Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 146.00 - Specified Disease Insurance
Section 146.100 - Policy Disclosure Form

(1) Policies of individual insurance and certificates and policies of group insurance shall use the following prescribed statement only, except that appropriate policy and certificate identification may be included:

COMPANY NAME

SPECIFIED DISEASE COVERAGE ONLY

REQUIRED DISCLOSURE STATEMENT

This policy or certificate is (an individual policy of insurance) (a group policy or certificate). This policy or certificate provides specified disease coverage ONLY. This policy orcertificatedoes NOT provide basic hospital, basic medical or major medical insurance. It is a supplement to your health benefit plan and cannot replace your health benefit plan.

(Accurately list benefits, exclusions, reductions and limitations of the policy or certificate in a manner which does not encourage misrepresentation of the actual coverage provided.)

This disclosure statement is a very brief summary of your policy or certificate.

The policy or certificate itself sets forth the rights and obligations of both you and the insurance company. It is therefore imperative that you READ YOUR POLICY OR CERTIFICATE carefully.

The expected benefit ratio for this policy or certificate is ___%. This ratio is the portion of future premiums which the company expects to return as benefits, when averaged over all people with this policy or certificate.

(2) Required Disclosure for Medicare-EligibleApplicants. Carriers shall provide the Guide to Health Insurance for People with Medicare and disclosure notice as required by 211 CMR 42.09(4).