California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 2 - Policy Forms and Other Documents
Article 11 - Standards for Health History Questionnaires in Health Insurance Applications, Pre-Issuance Medical Underwriting and Rescission of Health Insurance Policies
Section 2274.73 - Standards for Health History Questions on an Application for Health Insurance Coverage

Universal Citation: 10 CA Code of Regs 2274.73

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Inquiries into an applicant's health history shall hold applicants to the reasonable layperson standard. Whenever possible, information from a PHR shall be requested and, if available, relied upon during medical underwriting in addition to self-reported information on health history questionnaires.

(b) All questions designed to ascertain the health condition or history of an applicant shall be limited to eliciting only medical information that is reasonable and necessary for medical underwriting.

(c) Medical information that is reasonable and necessary for medical underwriting means only such information that is essential to an insurer's calculation of prospective risk of the coverage being requested.

(d) Questions on an application for health insurance coverage shall:

(1) Be clear, specific, unambiguous and written to be understood by a reasonable layperson.

(2) Clearly state the period of time covered by the question. Specified time periods for each question shall be as short as possible to make a reasonable underwriting determination and must be limited to time periods required by sound actuarial underwriting standards used by the insurer.

(3) Be phrased to elicit information about diagnoses, treatments and recent consultations with health care providers known to the applicant.

(4) Provide each applicant with the opportunity to indicate whether he or she is unsure of the answer, does not know how to respond to any individual health history question, or does not understand the question. Health history questions shall offer response choices in addition to YES or NO, such as Not Sure.

(5) Offer the applicant an opportunity to indicate the applicant's inability to recall or remember the information requested. To the extent that such response choices impede the insurer's ability to apply its medical underwriting guidelines, the insurer shall pursue alternative methods of obtaining such information, including but not limited to telephone interviews, medical records or other sources of information.

(e) To avoid unclear, ambiguous and abstruse questions which may be likely to mislead, an application for health insurance coverage shall not:

(1) Include compound questions requiring a single answer or questions containing double negatives.

(2) Include questions that are unlimited in time and scope unless the insurer's medical underwriting guidelines based on sound actuarial principles reasonably require an unlimited time and scope.

(3) Include questions requiring the applicant to evaluate or understand the significance of a physical symptom or the cause of physical symptoms.

(4) Include questions requiring the applicant to guess or speculate regarding the kinds of symptoms that may be significant to the health insurer.

(5) Include questions phrased to require an applicant to guess or speculate about the significance of symptoms, conditions, disorders or impairments.

(6) Ask the applicant to make an overall appraisal of the applicant's general health or draw general conclusions about the applicant's medical or health status.

(7) Include any question which solicits or is reasonably calculated to solicit information regarding an HIV test result. Nor may any request for or use of objective, independently received information violate the statutory prohibition against an HIV test being used or required as a condition of obtaining health insurance coverage.

(f) Insurers shall use either a separate health history questionnaire for each individual applicant or a questionnaire in which each question calls for a separate, identifiable response from each applicant.

(g) An application for health insurance shall not ask any question that requires the applicant to make a determination as to whether an agent has or has not provided assistance as defined in Subdivision (c) of Section 2274.76.

1. New section filed 7-19-2010; operative 8-18-2010 (Register 2010, No. 30).
2. Change without regulatory effect amending NOTE filed 9-23-2010 pursuant to section 100, title 1, California Code of Regulations (Register 2010, No. 39).

Note: Authority cited: Sections 790.10, 10291.5, 10384, 12921 and 12926, Insurance Code; CalFarm Ins. Co. v. Deukmejian, 48 Cal.3d 805 (1989); and 20th Century Ins. Co. v. Garamendi, 8 Cal. 4th 216 (1994). Reference: Sections 106, 380, 730, 733, 734, 790.03, 796.04, 10113, 10291.5, 10380, 10381.5 and 10384, Insurance Code.

Disclaimer: These regulations may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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