Current through Register 1531, September 27, 2024
[CARRIER NAME]
[ADDRESS - CITY & STATE],[TELEPHONE
NUMBER]
SPECIFIED DISEASE INSURANCE - OUTLINE OF
COVERAGE
Policy Number:
1. This policy is [an individual policy of
insurance/a group policy which was issued in (indicate jurisdiction in which
group policy was issued)]. THIS IS A LIMITED POLICY.
[Except for policies or certificates that are guaranteed issue,
the following caution statement, or language substantially similar, must appear
as follows in the outline of coverage.]
Caution: The issuance of this specified disease
insurance [policy] [certificate] is based upon your responses to the questions
on your application. A copy of your [application] [enrollment form] [is
enclosed] [was retained by you when you applied]. If your answers are incorrect
or untrue as of the date you signed the applications, the carrier has the right
to deny benefits or rescind your policy subject to the [Time Limit on Certain
Defenses, Incontestable] section of your policy. The best time to clear up any
questions is now, before a claim arises! If, for any reason, any of your
answers were incorrect, contact the carrier at this address: [insert
address]
2.
SUMMARY OF
POLICY FEATURES
This policy:
1. is not a Medicare Supplement
policy.
2. [is guaranteed
renewable/is noncancelable] for your lifetime.
3. [is/is not] subject to automatic premium
increases as you get older.
4. [may
be/is not] subject to across the board premium increases for all policyholders
in your class.
5. [does/does not]
offer an option to purchase inflation protection.
6. [does/does not] offer an option to
purchase nonforfeiture protection.
7. [does/does not] contain special age
limitations for purchase.
8. [does
not cover services due to pre-existing conditions (existing health problems)
for a period of __ months from policy issue][does not have a waiting period
before pre-existing conditions (existing health problems) are
covered].
9. [may have/has] a
waiting period of __ days before benefits are payable by policy.
10. [offers a waiver of premium after __ days
of __ benefits][does not offer a waiver of premium].
3.
PURPOSE OF OUTLINE OF
COVERAGE. An outline of coverage provides a very brief description of
the important features of the coverage. You should compare this outline of
coverage to outlines of coverage for other policies available to you. This is
not an insurance contract, but only a summary of coverage. Only the individual
or group policy contains actual contractual provisions. This means that your
[policy/certificate] sets forth in detail the rights and obligations of both
you and the carrier. Therefore, if youpurchase this coverage, or any other
coverage, it is important that you READ YOUR [POLICY/CERTIFICATE]
CAREFULLY!
4.
TERMS UNDER
WHICH THE [POLICY/CERTIFICATE] MAY BE CONTINUED IN FORCE OR
DISCONTINUED.
(a) [For specified
disease insurance policies or certificates describe one of the following
permissible policy renewability provisions:
(1) Policies and certificates that are
guaranteed renewable must contain the following statement:] RENEWABILITY: THIS
[POLICY[/CERTIFICATE] IS GUARANTEED RENEWABLE. This means you have the right,
subject to the terms of your policy, to continue this coverage as longas
youpayyour premiums on time. [Carrier Name] cannot change any of the terms of
your policy on its own, except that, in the future, IT MAY INCREASE THE PREMIUM
YOU PAY.
OR
(1)
Policies and certificates that are noncancelable must contain the following
statement:] RENEWABILITY: THIS [POLICY/CERTIFICATE] IS NONCANCELABLE. This
means you have the right, subject to the terms of your policy, to continue this
coverage as long as you pay your premiums on time. [Carrier Name] cannot change
any of the terms of your policy on its own without your agreement, and cannot
change the premium you currently pay. However, if your policy contains an
inflation protection feature where you choose to increase your benefits,
[Carrier Name] may increase your premium at that time for those additional
benefits.
OR
(1)
Policies and certificates that are convertiblefrom a group policy must contain
the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS
CONVERTIBLE TO AN INDIVIDUAL POLICY.](For group coverage, specifically describe
continuation/conversion provisions applicable to the certificate and group
policy:]
(b) [Describe
waiver of premium provisions or state such provisions are not in the
policy.]
(c) [State whether or not
the carrier has a right to change premium, and if the right exists, describe
clearly and concisely each circumstance under which premium may change,
including that it is subject to the commissioner's
approval.]
5.
TERMS UNDER WHICH THE [POLICY/CERTIFICATE] MAYBERETURNED AND PREMIUM
REFUNDED.
(a) [Provide a brief
description of the right to return-the policy's "free look" provision, which
must be a minimum of ten days from the date of policy delivery.]
(b) [Include a statement that the policy
either does or does not contain provisions providing for a refund or partial
refund of premium upon the death of an insured or surrender of the policy or
certificate. If the policy contains such provisions, include a description of
them.]
6.
THIS IS
NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare,
review the Medicare Supplement Buyer's Guide available from the carrier.
(a) [For agents] Neither [insert carrier
name] nor its agents represent Medicare, the federal government, or any state
government.
(b) [For direct
response] [insert carrier name] is not representing Medicare, the federal
government or any state government.
7.
BENEFITS PROVIDED BY THIS
[POLICY/CERTIFICATE].
(a) [Covered
services, deductible(s), waiting periods, and maximums.]
[A policy that provides for the payment of benefits based on
standards described as "usual and customary," "reasonable and customary" or
words of similar import must include anexplanationof such terms in this section
of the outline of coverage.]
[Any benefit screening must be explained in this section. If
these screens differ for different benefits, explanation of the screen should
accompany each benefit description.]
8.
LIMITATIONS AND EXCLUSIONS
[Describe:
(a)
Pre-existing conditions
(b)
Non-eligible levels of care (e.g. unlicensed providers, care
by a family member, etc.)
(c)
Exclusions/exceptions
(d)
Limitations]
[This section should provide a brief specific description of
any policy provisions which limit, exclude, restrict, reduce, delay, or in any
other manner operate to qualify payment of the benefits described in (6)
above.]
9.
RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costsof care
services will likely increase over time, you should consider whether and how
the benefits of this plan may be adjusted. [As applicable, indicate the
following:
(a) That the benefit level will not
increase over time;
(b) Any
automatic benefit adjustment provisions;
(c) Whether the insured will be guaranteed
the option to buy additional benefits and the basis upon which benefits will be
increased over time if not by specified amount or percentage;
(d) If there is not a guarantee, include
whether additional underwritingor healthscreeningwillbe required, the frequency
and amounts of the upgrade options, and any significant restrictions or
limitations;
(e) Describe whether
there will be any additional premium charge imposed, and how that is to be
calculated.]
10.
NONFORFEITURE BENEFITS (if applicable). As an accident and sickness
policy, this policy does not have a cash value associated with life insurance
products. This policy does offer [for an additionalcharge (ifapplicable)] a
nonforfeiture benefit that will continue until exhausted even if the policy
lapses due to nonpayment of policy premiums. The following represents an
example of how this benefit would apply to your policy: [As applicable,
indicate the following:
[Carriers must include the following information in or with the
outline of coverage:
(a) A description
of the benefits that would accrue at different periods of policy
lapse
(b) Whether or not the
benefit was chosen by the policyholder.]
11.
PREMIUM.
[(a) State the total annual premium for the
policy;
(b) If the premium varies
with an applicant's choice of benefit options, indicate the portion of annual
premium that corresponds to each benefit option; OR
(c) Refer individual to schedule page of the
policy. ]
COMPLAINTS. If you have a complaint, call your
agent. If you are not satisfied, you may call or write the Massachusetts
Division of Insurance, Consumer Services Section, One South Station,
5th Floor, Boston, MA 02110-2208.
