Current through September 9, 2024
(A)
General
Rules.
(1) Each individual policy of
accident and sickness insurance or fraternal benefit society certificate shall
include a renewal, continuation, or non-renewal 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, where
limited, of renewability and the duration of the term of coverage for which the
policy is issued and for which it may be renewed.
(2) 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, except if the increase benefit or coverage is required by
law.
(3) Where a separate
additional premium is charged for benefits provided in connection with riders
or endorsements, such premium charge shall be set forth in the
policy.
(4) 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.
(5) 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 Conditions
Limitations."
(6) All accident only
policies shall contain a prominent statement on the first page of the policy or
attached thereto in either contrasting color or in boldface type at least equal
to the size of type used for policy captions, a prominent statement as follows:
"This is an accident only policy and it does not pay benefits for loss from
sickness."
(7) All policies, except
single premium non-renewable policies, 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.
(8) 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.
(9) 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.
(B)
Outline of Coverage
Requirements for Individual Coverages-No individual accident and
sickness insurance policy or fraternal benefit society certificate subject to
this regulation shall be delivered or issued for delivery in this State unless
an appropriate outline of coverage as prescribed in Sections
38a-505-10(C)
through
38a-505-10(K)
is completed as to such policy or contract; and
(1) Is either delivered with the policy;
or
(2) Delivered to the applicant
at the time application is made and acknowledgement 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
38a-505-9(B)
shall be that statement contained in Section
38a-505-10(C).
The appropriate outline of coverage for policies providing coverage which meets
the standards of both Sections
38a-505-9(B)
and
38a-505-10(C)
shall be the statement contained in Section
38a-505-9(E).
The appropriate outline of coverage for policies providing coverage which meets
the standards of both Sections
38a-505-9(B)
and
38a-505-9(E)
or Sections
38a-505-9(C)
and
38a-505-9(E)
or Sections
38a-505-9(B),
38a-505-9(C)
and
38a-505-9(E)
shall be the statement contained in Section
38a-505-10(C).
In any other case where the prescribed outline of coverage is
inappropriate for the coverage provided by the policy or contract, an alternate
outline of coverage may be submitted to the Commissioner for prior
approval.
(C)
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
38a-505-9(B).
The items included in the outline of coverage must appear in the
sequence prescribed.
(Company Name)
Basic Hospital Expense Coverage
Outline of Coverage
(1)
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!
(2)
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 outpatient services, subject to
any limitations, deductibles and co-payment requirements set forth in the
policy. Coverage is not provided for physician's or surgeon's fees or
unlimited hospital expenses.
(3) (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:
(a) Daily hospital room and
board;
(b) Miscellaneous hospital
services;
(c) Hospital outpatient
services; and
(d) 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
co-payment provision applicable to the benefits described.)
(4) (A description of any policy
provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any
other manner operate to qualify payment of benefits described in (3)
above.)
(5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(D)
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
38a-505-9(C).
The items included in the outline of coverage must appear in the
sequence prescribed.
(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
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!
(2)
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 co-payment requirements set forth in the policy.
Coverage is not provided for hospital expenses or unlimited
medical-surgical expenses.
(3) (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:
(a)
Surgical services;
(b) Anesthesia
services;
(c) In-hospital medical
services; and
(d) 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
co-payment provision applicable to the benefits described.)
(4) (A descripton 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.)
(5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(E)
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 Sections
38a-505-9(B)
and
38a-505-9(C).
The items included in the outline of coverage must appear in the
sequence prescribed.
(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
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!
(2)
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 co-payment requirements
set forth in the policy. Coverage is not provided for
unlimited hospital or medical-surgical expenses.
(3) (A brief
specific
descripton of the benefits, including dollar amounts and number of days
duration where applicable, contained in
this policy, in the
following order:
(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; and
(g) 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
co-payment provision applicable to the benefits described.)
(4) (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.)
(5) (A description of
policy provisions respecting renewability of continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(F)
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
38a-505-9(D).
The items included in the outline of coverage must appear in the
sequence prescribed.
(Company Name)
Hospital Confinement Indemnity Coverage
Outline of Coverage
(1)
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!
(2)
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 benefits described below.
(3) (A brief
specific
description of the benefits contained in
this policy, in the
following order:
(a) Daily benefit payable
during hospital confinement; and
(b) Duration of benefit described in (a).
*NOTE: The above description of benefits shall be stated
clearly and concisely.)
(4) (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.)
(5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(6) Any benefits
provided in addition to the daily hospital benefit.
(G)
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
38a-505-9(E).
The items included in the outline of coverage must appear in the
sequence prescribed.
(Company Name)
Major Medical Expense Coverage
Outline of Coverage
(1)
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!
(2)
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, 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) (A brief
specific
description of the benefits, including dollar amounts, contained in
this policy, in the following order:
(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) Maximum dollar amount for
covered charges; and
(h) 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
co-payment provision applicable to the benefits described.)
(4) (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.)
(5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.
(H)
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
38a-505-9(F).
The items included in the outine of coverage must appear in the
sequence prescribed.
(Company Name)
Disability Income Protection Coverage
Outline of Coverage
(1)
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!
(2)
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.
(3) (A brief
specific description of the benefits contained in this
policy: *NOTE: The above description of benefits shall be stated
clearly and concisely.)
(4) (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.)
(5) (A description of policy provisions
respecting renewability or continuation of coverage, including age restrictions
or any reservation of right to change premiums.)
(I)
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
38a-505-9(G).
The items included in the outline of coverage must appear in the
sequence prescribed.
(Company Name)
Accident Only Coverage
Outline of Coverage
(1)
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!
(2)
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.
(3) (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 co-payment provisions applicable to the benefits described. Proper
disclosure of benefits which vary according to accidental cause shall be made
in accordance with subsection (A) (13) of Section
38a-505-9.)
(4) (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.)
(5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(J)
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
38a-505-9(H).
The items included in the outline of coverage must appear in the
sequence prescribed.
(Company Name)
Specified Accident Coverage
Outline of Coverage
(1)
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!
(2)
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 accidents. Coverage is not provided for basic hospital,
basic medical-surgical, or major-medical expense.
(3) (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
co-payment provisions applicable to the benefits described. Proper disclosure
of benefits which vary according to accidental cause shall be made in
accordance with subsection (A) (13) of Section
38a-505-9.)
(4) (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.)
(5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
(K)
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
38a-505-9(B),
(C), (D), (E), (F), (G) and (H). The items included in the outline of coverage
must appear in the sequence prescribed.
(Company Name)
Limited Benefit Health Coverage
Outline of Coverage
(1)
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!
(2)
Limited Benefit Health
Coverage-Policies of this category are designed to provide, to persons
insured, limited or supplemental coverage.
(3) (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
co-payment provisions applicable to the benefits described. Proper disclosure
of benefits which vary according to accidental cause shall be made in
accordance with subsection (A) (13) of Section
38a-505-9.)
(4) (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.)
(5) (A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservation of right to change
premiums.)
