Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Policies which
provide more than one category of coverage shall be accompanied by the disclosure
form for the category of coverage most appropriate to the coverage provided.
Benefits not included in the category selected shall be set forth in an orderly
manner following the disclosure of the benefits included in the category selected.
Where no prototype disclosure form is appropriate to the coverage provided, a
disclosure form shall be used which is based, to the extent possible, upon the
prototype forms set forth herein. Such disclosure form shall contain information
relative to benefits, exceptions, reductions, limitations, renewability and premiums
in the order set forth in the prototype forms and shall disclose such information in
accordance with subsection (a) and subsections (c) through (f) of Section
2540.4, above.
(b) Prototype Standard Supplemental Disclosure
Form for Policies Providing Basic Hospital Expense Coverage. "Basic Hospital Expense
Coverage" provides benefits for expenses incurred for daily hospital room and board
and miscellaneous hospital services incurred as a result of covered accident or
sickness. Benefits may be subject to a deductible amount and to a co-payment
requirement.
(COMPANY NAME) BASIC HOSPITAL EXPENSE COVERAGE OUTLINE OF
COVERAGE
[1] Read Your (Policy)
Carefully. This outline of coverage provides a very brief description of some
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!
[2] Basic Hospital Expense Coverage. This category
of coverage is designed to provide to persons insured benefits for hospital expenses
incurred as a result of a covered accident or sickness. Benefits may be provided for
daily hospital room and board, miscellaneous hospital services, and hospital
outpatient services, subject to any limitations, deductibles and co-payment
requirements set forth in the (policy). Benefits are not provided for physicians; or
surgeons; fees or unlimited hospital expenses.
[3] Benefits of This (Policy).
(a) [Daily hospital room and board and benefit
period;]
(b) [Miscellaneous hospital
services;]
(c) [Hospital outpatient
services;]
(d) [Other benefits, if
any.]
[4] Exceptions,
Reductions and Limitations of This (Policy).
(Benefits are not provided for physicians' or surgeons'
fees.)
[5] (Renewability) of This
(Policy).
[6] (Premium) for This
(Policy).
(c) Prototype
Standard Supplemental Disclosure Form for Policies Providing Basic Medical-Surgical
Expense Coverage. "Basic Medical-Surgical Expense Coverage" provides benefits for
expenses incurred for surgical, anesthesia and in-hospital medical services incurred
as a result of covered accident or sickness. Benefits may be subject to a deductible
amount and to a co-payment requirement.
(COMPANY NAME) BASIC MEDICAL-SURGICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
[1] Read Your
(Policy) Carefully. This outline of coverage provides a very brief description of
some 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!
[2] Basic Medical-Surgical Expense Coverage. This
category of coverage is designed to provide to persons insured benefits for
medical-surgical expenses incurred as a result of a covered accident or sickness.
Benefits may be provided for surgical services, anesthesia services, and in-hospital
medical services, subject to any limitations, deductibles and co-payment
requirements set forth in the (policy). Benefits are not provided for
unlimited hospital expenses or medical-surgical expenses.
[3] Benefits of This (Policy).
(a) [Surgical services;]
(b) [Anesthesia services;]
(c) [In-hospital medical services;]
(d) [Other benefits, if any.]
[4] Exceptions, Reductions and Limitations of This
(Policy).
(Benefits are not provided for hospital
expenses)
[5] (Renewability) of
This (Policy).
[6] (Premium) for This
(Policy).
(d) Prototype
Standard Supplemental Disclosure Form for Policies Providing Basic Hospital and
Medical-Surgical Expense Coverage. "Basic Hospital and Medical-Surgical Coverage"
provides benefits for expenses incurred for daily hospital room and board,
miscellaneous hospital services, surgical, anesthesia and in-hospital medical
services incurred as a result of covered accident or sickness. Benefits may be
subject to a deductible amount and to a co-payment requirement.
(COMPANY NAME) BASIC HOSPITAL AND MEDICAL-SURGICAL EXPENSE
COVERAGE OUTLINE OF COVERAGE
[1]
Read Your (Policy) Carefully. This outline of coverage provides a very brief
description of some 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!
[2] Basic Hospital and
Medical-Surgical Expense Coverage. This category of coverage is designed to provide
to persons insured benefits for hospital and medical-surgical expenses incurred as a
result of a covered accident or sickness. Benefits may be provided for daily
hospital room and board, miscellaneous hospital services, hospital outpatient
services, surgical services, anesthesia services, and in--hospital medical services,
subject to any limitations, deductibles and co-payment requirements set forth in the
(policy). Benefits are not provided for unlimited hospital or
medical-surgical expenses.
[3] Benefits
of this (Policy)
(a) [Daily hospital room and
board;]
(b) [Miscellaneous hospital
services;]
(c) [Hospital outpatient
services;]
(d) [Surgical
services;]
(e) [Anesthesia
services;]
(f) [In-hospital medical
services;]
(g) [Other benefits, if
any.]
[4] Exceptions,
Reductions and Limitations of This (Policy).
[5] (Renewability) of This (Policy).
[6] (Premium) for This
(Policy).
(e) Prototype
Standard Supplemental Disclosure Form for Policies Providing Hospital Confinement
Indemnity Coverage. "Hospital Confinement Indemnity Coverage" provides a stipulated
daily benefit for hospital confinement as a result of covered accident or sickness.
Benefits may be subject to elimination periods.
(COMPANY NAME) HOSPITAL CONFINEMENT INDEMNITY COVERAGE
OUTLINE OF COVERAGE
[1] Read Your
(Policy) Carefully. This outline of coverage provides a very brief description of
some 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!
[2] Hospital Confinement Indemnity Coverage. This
category of coverage is designed to provide, to persons insured, a fixed daily
benefit during periods of hospitalization resulting from a covered accident or
sickness, subject to any limitations set forth in the (policy). This coverage does
not provide any benefits other than the fixed daily indemnity for hospital
confinement. [The last sentence may be omitted or modified to reflect the benefits
provided by the policy.]
[3] Benefits of
This (Policy).
(a) [Daily benefit payable during
hospital confinement and duration of such benefit;]
(b) [Elimination period, if any;]
(c) [Other benefits, if any.]
[4] Exceptions, Reductions and Limitations of This
(Policy). (Benefits are not provided for physicians' or surgeons' fees nor for
miscellaneous hospital services.) [The foregoing sentence may be modified to reflect
the benefits provided by the policy.]
[5] (Renewability) of This (Policy).
[6] (Premiums for This
(Policy).
(f) Prototype
Standard Supplemental Disclosure Form for Policies Providing Major Medical Expense
Coverage. "Major Medical Expense Coverage" provides benefits for major hospital,
medical and surgical expenses incurred as a result of covered accident or sickness.
Benefits are provided for daily hospital room and board, miscellaneous hospital
services, surgical and anesthesia services, in-hospital medical services and
prosthetic appliances, among other expenses. The maximum benefit for covered charges
must at least equal $10,000. Benefits are subject to substantial fixed or variable
deductibles, and may be subject to a co-payment requirement.
(COMPANY NAME) MAJOR MEDICAL EXPENSE COVERAGE OUTLINE OF
COVERAGE
[1] Read Your (Policy)
Carefully. This outline of coverage provides a very brief description of some
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!
[2] Major Medical Expense Coverage. This category
of coverage is designed to provide, to persons insured, benefits for major hospital,
medical, and surgical expenses incurred as a result of a covered accident or
sickness. Benefits may be provided for daily hospital room and board, miscellaneous
hospital services, surgical services, anesthesia services, in-hospital medical
services, out of hospital care, and prosthetic appliances, subject to any
deductibles, co-payment provisions, or other limitations which may be set forth in
the (policy). Basic hospital or basic medical
insurance coverage is not provided.
[3]
Benefits of This (Policy).
(a) [Daily hospital room
and board;]
(b) [Miscellaneous hospital
services;]
(c) [Surgical
services;]
(d) [Anesthesia
services;]
(e) [In-hospital medical
services;]
(f) [Out-of-hospital
care;]
(g) [Prosthetic
appliances;]
(h) [Maximum dollar amount
for covered charges;]
(i) [Other
benefits, if any.]
[4]
Exceptions, Reductions and Limitations of This (Policy). (This coverage does not
provide basic hospital and medical coverage.)
[5] (Renewability) of This (Policy).
[6] (Premium) for This
(Policy).
(g) Prototype
Standard Supplemental Disclosure Form for Policies Providing Disability Income
Protection Coverage. "Disability Income Protection provides benefits on account of
the insured's inability, as a result of covered accident or sickness, to perform
certain activities as defined in the policy.
(COMPANY NAME) DISABILITY INCOME PROTECTION COVERAGE
OUTLINE OF COVERAGE
[1] Read Your
(Policy) Carefully. This outline of coverage provides a very brief description of
some 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!
[2] Disability Income Protection Coverage. This
category of coverage is designed to provide, to persons insured, benefits for
disabilities resulting from a covered accident or sickness, subject to any
limitations set forth in the (policy). Benefits are not provided for basic hospital,
basic medical-surgical, or major-medical expenses.
[3] Benefits of This (Policy). [The benefit
description shall briefly describe the definition or definitions of total disability
used in the policy. Benefit and elimination periods may be stated in the time units
used in the policy.]
[4] Exceptions,
Reductions and Limitations of This (Policy).
(No benefits are provided for hospital, medical or surgical
expenses.) [The foregoing sentence may be omitted or modified to reflect the
benefits provided by the policy.]
[5] (Renewability) of This (Policy).
[6] (Premium for This
(Policy).
(h) Prototype
Standard Supplemental Disclosure Form for Policies Providing Accident Only Coverage.
"Accident Only Coverage" provides benefits of the nature specified in the policy for
losses resulting to the insured from covered accidents. Any policy whose principal
benefits are limited to accidental losses shall be included in this category, unless
it falls within the following subsection. Benefits payable may vary according to
accidental cause.
(COMPANY NAME) ACCIDENT ONLY COVERAGE OUTLINE OF
COVERAGE
[1] Read Your (Policy)
Carefully. This outline of coverage provides a very brief description of some
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!
[2] Accident Only Coverage. This category of
coverage is designed to provide, to persons insured, benefits for certain losses
resulting from a covered accident ONLY, subject to any limitations contained in the
(policy). Benefits are not provided for basic hospital, basic medical-surgical, or
major-medical expenses.
[3] Benefits of
This (Policy). [Prototype disclosure forms for other types of coverage should be
used as guides in drafting the benefit description, where appropriate. Where policy
benefits vary according to accidental cause, this paragraph shall prominently set
forth the circumstances under which benefits are payable which are lesser than the
maximum amount payable under the policy.]
[4] Exceptions, Reductions and Limitations of This
(Policy). (No benefits are provided for any loss resulting from sickness.) [The
foregoing sentence may be omitted or modified to reflect the benefits provided by
the policy.]
[5] (Renewability) of This
(Policy).
[6] (Premium for This
(Policy).
(i) Prototype
Standard Supplemental Disclosure Form for Policies Providing Specified Disease or
Specified Accident Coverage.
"Specified Disease or Specified Accident Coverage" provides
benefits of the nature specified in the policy only for losses resulting from the
disease or type of accident specified in the policy.
(COMPANY NAME) (SPECIFIED DISEASE) (SPECIFIED ACCIDENT)
COVERAGE OUTLINE OF COVERAGE
[1]
Read Your (Policy) Carefully. This outline of coverage provides a very brief
description of some 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!
[2] (Specified Disease)
(Specified Accident) Coverage. This category of coverage is designed to provide, to
persons insured, benefits ONLY when certain losses occur as a result of (specified
diseases) (specified accidents). Benefits are not provided for basic hospital, basic
medical-surgical, or major-medical expenses.
[3] Benefits of This (Policy). [Prototype
disclosure forms for other types of coverage should be used as guides in drafting
the benefit description, where appropriate. Where specified accident policy benefits
vary according to accidental cause, this paragraph shall prominently set forth the
circumstances under which benefits are payable which are lesser than the maximum
amount payable under the policy.]
[4]
Exceptions, Reductions and Limitations of This (Policy). (Benefits are not provided
for losses caused by anything other than [specified diseases][specified
accidents].)
[5] (Renewability) of This
(Policy).
[6] (Premium for This
(Policy).
(j) Prototype
Standard Supplemental Disclosure Form for Policies Providing Comprehensive Major
Medical Expense Coverage.
"Comprehensive Major Medical Expense Coverage" provides those
benefits enumerated in subsection (f) of this section, except that coverage is not
designed to supplement other coverage and may be subject only to modest fixed
deductible amounts. Benefits may also be subject to a co-payment requirement.
(COMPANY NAME) COMPREHENSIVE MAJOR MEDICAL EXPENSE
COVERAGE OUTLINE OF COVERAGE
[1]
Read Your (Policy) Carefully. This outline of coverage provides a very brief
description of some 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!
[2] Comprehensive Major
Medical Expense Coverage. This category of coverage is designed to provide, to
persons insured, benefits for major hospital, medical, and surgical expenses
incurred as a result of a covered accident or sickness. Benefits may be provided for
daily hospital room and board, miscellaneous hospital services, surgical services,
anesthesia services, in-house medical services, out of hospital care, and prosthetic
appliances, subject to any deductibles, co-payment provisions, or other limitations
which may be set forth in the (policy).
[3] Benefits of This (Policy).
(a) [Daily hospital room and board;]
(b) [Miscellaneous hospital services;]
(c) [Surgical services;]
(d) [Anesthesia services;]
(e) [In-hospital medical services;]
(f) [Out-of-hospital care;]
(g) [Prosthetic appliances;]
(i) [Other benefits, if any.]
[4] Exceptions, Reductions and Limitations of This
(Policy).
[5] (Renewability) of This
(Policy).
[6] (Premium) for This
(Policy).
(k) Disclosure Forms
for Medicare Supplement Policies: Special Instructions. The name, address and
telephone number of a representative of the insurer or the General Agent shall be
inserted in the blank in the sentence following Paragraph (8). (Such representative
may not be the agent, if any, who solicited or delivered the policy.) Such
representative shall be located in this State unless a toll-free "800" telephone
number is specified.
Insurers shall establish affirmative procedures for insuring
that Medicare Supplement Policy Disclosure Forms are properly delivered pursuant to
Insurance Code Sections
10601(e)
and
10605, where
solicitation is made on an other-than-direct response basis. Such procedures could
include physically attaching disclosure forms to field-issued policies; requiring
return to the insurer of copies of disclosure forms signed by prospective insureds;
or requiring separately signed acknowledgments of receipt on application for
insurance when such applications are returned to the insurer. (This requirement
shall not be construed to mean that insurers need not establish reasonable
procedures for insuring that other categories of disclosure forms are properly
delivered to prospective insureds.)
(l) Prototype Standard Supplemental Disclosure
Form for Policies Providing Medicare Supplement Coverage.
[1] Read Your (Policy) Carefully. This outline of
coverage provides a very brief description of some important features of your
(policy). This is not the insurance contra
(COMPANY NAME) MEDICARE SUPPLEMENT COVERAGE OUTLINE OF
COVERAGE
ns of both you and (your insurance company). It is, therefore,
important that you READ YOUR POLICY CAREFULLY!
[2] Medicare Supplement Coverage--Policies of this
category are designed to supplement Medicare by covering some hospital, medical, and
surgical services which are partially covered by Medicare. Coverage is provided for
hospital in-patient charges and some physician charges, subject to any deductibles
and co-payment provisions which may be in addition to those provided by Medicare,
and subject to other limitations which may be set forth in the policy. The policy
does not provide benefits for custodial care such as help in walking, getting in and
out of bed, eating, dressing, bathing and taking medicine (delete if such coverage
is provided).
[3]
(a) (For agents:) Neither (insert company's name)
nor its agents are connected with Medicare.
(b) (For direct response:) (insert company's name)
is not connected with Medicare.
[4] (A brief summary of the major benefit gaps in
Medicare Parts A and B with a parallel description of supplemental benefits,
including dollar amounts, provided by the Medicare Supplement Coverage in the
following order:)
|
Service |
Benefit |
Medicare
pays |
This Policy
Pays |
You
Pay |
|
HOSPITALIZATION - Semiprivate room and board, general
nursing |
First 60 days |
All But $() |
| |
|
and miscellaneous hospital services and supplies
Includes meals, |
61st to
|
All but $()
|
|
|
|
|
90th day
|
a day
|
|
|
|
special care units, drugs, lab tests, diagnostic X-rays,
medical supplies, |
90th to
|
All but $()
|
|
|
|
|
150th day |
a day |
|
|
|
operating and recovery room, anesthesia and
rehabilitation services |
Beyond 150 |
Nothing |
|
|
|
|
days |
|
|
|
|
POST HOSPITAL SKILLED NURSING CARE -In a facility
approved by |
First 20 |
100% of costs |
|
|
|
|
days |
|
|
|
|
Medicare you must have been in a hospital for at
least |
Additional |
All but $() |
|
|
|
|
80 days |
a day |
|
|
|
three days and enter the facility within 14 days after
hospital discharge |
Beyond 100 |
Nothing |
|
|
|
|
days |
|
|
|
|
MEDICAL EXPENSE |
Physician's services in-patient and out-patient medical
services and supplies at a hospital, physical and Speech therapy and
ambulance. |
80% of reasonable charge [after $()
deductible] |
|
|
[5] (A
statement that the policy does or does not cover the following:)
(a) Private duty nursing.
(b) Skilled nursing home care costs (beyond what
is covered by Medicare).
(c) Custodial
nursing home care costs.
(d)
Intermediate nursing home care costs.
(e) Home health care (above number of visits
covered by Medicare).
(f) Physician
charges (above Medicare's reasonable charge).
(g) Drugs (other than prescription drugs furnished
during a hospital or skilled nursing facility stay).
(h) Care received outside of U.S.A.
(i) Dental care or dentures, checkups, routine
immunizations, cosmetic surgery, routine foot care, examinations for the cost of
eyeglasses or hearing aids.
[6] (A description of any policy provisions which
excludes, eliminates, resists, reduces, limits, delays or in any other manner
operates to qualify payment of the benefits described in (4) above, including
conspicuous statements:)
(a) (That the chart
summarizing Medicare benefits only briefly described such benefits.)
(b) (That the Health Care Financing Administration
or its Medicare publications should be consulted for further details and
limitation.)
[7] (A
description of policy provisions respecting renewability or continuation of
coverage, including any reservation of right to change premium.)
[8] (The amount of premium for this policy.)
If you have questions about this (policy), please write or
call___.
1. Amendment
filed 1-8-76; effective thirtieth day thereafter (Register 76, No. 2).
2.
Amendment of subsections (e)(4), (h)(4), repealer and new subsection (k) and new
subsections (l), (m) and (n) filed 4-5-78; designated effective 1-1-79 (Register 78,
No. 14).
3. Repealer of subsections (k)-(n) and new subsections (k) and
(l) filed 3-31-83; effective thirtieth day thereafter (Register 83, No.
14).
Note: Authority cited: Sections
790.10,
10608 and
10195(g), Insurance Code. Reference: Sections 10195(g) and
10603, Insurance
Code.
