
in an amount not less than $100; and
(d) benefits provided under (a) and (b) of
(2) above, may be provided subject to a combined deductible amount not in
excess of $100.00.
(3)
Basic Medical-Surgical Expense Coverage: "Basic Medical-Surgical Expense
Coverage" is a policy of accident and health insurance which provides coverage
for each person insured under the policy for the expenses incurred for the
necessary services rendered by a physician for treatment of an injury or
sickness for at least the following:
(a)
Surgical Services:
1. in amounts not less
than those provided on a fee schedule based on the relative values contained in
the state of New York certified surgical fee schedule, or the 1964 California
Relative Value Schedule or other acceptable relative value scale or surgical
procedures, up to a maximum of at least $500.00 for any one procedure;
or
2. not less than 80% of the
reasonable charges.
(b)
Anesthesia services, consisting of administration of necessary general
anesthesia and related procedures in connection with covered surgical service
rendered by a physician other than the surgeon or the assistant surgeon
performing the surgical services:
1. in an
amount not less than 80% of the reasonable charges; or
2. 15% of the surgical service
benefit.
(c) In-hospital
medical services, consisting of physician services rendered to a person who is
a bed patient in a hospital for treatment of sickness or injury other than that
for which surgical care is required, in an amount not less than 80% of the
reasonable charges; or $5.00 per day for not less than twenty-one (21) days
during one period of confinement.
(4) Hospital Confinement Indemnity Coverage:
"Hospital Confinement Indemnity Coverage" is a policy of accident and health
insurance which provides daily benefits for hospital confinement on an
indemnity basis in an amount not less than $30.00 per day and not less than
thirty-one (31) days during any one period of confinement for each person
insured under the policy.
(5) Major
Medical Expense Coverage: "Major Medical Expense Coverage" is an accident and
health insurance policy which provides hospital, medical and surgical expense
coverage, to an aggregate maximum of not less than $20,000.00; copayment by the
covered person not to exceed 25% of covered charges; a deductible stated on a
per person, per family, per illness, per benefit period, or per year basis, or
a combination of such bases not to exceed 5% of the aggregate maximum limit
under the policy, unless the policy is written to complement underlying
hospital and medical insurance in which case such deductible may be increased
to the amount of the benefits provided by such underlying insurance, for each
covered person for at least:
(a) Daily
hospital room and board expenses, prior to application of the copayment
percentage, for not less than $70.00 daily (or in lieu thereof the average
daily cost of semiprivate room rate in the area where the insured resides) for
a period of not less than 31 days during continuous hospital
confinement;
(b) miscellaneous
hospital services, prior to application of the copayment percentage, for an
aggregate maximum of not less than $1,500 or 15 times the daily room and board
rate if specified in dollar amounts;
(c) surgical services, prior to application
of copayment percentage to a maximum of not less than $600 for the most severe
operation with the amounts provided for other operations reasonably related to
such maximum amount;
(d) anesthesia
services prior to application of the copayment percentage, for a maximum of not
less than 15 percent of the covered surgical fees or, alternatively, if the
surgical schedule is based on relative values, not less than the amount
provided therein for anesthesia services at the same unit value as used for the
surgical schedule;
(e) in-hospital
medical services, prior to application of the copayment percentage, as defined
in subdivision (3)(c) of G.
(f)
out-of-hospital care prior to application of the copayment percentage,
consisting of physicians' services rendered on an ambulatory basis where
coverage is not provided elsewhere in the policy for diagnosis and treatment of
sickness or injury, and diagnostic X-ray, laboratory services, radiation
therapy, and hemodialysis ordered by a physician; and
(g) not fewer than three of the following
additional benefits, prior to application of the copayment percentage, for an
aggregate maximum of such covered charges of not less than $1,000:
1. In-hospital private duty graduate
registered nurse services.
2.
Convalescent nursing home care.
3.
Diagnosis and treatment by a radiologist or physiotherapist.
4. Rental of special medical equipment, as
defined by the insurer in the policy.
5. Artificial limbs or eyes, casts, splints,
trusses or braces.
6. Treatment for
functional nervous disorders, and mental and emotional disorders.
7. Out-of-hospital prescription drugs and
medications.
(6) Disability Income Protection
Coverage--This section does not apply to those policies providing business
buyout coverage.
"Disability Income Protection Coverage" is a policy which
provides for periodic payments, weekly or monthly, for a specified period
during the continuance of disability resulting from either sickness or injury
or a combination thereof which:
(a)
Provides that periodic payments which are payable at ages after 62 and reduced
solely on the basis of age are at least 50% of amounts payable immediately
prior to 62.
(b) Contains an
elimination period no greater than:
1. Ninety
(90) days in the case of a coverage providing a benefit of one (1) year or
less;
2. One hundred and eighty
(180) days in the case of coverage providing a benefit of more than one year
but not greater than two (2) years; or
3. Three hundred sixty five (365) days in all
other cases during the continuance of disability resulting from sickness or
injury.
(c) Has a
maximum period of time for which it is payable during disability of at least
six (6) months except in the case of a policy covering disability arising out
of pregnancy, childbirth, or miscarriage in which case the period for such
disability may be one (1) month. No reduction in benefits shall be put into
effect because of an increase in Social Security or similar benefits during a
benefit period.
(7)
Accident Only Coverage: "Accident Only Coverage" is a policy of accident
insurance which provides coverage, singly or in combination, for death,
dismemberment, disability, or hospital and medical care caused by accident.
Accidental death and double dismemberment amounts under such a policy shall be
at least $1,000.00 and a single dismemberment amount shall be at least
$500.00.
(8) Specified Disease and
Specified Accident Coverage
(a) "Specified
disease coverage" pays benefits for the diagnosis and/or treatment of a
specifically named disease or diseases. Any such policy must meet the following
general rules of subsection 1. In addition, policies providing coverage on an
expense-incurred basis must meet the standards of subsection 2, while policies
providing coverage on an indemnity basis must meet the standards of subsection
3.
1. General Rules.
The following rules shall apply to specified-disease coverages in
addition to all other rules imposed by this regulation; in cases of conflict
between the following and other rules, the following ones shall govern:
(i) Policies covering a single specified
disease or combination of specified diseases may not be sold or offered for
sale other than as specified-disease coverage under this section.
(ii) Any policy issued pursuant to this
section which conditions payment upon pathological diagnosis of a covered
disease, shall also provide that if such a pathological diagnosis is medically
inappropriate, a clinical diagnosis will be accepted in lieu thereof.
(iii) Notwithstanding any other provision of
this regulation, specified-disease policies shall provide benefits to any
covered person not only for the specified disease(s) but also for any other
condition(s) or disease(s), directly caused or aggravated by the specified
disease(s) or the treatment of the specified disease(s).
(iv) Policies containing specified disease
coverage shall be at least Guaranteed Renewable.
(v) No policy issued pursuant to this section
shall contain a waiting or probationary period greater than thirty (30)
days.
(vi) Payments may be
conditioned upon a covered person's receiving medically necessary care, given
in a medically appropriate location, under a medically accepted course of
diagnosis or treatment.
(vii)
Except for the uniform provision regarding other insurance with this insurer,
benefits for specified disease coverage shall be paid regardless of other
coverage.
(viii) After the
effective date of the coverage (or applicable waiting period, if any) benefits
shall begin with the first day of care or confinement if such care or
confinement is for a covered disease even though the diagnosis is made at some
later date. The retroactive application of such coverage may not be less than
forty-five (45) days prior to such diagnosis.
2. Expense-Incurred Policies.
(i) Coverage must be provided for each person
insured under the policy for a specifically named disease (or diseases) with a
deductible amount not in excess of $250.00 and an overall aggregate benefit
limit of no less than $10,000 and a benefit period of not less than two (2)
years for at least the following incurred expenses with no unreasonable inside
limits:
(A) Hospital room and board and any
other hospital furnished medical services or supplies;
(B) Treatment by a legally qualified
physician or surgeon;
(C) Private
duty services of a registered nurse (R.N.);
(D) X-ray, radium and other therapy
procedures used in diagnosis and treatment;
(E) Professional ambulance for local service
to or from a local hospital;
(F)
Blood transfusions, including expense incurred for blood donors;
(G) Drugs and medicines prescribed by a
physician;
(H) The rental of an
iron lung or similar mechanical apparatus;
(I) Braces, crutches and wheel chairs as are
deemed necessary by the attending physician for the treatment of the
disease;
(J) Emergency
transportation if in the opinion of the attending physician it is necessary to
transport the insured to another locality for treatment of the
disease.
(ii) The policy
may include coverage of any other expenses necessarily incurred in the
treatment of the disease.
3. Indemnity Policies.
Coverage must be provided for each person insured under the
policy for a specifically named disease (or diseases) with no deductible
amount, and an overall aggregate benefit limit of not less than $25,000 payable
at a daily rate not expected to produce a claim payment less than that which
would be produced by a policy paying $50 a day while confined in a hospital
with a benefit period of 500 days.
(b) "Specified Accident Coverage" is an
accident insurance policy which provides coverage for a specifically identified
kind of accident (or accidents) for each person insured under the policy for
accidental death or accidental death and dismemberment, combined with a benefit
amount not less than $1,000.00 for accidental death, $1,000.00 for double
dismemberment and $500.00 for single dismemberment.
(9) Limited Benefit Health Insurance
Coverage: "Limited Benefit Health Insurance Coverage" is any policy or
contract, other than a policy or contract covering only a specified disease or
diseases, which provides benefits that are less than the minimum standards for
benefits required under G(2), (3), (4), (5), (6), (7), and (8). A policy
covering a single specified disease or combination of diseases shall meet the
requirements of Section G(8) and shall not be offered for sale as a "Limited
Coverage." Limited benefit policies or contracts may be delivered or issued for
delivery in this state only if the outline of coverage required by Section
H(11) of this Regulation is completed and delivered as required by Section H(2)
of this Regulation.
H.
Required Disclosure Provisions.
(1) General
Rules
(a) Each individual policy of accident
and health insurance or hospital, medical or dental service corporation
subscriber contract shall include a renewal, continuation, or nonrenewal
provision. The language or specifications of such provision must be consistent
with the type of contract to be issued. Such provision shall be appropriately
captioned, shall appear on the first page of the policy, and shall clearly
state the duration of renewability and the duration of the term of coverage for
which the policy is issued and for which it may be renewed.
(b) Except for riders or endorsements by
which the insurer effectuates a request made in writing by the policyholder or
exercises a specifically reserved right under the policy, all riders or
endorsements added to a policy after date of issue or at reinstatement or
renewal which reduce or eliminate benefits or coverage in the policy shall
require signed acceptance by the policyholder. After date of policy issue, any
rider or endorsement which increases benefits or coverage with a concomitant
increase in premium during the policy term must be agreed to in writing signed
by the insured, unless the increased benefits or coverage is required by
law.
(c) Where a separate
additional premium is charged for benefits provided in connection with riders
or endorsements, such additional premium charge shall be clearly set forth
separately in the policy or on the rider.
(d) A policy which provides for the payment
of benefits based on standards described as "usual and customary," "reasonable
and customary," or words of similar import shall include a definition of such
terms and an explanation of such terms in its accompanying outline of
coverage.
(e) If a policy contains
any limitations with respect to pre-existing conditions such limitations must
appear as a separate paragraph of the policy and be labeled as "Pre-existing
Condition Limitations."
(f) Each
accident only policy or a policy providing benefits for a specified disease
only shall contain an appropriate prominent statement on the first page of the
policy in boldface type or in contrasting color similar to the following,
whichever is appropriate:
1. This is an
accident only policy which does not pay benefits for a loss from
sickness.
2. This is a specified
disease policy which only provides benefits for a loss due to ______. It does
not provide benefits for any other sickness or condition.
(g) All policies, except trip or travel
ticket policies and as otherwise provided in this paragraph, shall have a
notice prominently printed on the first page of the policy or attached thereto
stating in substance that the policyholder shall have the right to return the
policy within ten (10) days of its delivery and to have the premium refunded
if, after examination of the policy, the policyholder is not satisfied for any
reason. With respect to policies issued pursuant to a direct response
solicitation, the policy shall have a notice prominently printed on the first
page of the policy or attached thereto stating in substance that the
policyholder shall have the right to return the policy within thirty (30) days
of its delivery and to have the premium refunded if, after examination of the
policy, the policyholder is not satisfied for any reason.
(h) If age is to be used as a determining
factor for reducing the maximum aggregate benefits made available in the policy
as originally issued, such fact must be prominently set forth in the outline of
coverage.
(i) If a policy contains
a conversion privilege, it shall comply, in substance, with the following: the
caption of the provision shall be "Conversion Privilege," or words of similar
import. The provision shall indicate the persons eligible for conversion, the
circumstances applicable to the conversion privilege, including any limitations
on the conversion, and the person by whom the conversion privilege may be
exercised. The provision shall specify the benefits to be provided on
conversion or may state that the converted coverage will be as provided on a
policy form then being used by the insurer for that purpose.
(j) Insurers issuing policies which provide
hospital or medical expense coverage on either an expense incurred or indemnity
basis to person(s) eligible for Medicare by reason of age, shall provide to the
policyholder a medicare supplement buyer's guide in a form approved by the
Commissioner. Delivery of the buyer's guide shall be made whether or not the
policy qualifies as a medicare supplement coverage under Regulation Regulation
69-46.
Except in the case of direct response insurers, delivery of the buyer's guide
shall be made at the time of application, and acknowledgment of receipt or
certification of delivery of the buyer's guide shall be provided to the
insurer. Direct response insurers shall deliver the buyer's guide upon prior
request but not later than at the time the policy is delivered. (NOTE: The NAIC
Model Buyer's Guide is acceptable. Any substantially equivalent Buyer's Guide
which has been approved by the Insurance Department of any other state may be
used upon prior approval by the Commissioner.)
(k) Outlines of coverage delivered in
connection with policies defined in this Regulation as Hospital Confinement
Indemnity (G(4)), Specified Disease (G(8)), or Limited Benefit Health Insurance
Coverages (G(9)) to persons eligible for Medicare by reason of age shall
contain, in addition to the requirements of subsections H(6), H(
10), and H(11), the following language
which shall be printed on or attached to the first page of the outline of
coverage:
This policy IS NOT A MEDICARE SUPPLEMENT policy. If you are
eligible for Medicare, review the Medicare Supplement Buyer's Guide furnished
by the company.
(2) Outline of Coverage Requirements for
Individual Coverages: No individual accident and health insurance policy or
non-profit hospital, medical or dental service corporation subscriber contract
subject to this regulation shall be delivered or issued for delivery in this
State unless an appropriate outline of coverage, as prescribed in Section
H(
3) through
(11) is completed as to such policy or contract, and the outline is either: (a)
delivered with the policy; or (b) delivered to the applicant at the time
application is made and acknowledgment of receipt or certification of delivery
of such outline of coverage is provided to the insurer.
(a) for policies offered for sale as Medicare
Supplement Coverage the outline is delivered to the applicant at the time
application is made and, except for the direct response policy, acknowledgment
of receipt or certification of delivery of such outline of coverage is provided
to the insurer; and
(b) for all
other policies, the outline is either:
1.
delivered with the policy; or
2.
delivered to the applicant at the time application is made and acknowledgment
of receipt or certification of delivery of such outline of coverage is provided
to the insurer.
If an outline of coverage was delivered at the time of
application and the policy or contract is issued on a basis which would require
revision of the outline, a substitute outline of coverage properly describing
the policy or contract must accompany the policy or contract when it is
delivered and contain the following statement, in no less than twelve (12)
point type, immediately above the company name: "NOTICE: Read this outline of
coverage carefully. It is not identical to the outline of coverage provided
upon application and the coverage originally applied for has not been
issued."
The appropriate outline of coverage for policies or contracts
providing hospital coverage which only meets the standards of section G(2)
shall be that statement contained in section H(3). The appropriate outline of
coverage for policies providing coverage which meets the standards of both
sections G(2) and (3) shall be the statement contained in section H(5). The
appropriate outline of coverage for policies providing coverage which meets the
standards of both sections G(2) and (5) or sections G(3) and (5) or sections
G(2), (3), and (5) shall be the statement contained in section H(7).
An appropriate outline of coverage will be filed with each policy
submitted for approval. In any case where the prescribed outline of coverage is
inappropriate for the coverage provided by the policy or contract, an alternate
outline of coverage shall be submitted to the Commissioner for prior
approval.
(3) Basic Hospital Expense Coverage (Outline
of Coverage): An outline of coverage, in the form prescribed below, shall be
issued in connection with policies meeting the standards of section G(2) of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed:
COMPANY NAME AND ADDRESS
LOCAL TELEPHONE NUMBER: ______ (if available) ______
BASIC HOSPITAL EXPENSE COVERAGE
Policy Form Number ______
OUTLINE OF COVERAGE
(a)
Read Your Policy Carefully--This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
(b) Basic Hospital
Expense Coverage--Policies of this category are designed to provide, to persons
insured, coverage for hospital expenses incurred as a result of a covered
accident or sickness. Coverage is provided for daily hospital room and board,
miscellaneous hospital services, and hospital out-patient services, subject to
any limitations, deductibles and copayment requirements set forth in the
policy. Coverage is not provided for physicians or surgeons fees or unlimited
hospital expenses.
(c) (A brief
specific description of the benefits, including dollar amounts and number of
days duration where applicable, contained in this policy, in the following
order:
1. daily hospital room and
board;
2. miscellaneous hospital
services;
3. hospital out-patient
services; and
4. other benefits, if
any.)
(Note: The above description of benefits shall be stated clearly
and concisely, and shall include a description of any deductible or copayment
provision applicable to the benefits described.)
(d) (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described in (c)
above.)
(e) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(4) Basic
Medical-Surgical Expense Coverage (Outline of Coverage): An outline of
coverage, in the form prescribed below, shall be issued in connection with
policies meeting the standards of section G(3) of this Regulation. The items
included in the outline of coverage must appear in the sequence prescribed:
COMPANY NAME AND ADDRESS
LOCAL TELEPHONE NUMBER: ______ (if available) ______
BASIC MEDICAL-SURGICAL EXPENSE COVERAGE
Policy Form Number ______
OUTLINE OF COVERAGE
(a)
Read Your Policy Carefully--This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control your policy. The
policy itself sets forth in detail the rights and obligations of both you and
your insurance company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
(b) Basic
Medical-Surgical Expense Coverage--Policies of this category are designed to
provide, to persons insured, coverage for medical-surgical expenses incurred as
a result of a covered accident or sickness. Coverage is provided for surgical
services, anesthesia services, and in-hospital medical services, subject to any
limitations, deductibles and copayment requirements set forth in the policy.
Coverage is not provided for hospital expenses in unlimited medical-surgical
expenses.
(c) (A brief specific
description of the benefits, including dollar amounts and number of days
duration where applicable, contained in this policy, in the following order:
1. surgical services;
2. anesthesia services;
3. in-hospital medical services;
and
4. other benefits, if any.)
(Note: The above description of benefits shall be stated clearly
and concisely, and shall include a description of any deductible or copayment
provisions applicable to the benefits described.)
(d) (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described in (3)
above.)
(e) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(5) Basic
Hospital and Medical Surgical Expense Coverage (Outline of Coverage): An
outline of coverage, in the form prescribed below, shall be issued in
connection with policies meeting the standards of section G(2) and (3) of this
Regulation. The items included in the outline of coverage must appear in the
sequence prescribed.
COMPANY NAME AND ADDRESS
LOCAL TELEPHONE NUMBER: ______ (if available) ______
BASIC HOSPITAL AND MEDICAL SURGICAL
EXPENSE COVERAGE
Policy Form Number ______
OUTLINE OF COVERAGE
(a)
Read Your Policy Carefully--This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOU POLICY
CAREFULLY!
(b) Basic Hospital and
Medical Surgical Expense Coverage--Policies of this category are designed to
provide, to persons insured, coverage for hospital and medical-surgical
expenses incurred as a result of a covered accident or sickness. Coverage is
provided for daily hospital room and board, miscellaneous hospital services,
hospital out-patient services, surgical services, anesthesia services, and
in-hospital medical services, subject to any limitations, deductibles and
copayment requirements set forth in the policy. Coverage is not provided for
unlimited hospital or medical-surgical expenses.
(c) A brief specific description of the
benefits, including dollar amounts and number of days duration where
applicable, contained in this policy, in the following order:
1. daily hospital room and board;
2. miscellaneous hospital services;
3. hospital out-patient services;
4. surgical services;
5. anesthesia services;
6. in-hospital medical services;
and
7. other benefits, if any.)
(Note: The above description of benefits shall be stated clearly
and concisely, and shall include a description of any deductible or copayment
provision applicable to the benefits described.)
(d) (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described in (c)
above.)
(e) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(6) Hospital
Confinement Indemnity Coverage (Outline of Coverage): An outline of coverage,
in the form prescribed below, shall be issued in connection with policies
meeting the standards of section G(4) of this Regulation. The items included in
the outline of coverage must appear in the sequence prescribed:
COMPANY NAME AND ADDRESS LOCAL TELEPHONE NUMBER: ______ (if
available) ______
HOSPITAL CONFINEMENT INDEMNITY COVERAGE
Policy Form Number ______
OUTLINE OF COVERAGE
(a)
Read Your Policy Carefully--This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
(b) Hospital Confinement
Indemnity Coverage--Policies of this category are designed to provide, to
persons insured, coverage in the form of a fixed daily benefit during periods
of hospitalization resulting from a covered accident or sickness, subject to
any limitations set forth in the policy. Such policies do not provide any
benefits other than the fixed daily indemnity for hospital confinement and any
additional benefit described below.
(c) (A brief specific description of the
benefits contained in this policy, in the following order:
1. daily benefit payable during hospital
confinement; and
2. duration of
benefit described in (a).)
(Note: The above description of benefits shall be stated clearly
and concisely.)
(d) (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described in (c)
above.)
(e) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(f) (Any benefits
provided in addition to the daily hospital benefit.)
(7) Major Medical Expense Coverage (Outline
of Coverage): An outline of coverage, in the form prescribed below, shall be
issued in connection with policies meeting the standards of Section G(5) of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed:
COMPANY NAME AND ADDRESS
LOCAL TELEPHONE NUMBER ______ (if available) ______
MAJOR MEDICAL EXPENSE COVERAGE
Policy Form Number ______
OUTLINE OF COVERAGE
(a)
Read Your Policy Carefully--This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
(b) Major Medical
Expense Coverage--Policies of this category are designed to provide, to persons
insured, coverage for major hospital, medical, and surgical expenses incurred
as a result of a covered accident or sickness. Coverage is provided for daily
hospital room and board, miscellaneous hospital services, surgical services,
anesthesia services, in-hospital medical services, and out-of-hospital care,
subject to any deductibles, copayment provisions, or other limitations which
may be set forth in the policy. Basic hospital or basic medical insurance
coverage is not provided.
(c) (A
brief specific description of the benefits, including dollar amount, contained
in this policy, in the following order:
1.
daily hospital room and board;
2.
miscellaneous hospital services;
3.
surgical services;
4. anesthesia
services;
5. in-hospital medical
services;
6. out-of-hospital
care;
7. maximum dollar amount for
covered charges; and
8. other
benefits, if any.)
(Note: The above description of benefits shall be stated clearly
and concisely, and shall include a description of any deductible or copayment
provision applicable to the benefits described.)
(d) (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described in (c)
above.)
(e) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(8)
Disability Income Protection Coverage (Outline of Coverage): An outline of
coverage, in the form prescribed below, shall be issued in connection with
policies meeting the standards of section G(6) of this Regulation. The items
included in the outline of coverage must appear in the sequence prescribed:
COMPANY NAME AND ADDRESS
LOCAL TELEPHONE NUMBER: ______ (if available) ______
DISABILITY INCOME PROTECTION COVERAGE
Policy Form Number ______
OUTLINE OF COVERAGE
(a)
Read Your Policy Carefully--This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
(b) Disability Income
Protection Coverage--Policies of this category are designed to provide, to
persons insured, coverage for disabilities resulting from a covered accident or
sickness, subject to any limitations set forth in the policy. Coverage is not
provided for basic hospital, basic medical-surgical, or major medical
expenses.
(c) (A brief specific
description of the benefits contained in this policy).
(Note: The above description of benefits shall be stated clearly
and concisely.)
(d) (A
description of any policy provisions which exclude, eliminate, restrict, reduce
limit, delay, or in any other manner operate to qualify payment of the benefits
described in (c) above.)
(e) (A
description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
(9) Accident
Only Coverage (Outline of Coverage): An outline of coverage in the form
prescribed below, shall be issued in connection with policies meeting the
standards of section G(7) of this Regulation. The items included in the outline
of coverage must appear in the sequence prescribed:
COMPANY NAME AND ADDRESS LOCAL TELEPHONE NUMBER: ______ (if
available) ______
ACCIDENT ONLY COVERAGE
Policy Form Number ______
OUTLINE OF COVERAGE
(a)
Read Your Policy Carefully--This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
(b) Accident Only
Coverage--Policies of this category are designed to provide, to persons
insured, coverage for certain losses resulting from a covered accident ONLY,
subject to any limitations contained in the policy. Coverage is not provided
for basic hospital, basic medical-surgical, or major medical expenses due to
sickness.
(c) (A brief specific
description of the benefits contained in this policy.)
(Note: The above description of benefits shall be stated clearly
and concisely, and shall include a description of any deductible or copayment
provision applicable to the benefits described. Proper disclosure of benefits
which vary according to accidental cause shall be made in accordance with
subsection (1)(o) of section G of this Regulation.)
(d) (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described in (c)
above.)
(e) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(10)
Specified Disease or Specified Accident Coverage (Outline of Coverage): An
outline of coverage in the form prescribed below, shall be issued in connection
with policies meeting the standards of section G(8) of this Regulation. The
coverage shall be identified by the appropriate bracketed title. The items
included in the outline of coverage must appear in the sequence prescribed:
COMPANY NAME AND ADDRESS
LOCAL TELEPHONE NUMBER: ______ (if available) ______
(SPECIFIED DISEASE) (SPECIFIED ACCIDENT) COVERAGE
Policy Form Number ______
OUTLINE OF COVERAGE
(a)
Read Your Policy Carefully--This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore, important that you READ YOUR POLICY
CAREFULLY!
(b) (Specified Disease)
(Specified Accident) Coverage--Policies of this category are designed to
provide, to persons insured, restricted coverage paying benefits ONLY when
certain losses occur as a result of (Specified diseases) or (specified
accidents). Coverage is not provided for basic hospital, basic
medical-surgical, or major medical expenses.
(c) (A brief specific description of the
benefits, including dollar amounts, contained in this policy.)
(Note: The above description of benefits shall be stated clearly
and concisely, and shall include a description of any deductible or copayment
provisions applicable to the benefits described. Proper disclosure of benefits
which vary according to accidental cause shall be made in accordance with
subsections (1)(o) of section G of this Regulation.)
(d) (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described in (c)
above.)
(e) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(11) Limited
Benefit Health Coverage (Outline of Coverage): An outline of coverage, in the
form prescribed below, shall be issued in connection with policies which do not
meet the minimum standards of section G(2), (3), (4), (5), (6), (7), and (8) of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed:
COMPANY NAME AND ADDRESS LOCAL TELEPHONE NUMBER: ______ (if
available) ______ LIMITED BENEFIT HEALTH COVERAGE Policy Form Number ______
OUTLINE OF COVERAGE
(a) Read Your
Policy Carefully--This outline of coverage provides a very brief description of
the important features of your policy. This is not the insurance contract and
only the actual policy provisions will control. The policy itself sets forth in
detail the rights and obligations of both you and your insurance company. It
is, therefore important that you READ YOUR POLICY CAREFULLY!
(b) Limited Benefit Health Coverage--Policies
of this category are designed to provide, to persons insured, limited or
supplemental coverage.
(c) (A brief
specific description of the benefits, including dollar amounts, contained in
this policy.)
(Note: The above description of benefits shall be stated clearly
and concisely, and shall include a description of any deductible or copayment
provisions applicable to the benefits described. Proper disclosure of benefits
which vary according to accidental cause shall be made in accordance with
subsection (1)(o) of section G of this Regulation.)
(d) (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described in (c)
above.)
(e) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(12) Limited
Benefit Health Coverage (Outline of Coverage): An outline of coverage, in the
form prescribed below, shall be issued in connection with policies which do not
meet the minimum standards of section G(2), (3), (4), (5), (6), (7), and (8) of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed:
COMPANY NAME AND ADDRESS
LOCAL TELEPHONE NUMBER: ______ (if available) ______
LIMITED BENEFIT HEALTH COVERAGE
Policy Form Number ______
OUTLINE OF COVERAGE
(a)
Read Your Policy Carefully--This outline of coverage provides a very brief
description of the important features of your policy. This is not the insurance
contract and only the actual policy provisions will control. The policy itself
sets forth in detail the rights and obligations of both you and your insurance
company. It is, therefore important that you READ YOUR POLICY
CAREFULLY!
(b) Limited Benefit
Health Coverage--Policies of this category are designed to provide, to persons
insured, limited or supplemental coverage.
(c) (A brief specific description of the
benefits, including dollar amounts, contained in this policy.)
(Note: The above description of benefits shall be stated clearly
a description of any deductible or copayment provisions applicable to the
benefits described. Proper disclosure of benefits which vary according to
accidental cause shall be made in accordance with subsection (1)(o) of section
G of this Regulation.)
(d)
(A description of any policy provisions which exclude, eliminate, restrict,
reduce, limit, delay, or in any other manner operate to qualify payment of the
benefits described in (c) above.)
(e) (A description of policy provisions
respecting renewability or continuation of coverage, including age restrictions
or any reservation of right to change premiums.)