Current through September 9, 2024
The following minimum standards for benefits are prescribed for
the categories of coverage noted in the following subsections. No individual
policy of accident and sickness insurance or fraternal benefit society
certificate 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 are approvable as limited
benefit health insurance and the outline of coverage complies with the
appropriate outline in Section
38a-505-10(K).
Nothing in this section shall preclude the issuance of any policy or contract
combining two or more categories of coverage such as hospital expense coverage
and medical-surgical expense coverage.
(A)
General Rules.
(1) A "non-cancellable," "guaranteed
renewable," or "non-cancellable 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 non-payment 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 become the insured.
(2) The
terms "non-cancellable," "guaranteed renewable," or "non-cancellable and
guaranteed renewable" shall not be used without further explanatory language in
accordance with the disclosure requirements of Section
38a-505-10(A)
(1). The terms "non-cancellable" or "non-cancellable and guaranteed renewable"
may be used only in a policy which the insured has the right to continue in
force by the timely payment of premiums set forth in the policy until the age
of sixty-five (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; provided, however, any accident and health
or accident only policy which provides for periodic payments, weekly or
monthly, for a specified period during the continuance of disability resulting
from accident or sickness may provide that the insured has the right to
continue the policy only to age sixty (60) if, at age sixty (60), the insured
has the right to continue the policy in force at least to age sixty-five (65)
while actively or regularly employed. Except as provided above, the term
"guaranteed renewable" may be used only in a policy which the insured has the
right to continue in force by the timely payment of premiums until the age of
sixty-five (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 as mandated by statute and except that the
insurer may make changes in premium rates by classes; provided, however, any
accident and health or accident only policy which provides for periodic
payments, weekly or monthly, for a specified period during the continuance of
disability resulting from accident or sickness may provide that the insured has
the right to continue the policy only to age sixty (60) if at age sixty (60),
the insured has the right to continue the policy in force at least to age
sixty-five (65) while actively and regularly employed.
(3) In a family 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 "non-cancellable" 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.
(4) 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.
(5) 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 person on a pro rata
basis.
(6) In the event the insurer
cancels or refuses to renew, policies providing pregnancy benefits 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.
(7)
Policies providing convalescent or extended care benefit 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.
(8) Family coverage shall continue for any
dependent child who is incapable of self-sustaining employment due to mental
retardation 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.
(9) Any policy
providing 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.
(10) 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.
(11) 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, 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.
(12) Specific
dismemberment benefits shall not be in lieu of other benefits unless the
specific benefit equals or exceeds the other benefits.
(13) 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.
(14) All Medicare
supplement policies providing in-hospital benefits only shall include in their
provided benefits the initial Part A Medicare deductible as established from
time to time by the Social Security Administration.
(15) Termination of the policy shall be
without prejudice 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 total disability of the insured,
limited to the duration of the policy benefit period, if any, or payment of the
maximum benefits.
(B)
Basic Hospital Expense Coverage-"Basic Hospital Expense Coverage"
is a policy of accident and sickness insurance which provides coverage for a
period of not less than thirty-one (31) days during any one period of
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:
(1) Daily
hospital room and board in an amount not less than the lesser of (a) 80% of the
charges for semi-private room accommodations, or (b) $30.00 per day;
(2) 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 either 80%
of the charges incurred up to at least $1,000.00 or ten times the daily
hospital room and board benefits; and
(3) Hospital outpatient services consisting
of (a) hospital services on the day surgery is performed, and (b) hospital
services rendered within seventy-two (72) hours after accidental injury, in an
amount not less than $50.00, and (c) X-ray laboratory tests to the extent that
benefits for such services would have been provided to an extent not less than
$100.00 if rendered to an in-patient of the hospital.
(4) Benefits provided under (1) and (2) above
may be provided subject to a combined deductible amount not in excess of
$100.00.
(C)
Basic
Medical-Surgical Expense Coverage-"Basic Medical-Surgical Expense
Coverage" is a policy of accident and sickness 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:
(1)
Surgical services:
(a) In amounts not less
than those provided on a fee schedule based on an acceptable relative value
scale of surgical procedures, such as the 1964 California Relative Value
Schedule, up to a maximum of at least $500.00 for any one procedure;
or
(b) Not less than 80% of the
reasonable charges.
(2)
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 physician (or his assistant) performing
the surgical service:
(a) In an amount not
less than 80% of the reasonable charges; or
(b) 15% of the surgical service
benefit.
(3) 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.
(D)
Hospital Confinement Indemnity
Coverage-"Hospital Confinement Indemnity Coverage" is a policy of
accident and sickness 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.
(E)
Major Medical Expense
Coverage-"Major medical expense coverage" is an accident and sickness
insurance policy which provides hospital, medical and surgical expense
coverage, to an aggregate maximum of not less than $10,000.00; 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
by the amount of the benefits provided by such underlying insurance, for each
covered person for at least:
(1) Daily
hospital room and board expenses, prior to application of the copayment
percentage, for not less than $50.00 daily (or in lieu thereof the average
daily cost of semi-private room rate in the area where the insured resides) for
a period of not less than 31 days during continuous hospital
confinement;
(2) 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;
(3) Surgical services, prior to application
of the copayment percentage, to a maximum of not less than $600 for the most
severe operations with the amounts provided for other operations reasonably
related to such maximum amount;
(4)
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;
(5) In-hospital medical services, prior to
the application of the copayment percentage, as defined in subdivision (C) (3)
of Section 38a-505-9;
(6)
Out-of-hospital care, prior to application of the copayment percentage,
consisting of physician's 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
(7) 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;
(a) In-hospital private duty graduate
registered nurse services;
(b)
Convalescent nursing home care;
(c)
Diagnosis and treatment by a radiologist or physiotherapist;
(d) Rental of special medical equipment, as
defined by the insurer in the policy;
(e) Artificial limbs or eyes, casts, splints,
trusses or braces;
(f) Treatment
for functional nervous disorders, and mental and emotional disorders;
(g) Out-of-hospital prescription drugs and
medications.
(F)
Disability Income Protection
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:
(1) 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.
(2) Contains an elimination
period no greater than:
(a) Ninety (90) days
in the case of a coverage providing a benefit period of one (1) year or
less;
(b) One hundred and eighty
(180) days in the case of coverage providing a benefit of more than one year
but not greater than two years, or
(c) Three hundred and sixty-five (365) days
in all other cases during the continuance of disability resulting from sickness
or injury.
(3) 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. Section
38a-505-9(F)
does not apply to those policies providing business buyout coverage.
(G)
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 demberment amount shall be at least $500.00.
(H)
"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.
(I)
"Limited
Benefit Health Insurance Coverage" is any policy or contract which
provides benefits that are less than the minimum standards for benefits
required under Sections
38a-505-7(B),
(C), (D), (E), (F), (G) and (H). Such policies or contracts may be delivered or
issued for delivery in this state only if the outline of coverage required by
Section
38a-505-10(K)
is completed and delivered as required by Section
38a-505-10(B).
