Current through 2024-38, September 18, 2024
The requirements set forth in this section are in addition to
any other applicable requirements as specified in Section
3(D).
A. General Rules
(1) All applications for coverages specified
in Sections 6B, C, D, E, G, I, J, K and L shall contain a prominent statement
by type, stamp or other appropriate means in either contrasting color or in
boldface type at least equal to the size type used for the headings or captions
of sections of the application and in close conjunction with the applicant's
signature block on the application as follows:
"The [policy] [certificate] provides limited benefits. Review
your [policy][certificate] carefully."
(2) All applications for dental plans shall
contain a prominent statement by type, stamp or other appropriate means in
either contrasting color or in boldface type at least equal to the size type
used for the headings or captions of sections of the application and in close
conjunction with the applicant's signature block on the application as follows:
"The [policy] [certificate] provides dental benefits only.
Review your [policy] [certificate] carefully."
(3) All applications for vision plans shall
contain a prominent statement by type, stamp or other appropriate means in
either contrasting color or in boldface type at least equal to the size type
used for the headings or captions of sections of the application and in close
conjunction with the applicant's signature block on the application as follows:
"The [policy] [certificate] provides vision benefits only.
Review your [policy] [certificate] carefully."
(4) Each policy of individual health
insurance and group health insurance shall include a renewal, continuation, or
nonrenewal provision. The language or specification of the provision shall be
consistent with the type of contract to be issued. The 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.
(5) The
following requirements apply to riders or endorsements added to a policy after
date of issue, except as provided in subparagraph (e).
(a) 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 that reduce or eliminate benefits or coverage in the policy shall
require signed acceptance by the policyholder.
(b) After date of policy issue, any rider or
endorsement that increases benefits or coverage with a concomitant increase in
premium during the policy term must be agreed to in writing signed by the
policyholder, except if the increased benefits or coverage is required by
law.
(c) After date of policy
issue, any rider or endorsement added to a guaranteed renewable policy that
increases benefits or coverage must be agreed to in writing signed by the
policyholder, except if the increased benefits or coverage is required by law
or if the insurer certifies to the Superintendent that claims paid under the
rider or endorsement will be excluded when determining the need for future rate
increases.
(d) The signature
requirements in this paragraph also apply to group health insurance
certificates where the certificateholder pays the entire premium to the
carrier.
(e) The requirements of
this paragraph do not apply to policies that are "guaranteed renewable with
limited exceptions" as described in section
6(A)(2)(d) if the
policy's renewal provision does not restrict the insurer's right to
unilaterally modify benefits and the modification is otherwise consistent with
24-A M.R.S.A.
§2850-B. The requirements of this
paragraph do not apply to product replacements pursuant to
24-A M.R.S.A.
§2850-B(3)(G).
(6) Where a separate additional
premium is charged for benefits provided in connection with riders or
endorsements, the premium charge shall be set forth in the policy or
certificate.
(7) A policy or
certificate under which the insured may be subject to balance billing when
charges exceed a maximum considered "usual and customary," "reasonable and
customary," or words of similar import must comply with the following
requirements:
(a) It must include a definition
of the terms and an explanation of the terms in its accompanying outline of
coverage;
(b) It must clearly
disclose that the insured or enrollee may be subject to balance billing as a
result of claims adjustment;
(c) It
must provide a toll-free number that an insured or enrollee may call prior to
receiving services to determine the maximum allowable charge permitted by the
carrier for a specified service.
(d) The carrier must provide to the
Superintendent on request complete information on the methodology and specific
data used by the carrier or any 3rd party on behalf of the carrier in adjusting
any claim submitted by or on behalf of the insured or enrollee. In considering
the reasonableness of the methodology for calculating maximum allowable
charges, the Superintendent shall consider whether the methodology takes into
account relevant data specific to this State if there is sufficient data to
constitute a representative sample of charge data for the same or comparable
service.
(8) If a policy
or certificate contains any limitations with respect to preexisting conditions,
the limitations shall appear as a separate paragraph of the policy or
certificate and be labeled as "Preexisting Condition Limitations."
(9) All accident-only policies and
certificates shall contain a prominent statement on the first page of the
policy or certificate, in either contrasting color or in boldface type at least
equal to the size of type used for headings or captions of sections in the
policy or certificate, a prominent statement as follows:
"Notice to Buyer: This is an accident-only
[policy][certificate] and it does not pay benefits for loss from sickness.
Review your [policy][certificate] carefully."
Accident-only [policies][certificates] that provide coverage
for hospital or medical care shall contain the following statement in addition
to the Notice to Buyer above: "This [policy][certificate] provides limited
benefits. Benefits provided are supplemental and are not intended to cover all
medical expenses."
(10) All
individual policies, except nonrenewable accident policies, shall have a notice
prominently printed on the first page of the policy or certificate or attached
to it stating in substance that the policyholder or certificateholder shall
have the right to return the policy or certificate within ten days of its
delivery and to have the premium refunded if, after examination of the policy
or certificate, the policyholder or certificateholder is not satisfied for any
reason. Ten days is a minimum; longer periods are permitted.
(11) If age is to be used as a determining
factor for reducing the maximum aggregate benefits made available in the policy
or certificate as originally issued, that fact shall be prominently set forth
in the outline of coverage.
(12) If
a policy or certificate 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.
(13)
(a) Outlines of coverage delivered in
connection with policies defined in this rule as hospital confinement indemnity
(Section 6E), specified disease (Section 6J), or supplemental health coverages
(Section 6L) to persons eligible for Medicare by reason of age shall contain,
in addition to the requirements of Subsections F and J, the following language,
which shall be printed on or attached to the first page of the outline of
coverage:
This IS NOT A MEDICARE SUPPLEMENT policy. If you are eligible
for Medicare, review the Guide to Health Insurance for People With Medicare
available from the company.
(b) An insurer shall deliver to persons
eligible for Medicare any notice required under Bureau of Insurance Rule
Chapter 275(17)(D).
(14)
Insurers, except direct response insurers, shall give a person applying for
specified disease insurance that covers cancer the NAIC Buyer's Guide to Cancer
Insurance at the time of application enrollment and shall obtain the
recipient's written acknowledgement of the guide's delivery. Direct response
insurers shall provide the Buyer's Guide upon request, but not later than the
time that the policy or certificate is delivered.
(15) All specified disease policies and
certificates shall contain on the first page or attached to it in either
contrasting color or in boldface type at least equal to the size type used for
headings or captions of sections in the [policy][certificate], a prominent
statement as follows: Notice to Buyer: This is a specified disease [policy]
[certificate].This [policy] [certificate] provides limited benefits. Benefits
provided are supplemental and are not intended to cover all medical expenses.
[If the policy covers cancer, include the following sentence.] Read your
[policy] [certificate] carefully with the outline of coverage and the Buyer's
Guide to Cancer Insurance.
(16) All
hospital confinement indemnity policies and certificates shall display
prominently by type, stamp, or other appropriate means on the first page of the
policy or certificate, or attached to it, in either contrasting color or in
boldface type at least equal to the size type used for headings or captions of
sections in the [policy][certificate] the following:
"Notice to Buyer: This is a hospital confinement indemnity
[policy][certificate]. This [policy][certificate] provides limited benefits.
Benefits provided are supplemental and are not intended to cover all medical
expenses."
(17) All
supplemental health policies and certificates shall display prominently by
type, stamp, or other appropriate means on the first page of the policy or
certificate, or attached to it, in either contrasting color or in boldface type
at least equal to the size type used for headings or captions of sections in
the [policy][certificate] the following:
"Notice to Buyer: This is a supplemental health
[policy][certificate]. This [policy][certificate] provides limited benefits.
Benefits provided are supplemental and are not intended to cover all medical
expenses."
(18) All basic
hospital expense policies and certificates shall display prominently by type,
stamp, or other appropriate means on the first page of the policy or
certificate, or attached to it, in either contrasting color or in boldface type
at least equal to the size type used for headings or captions of sections in
the [policy][certificate] the following:
"Notice to Buyer: This is a basic hospital expense
[policy][certificate]. This [policy][certificate] provides limited benefits and
should not be considered a substitute for comprehensive health insurance
coverage."
(19) All basic
medical-surgical expense policies and certificates shall display prominently by
type, stamp, or other appropriate means on the first page of the policy or
certificate, or attached to it, in either contrasting color or in boldface type
at least equal to the size type used for headings or captions of sections in
the [policy][certificate] the following:
"Notice to Buyer: This is a basic medical-surgical expense
[policy][certificate]. This [policy][certificate] provides limited benefits and
should not be considered a substitute for comprehensive health insurance
coverage."
(20) All basic
hospital/medical-surgical expense policies and certificates shall display
prominently by type, stamp, or other appropriate means on the first page of the
policy or certificate, or attached to it, in either contrasting color or in
boldface type at least equal to the size type used for headings or captions of
sections in the [policy][certificate] the following:
"Notice to Buyer: This is a basic hospital/medical-surgical
expense [policy][certificate]. This [policy][certificate] provides limited
benefits and should not be considered a substitute for comprehensive health
insurance coverage."
(21)
All basic medical expense policies shall display prominently by type, stamp, or
other appropriate means on the first page of the policy, or attached to it, in
either contrasting color or in boldface type at least equal to the size type
used for headings or captions of sections in the policy the following:
"Notice to Buyer: This is a basic medical expense policy.
This policy provides benefits that are not as comprehensive as major medical
expense coverage and should not be considered a substitute for comprehensive
health insurance coverage."
(22) All dental plan policies and
certificates shall display prominently by type, stamp or other appropriate
means on the first page of the policy or certificate, or attached to it, in
either contrasting color or in boldface type at least equal to the size type
used for headings or captions of sections in the [policy][certificate] the
following:
"Notice to Buyer: This [policy] [certificate] provides dental
benefits only."
(23) All
vision plan policies and certificates shall display prominently by type, stamp,
or other appropriate means on the first page of the policy or certificate, or
attached to it, in either contrasting color or in boldface type at least equal
to the size type used for headings or captions of sections in the
[policy][certificate] the following:
"Notice to Buyer: This [policy] [certificate] provides vision
benefits only."
B. Outline of Coverage Requirements
(1) An insurer shall deliver an outline of
coverage to an applicant or enrollee in the sale of individual health
insurance, group health insurance, dental plans, and vision plans as required
in
24-A M.R.S.A.
§2695. This requirement shall not apply
to group major medical policies and certificates issued to employer groups as
described in
24-A M.R.S.A.
§2804 and labor union groups as
described in
24-A M.R.S.A.
§2805. Except as provided in Section
10, all outlines of coverage used in
this state require the approval of the Superintendent.
(2) If an outline of coverage was delivered
at the time of application or enrollment and the policy or certificate is
issued on a basis that would require revision of the outline, a substitute
outline of coverage properly describing the policy or certificate must
accompany the policy or certificate 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][enrollment],
and the coverage originally applied for has not been issued."
(3) In any case where the prescribed outline
of coverage is inappropriate for the coverage provided by the policy or
certificate, an alternate outline of coverage shall be submitted to the
Superintendent for prior approval.
(4) An outline of coverage may take the form
or an advertisement provided that it satisfies the standards specified for
outlines of coverage in
24-A M.R.S.A.
§2695(8) as well as
this rule.
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
6(B) of this rule,
but not meeting the standards of Sections
6(C) (basic
medical-surgical), 6(F) (major medical) or 6(G) (basic medical). The items
included in the outline of coverage must appear in the sequence
prescribed:
[COMPANY NAME]
BASIC HOSPITAL EXPENSE COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS
AND
SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR
COMPREHENSIVE HEALTH INSURANCE COVERAGE
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate]
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][CERTIFICATE]
CAREFULLY!
(2) Basic hospital
coverage is designed to provide 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 copayment
requirements set forth in the policy. Coverage is NOT provided for physicians'
or surgeons' fees or for out-of-hospital prescription drugs.
(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 out-patient
services; and
(d) Other benefits,
if any.
The description of benefits shall be stated clearly and
concisely, and shall include a description of any deductible or copayment
provision applicable to the benefits described.]
(4) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (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
6(C) of this rule but
not meeting the standards of Sections
6(B) (basic
hospital), 6(F) (major medical) or 6(G) (basic medical). The items included in
the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
BASIC MEDICAL-SURGICAL EXPENSE COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS
AND
SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR
COMPREHENSIVE HEALTH INSURANCE COVERAGE
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate]
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 your policy. 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] [CERTIFICATE]
CAREFULLY!
(2) Basic
medical-surgical expense coverage is designed to provide coverage for
physicians' and surgeons' fees 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
copayment requirements set forth in the policy. Coverage is NOT provided for
hospital expenses or for out-of-hospital prescription drugs.
(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.
The description of benefits shall be stated clearly and
concisely, and shall include a description of any deductible or copayment
provision applicable to the benefits described.]
(4) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (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/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
7(B) and
7(C) of this rule but
not meeting the standards of Section
6(F) (major medical)
or 6(G) (basic medical). The items included in the outline of coverage must
appear in the sequence prescribed.
[COMPANY NAME]
BASIC HOSPITAL/MEDICAL-SURGICAL EXPENSE COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS
AND
SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR
COMPREHENSIVE HEALTH INSURANCE COVERAGE
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate]
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] [CERTIFICATE]
CAREFULLY!
(2) Basic
hospital/medical-surgical expense coverage is designed to provide, to persons
insured, coverage for hospital expenses and for physicians' and surgeons' fees
incurred as a result of a covered accident or sickness. Coverage is 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 copayment
requirements set forth in the policy. Coverage is not provided for unlimited
hospital or medical surgical expenses. No coverage is provided for
out-of-hospital prescription drugs.
(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;
(d) Surgical
services;
(e) Anesthesia
services;
(f) In-hospital medical
services; and
(g) Other benefits,
if any.
The description of benefits shall be stated clearly and
concisely, and shall include a description of any deductible or copayment
provision applicable to the benefits described.]
(4) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (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.]
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
6(E) of this rule.
The items included in the outline of coverage must appear in the sequence
prescribed:
[COMPANY NAME]
HOSPITAL CONFINEMENT INDEMNITY COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO
COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate]
Carefully-This outline of coverage provides a very brief description of the
important features of coverage. 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] [CERTIFICATE]
CAREFULLY!
(2) Hospital confinement
indemnity coverage is designed to provide 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. Coverage is not
provided for any benefits other than the fixed daily indemnity for hospital
confinement and any additional benefit described below.
(3) [A brief specific description of the
benefits in the following order:
(a) Daily
benefit payable during hospital confinement; and
(b) Duration of benefit described in (a).
The description of benefits shall be stated clearly and
concisely.]
(4)
[A description of any policy provisions that exclude, eliminate, restrict,
reduce, limit, delay, or, in any other manner, operate to qualify payment of
the benefit, described in Paragraph (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
6(F) of this rule.
This requirement does not apply to group policies and certificates issued to
employer groups as described in
24-A M.R.S.A.
§2804 and labor union groups as
described in
24-A M.R.S.A.
§2805. 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 is
designed to provide comprehensive 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,
out-of-hospital care, and prescription drugs, subject to any deductibles,
copayment provisions, or other limitations that may be set forth in the
policy.
(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) Radiology and physiotherapy;
(h) Mental health treatment;
(i) Out-of-hospital prescription
drugs;
(j) Maximum dollar amount
for covered charges; and
(k) Other
benefits, if any.
The description of benefits shall be stated clearly and
concisely, and shall include a description of any deductible or copayment
provision applicable to the benefits described.]
(4) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (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. Basic
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
6(G) of this rule but
not meeting the standards of Section
6(F) (major medical).
The items included in the outline of coverage must appear in the sequence
prescribed:
[COMPANY NAME]
BASIC 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) Basic medical expense coverage is
designed to provide limited 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, copayment provisions, or
other limitations that may be set forth in the policy. No coverage is provided
for out-of-hospital prescription drugs.
(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
The description of benefits shall be stated clearly and
concisely, and shall include a description of any deductible or copayment
provision applicable to the benefits described.]
(4) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (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. Individual
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
6(H) of this rule.
The items included in the outline 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 is designed
to replace part of your earned income every month if you become unable to work
due to a covered accident or sickness, subject to any limitations set forth in
the policy. No coverage is provided for medical expenses.
(3) [A brief specific description of the
benefits contained in this policy. The description of benefits shall be stated
clearly and concisely.]
(4) [A
description of any policy provisions that exclude, eliminate, restrict, reduce,
limit, delay, or, in any other manner, operate to qualify payment of the
benefits described in Paragraph (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. 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
6(I) of this rule.
The items included in the outline of coverage must appear in the sequence
prescribed:
[COMPANY NAME]
ACCIDENT-ONLY COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND NOT INTENDED TO COVER
ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate]
Carefully-This outline of coverage provides a very brief description of the
important features of the coverage. 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][CERTIFICATE]
CAREFULLY!
(2) Accident-only
coverage is designed to provide coverage for certain losses resulting from a
covered accident ONLY, subject to any limitations contained in the policy.
Coverage is not provided for medical expenses.
(3) [A brief specific description of the
benefits. The description of benefits shall be stated clearly and concisely,
and shall include a description of any deductible or copayment provision
applicable to the benefits described. If benefits vary according to the type of
accidental cause, the outline of coverage shall prominently set forth the
circumstances under which benefits are payable that are less than the maximum
amount payable under the policy.]
(4) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (3)
above.]
(5) [A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservations of right to change
premiums.]
K. Specified
Disease Coverage (Outline of Coverage)
An outline of coverage in the form prescribed below shall be
issued in connection with policies or certificates meeting the standards of
Sections
7(J) of this rule.
The items included in the outline of coverage must appear in the sequence
prescribed:
[COMPANY NAME]
SPECIFIED DISEASE COVERAGE
THIS [POLICY] [CERTIFICATE] PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO
COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
(1) This coverage is designed only as a
supplement to a comprehensive health insurance policy and should not be
purchased unless you have this underlying coverage. [If the policy covers
cancer, include the following sentence.] Persons covered under Medicaid should
not purchase it. Read the Buyer's Guide to Cancer Insurance to review the
possible limits on benefits in this type of coverage.
(2) Read Your [policy] [certificate]
Carefully-This outline of coverage provides a very brief description of the
important features of coverage. 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] [CERTIFICATE]
CAREFULLY!
(3) Specified disease
coverage is designed to provide restricted coverage paying benefits ONLY when
certain losses occur as a result of specified diseases. Coverage is NOT
provided for other diseases or accidents.
(4) [A brief specific description of the
benefits, including dollar amounts. The description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
copayment provisions applicable to the benefits described.]
(5) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (4)
above.]
(6) [A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservations of right to change
premiums.]
L. Specified
Accident Coverage (Outline of Coverage)
An outline of coverage in the form prescribed below shall be
issued in connection with policies or certificates meeting the standards of
Sections
7(K) of this rule.
The items included in the outline of coverage must appear in the sequence
prescribed:
[COMPANY NAME]
SPECIFIED ACCIDENT COVERAGE
THIS [POLICY] [CERTIFICATE] PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO
COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate]
Carefully-This outline of coverage provides a very brief description of the
important features of the coverage. 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][CERTIFICATE]
CAREFULLY!
(2) Specified accident
coverage is 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 other accidents or for illness.
(3) [A brief specific description of the
benefits. The description of benefits shall be stated clearly and concisely,
and shall include a description of any deductible or copayment provision
applicable to the benefits described. If benefits vary according to the type of
accidental cause, the outline of coverage shall prominently set forth the
circumstances under which benefits are payable that are less than the maximum
amount payable under the policy.]
(4) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (3)
above.]
(5) [A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservations of right to change
premiums.]
M.
Supplemental Health Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed below, shall
be issued in connection with policies or certificates that do not meet the
minimum standards of Sections 7B, C, D, E, F, G, I and K of this rule. The
items included in the outline of coverage must appear in the sequence
prescribed:
[COMPANY NAME]
SUPPLEMENTAL HEALTH COVERAGE
BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO
COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate]
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][CERTIFICATE]
CAREFULLY!
(2) Supplemental health
coverage is designed to provide limited or supplemental coverage.
(3) [A brief specific description of the
benefits, including dollar amounts. The description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
copayment provisions applicable to the benefits described. If benefits vary
according to the type of accidental cause, the outline of coverage shall
prominently set forth the circumstances under which benefits are payable that
are less than the maximum amount payable under the policy.]
(4) [A description of any provisions that
exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner,
operate to qualify payment of the benefits described in Paragraph (3)
above.]
(5) [A description of
provisions respecting renewability or continuation of coverage, including age
restrictions or any reservations of right to change premiums.]
N. Dental Plans (Outline of
Coverage)
An outline of coverage in the form prescribed below shall be
issued in connection with dental plan policies and certificates. The items
included in the outline of coverage must appear in the sequence
prescribed:
(1) Read Your
[Policy][Certificate] 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][CERTIFICATE]
CAREFULLY!
(2) [A brief specific
description of the benefits. The description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
copayment provisions applicable to the benefits described.]
(3) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (2)
above.]
(4) [A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservations of right to change
premiums.]
O. Vision
Plans (Outline of Coverage)
An outline of coverage in the form prescribed below shall be
issued in connection with vision plan policies and certificates. The items
included in the outline of coverage must appear in the sequence
prescribed:
(1) Read Your
[Policy][Certificate] 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][CERTIFICATE]
CAREFULLY!
(2) [A brief specific
description of the benefits. The description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
copayment provisions applicable to the benefits described.]
(3) [A description of any policy provisions
that exclude, eliminate, restrict, reduce, limit, delay, or, in any other
manner, operate to qualify payment of the benefits described in Paragraph (2)
above.]
(4) [A description of
policy provisions respecting renewability or continuation of coverage,
including age restrictions or any reservations of right to change
premiums.]
