Current through Register 2024 Notice Reg. No. 52, December 27, 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.
