01.
Probationary or Waiting Period. Except as provided in Subsection
011.10 pertaining to the
definition of a preexisting condition or Paragraph 038.02.e. of this chapter
regarding specified disease coverage, a policy or certificate will not contain
provisions establishing a probationary or waiting period during which no
coverage is provided under the policy or certificate. Accident policies will
not contain probationary or waiting periods. (3-31-22)
02.
Additional Coverage as
Dividend. A policy or rider for additional coverage will not be issued
as a dividend unless an equivalent cash payment is offered as an alternative to
the dividend policy or rider. A dividend policy or rider for additional
coverage will not be issued for an initial term of less than six (6) months.
(3-31-22)
a. The initial renewal subsequent to
the issuance of a policy or rider as a dividend will clearly disclose that the
policyholder is renewing the coverage that was provided as a dividend for the
previous term and that the renewal is optional. (3-31-22)
03.
Return of Premium or Cash Value
Benefit. A disability income policy, accident only policy, limited
benefit policy, specified disease policy or hospital confinement indemnity
policy may contain a "return of premium" or "cash value benefit" so long as the
return of premium or cash value benefit is not reduced by an amount greater
than the aggregate of claims paid under the policy, and the insurer
demonstrates that the reserve basis for the policies is adequate. No other
policy subject to this chapter is to provide a return of premium or cash value
benefit, except return of unearned premium upon termination or suspension of
coverage, retroactive waiver of premium paid during disability, payment of
dividends on participating policies, or experience rating refunds.
(3-31-22)
04.
Exclusions. A policy or certificate will not limit or exclude
coverage by type of illness, accident, treatment or medical condition, except
that a policy or certificate may include one (1) or more of the following
limitations or exclusions: (3-31-22)
a.
Preexisting conditions or diseases, except for congenital anomalies of a
covered dependent child; (3-31-22)
b. Mental or emotional disorders, alcoholism
and drug addiction; (3-31-22)
c.
Pregnancy, except for complications of pregnancy; (3-31-22)
d. Illness, treatment or medical condition
arising out of: (3-31-22)
i. War or act of war
(whether declared or undeclared); participation in a felony, riot or
insurrections; service in the armed forces or units auxiliary to it;
(3-31-22)
ii. Suicide (sane or
insane), attempted suicide or intentionally self-inflicted injury;
(3-31-22)
iii. Professional
aviation for wage or profit; and (3-31-22)
iv. With respect to disability income
protection policies, incarceration. (3-31-22)
e. Cosmetic surgery, except that "cosmetic
surgery" will not include reconstructive surgery when the service is incidental
to or follows surgery resulting from trauma, infection or other diseases of the
involved part; reconstructive surgery because of congenital disease or anomaly
of a covered dependent child; or involuntary complications or complications
related to a cosmetic procedure; (3-31-22)
f. Foot care in connection with corns,
calluses, flat feet, fallen arches, weak feet, chronic foot strain or
symptomatic complaints of the feet; (3-31-22)
g. Care in connection with the detection and
correction by manual or mechanical means of structural imbalance, distortion,
or subluxation in the human body for purposes of removing nerve interference
and the effects of it, where the interference is the result of or related to
distortion, misalignment or subluxation of, or in the vertebral column;
(3-31-22)
h. Benefits in excess of
Medicare eligible expense, if enrolled in Medicare or other governmental
program (except Medicaid), or benefits provided under a state or federal
worker's compensation law, employers liability or occupational disease law, or
motor vehicle no-fault law unless the motor vehicle no-fault plan provides for
coordination of benefits; services performed by a member of the covered
person's immediate family; and services for which no charge is normally made in
the absence of insurance; (3-31-22)
i. Dental care or treatment;
(3-31-22)
j. Eye glasses and the
examination for the prescription, or fitting of them; (3-31-22)
k. Rest cures, custodial care,
transportation, and routine physical examinations; (3-31-22)
l. Territorial limitations;
(3-31-22)
m. Hearing aids, auditory
osseointegrated (bone conduction) devices, cochlear implants and examination
for or fitting of them, except for congenital or acquired hearing loss that
without intervention may result in cognitive or speech development deficits of
a covered dependent child, covering not less than one (1) device every
thirty-six (36) months per ear with loss and not less than forty-five (45)
language/speech therapy visits during the first twelve (12) months after
delivery of the covered device. (3-31-22)
n. Missed or canceled appointments;
completion of claim forms or records copying; failure to vacate a room on or
before the facility's established discharge hour; educational and training
services except as provided by the policy or certificate; over the counter
medical supplies, consumable or disposable supplies, including but not limited
to elastic stockings, ace bandages, gauze, alcohol swabs or dressings;
(3-31-22)
o. Treatment, services or
supplies not prescribed by or upon the direction of a licensed provider, acting
within the scope of his or her license; (3-31-22)
p. Services rendered prior to the effective
date of coverage or after termination of coverage, except as provided by an
extension of benefits provision, and; (3-31-22)
q. The reversal of an elective sterilization
procedure, including but not limited to vasovasostomies or salpingoplasties.
(3-31-22)
05.
Preexisting Conditions. (3-31-22)
a. Except as provided in this subsection, a
policy will not deny, exclude or limit benefits for covered expenses incurred
more than twelve (12) months following the effective date of the coverage due
to a preexisting condition. (3-31-22)
b. For policies other than disability income
or specified disease, an individual carrier will not modify a policy with
respect to an individual or dependent through riders, endorsements, or
otherwise, to restrict or exclude coverage for specifically named preexisting
diseases or conditions otherwise covered by the policy.
(3-31-22)
