Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 40.00 - Marketing of insured health plans
Section 40.07 - Benefits Payable, Losses Covered or Premiums Payable
Universal Citation: 211 MA Code of Regs 211.40
Current through Register 1531, September 27, 2024
(1) Deceptive Words, Phrases or Illustrations Prohibited.
(a) It
shall be considered misleading, and therefore prohibited to omit information or
use words, phrases, statements, references or illustrations if such omission
has the capacity, tendency or effect of misleading or deceiving purchasers or
prospective purchasers as to the nature or extent of any policy benefit
payable, loss covered or premium payable. The fact that the policy offered is
made available to a prospective insured for inspection prior to consummation of
the sale or an offer is made to refund the premium if the purchaser is not
satisfied, does not remedy misleading statements.
(b) It shall be considered misleading, and
therefore prohibited, to solicit an offer to contract for a health insurance
policy without a clear and conspicuous disclosure of the premium rate for such
policy.
(c) It shall be considered
misleading, and therefore prohibited, for a marketing method of a policy whose
benefits are conditional upon confinement in a hospital or similar facility, to
refer to the benefits or costs of the policy, or the risks against which the
policy is intended to provide protection unless it shall also disclose both
clearly and conspicuously in accordance with
211 CMR
40.05 as well as on the application for such
policy whether benefits are based on actual costs incurred and/or the length of
confinement.
(d) It shall be
considered misleading, and therefore prohibited, for a marketing method to
contain or use words or phrases such as "all"; "full"; "complete";
"comprehensive"; "unlimited"; "up to," "as high as"; "this policy will help pay
your hospital and surgical bills"; "this policy will help fill some of the gaps
that Medicare and your present insurance leaves out"; "this policy will help to
replace your income" (when used to express loss-of-time benefits); or similar
words and phrases, in a manner which exaggerates any benefits beyond the terms
of the policy.
(e) It shall be
considered misleading, and therefore prohibited, for a marketing method to
present descriptions of a policy limitation, exception, or reduction, worded in
a positive manner to imply that it is a benefit, such as, describing a waiting
period as a "benefit builder," or stating "even preexisting conditions are
covered after two years." Words and phrases used in a marketing method to
describe such policy limitations, exceptions and reductions shall fairly and
accurately describe the negative features of such limitations, exceptions and
reductions of the policy offered.
(f) It shall be considered misleading, and
therefore prohibited, for the marketing of a hospital or other similar facility
confinement benefit to state that the amount of the benefit is payable on a
monthly or weekly basis, when, in fact, the amount of the benefit payable is
based on a daily prorata basis relating to the number of days of confinement.
When the policy contains a limit on the number of days of coverage provided,
such limit must be stated in the marketing method.
(g) It shall be considered misleading, and
therefore prohibited, for a marketing method of a policy covering a list of
specified diseases to imply coverage beyond the terms of the policy. Synonymous
terms shall not be used to refer to any disease so as to imply broader coverage
than is the fact.
(h) A marketing
method for a policy providing benefits for specified illnesses only, or for
specified accidents only, such as automobile accidents, shall be considered
misleading and therefore prohibited unless it shall clearly and conspicuously
state the limited nature of the policy. The statement shall be worded in
language identical to, or substantially similar to the following: "THIS IS A
LIMITED POLICY"; "THIS IS A SPECIFIED DISEASE ONLY POLICY"; "THIS IS AN
AUTOMOBILE ACCIDENT ONLY POLICY."
(i) It shall be considered misleading, and
therefore prohibited, for the marketing method of a direct response insurance
product to imply that because "no insurance agent will call and no commissions
will be paid to agents" that it is "a low cost plan" or use other similar words
or phrases because the cost of advertising and servicing such policies is a
substantial cost in the marketing of a direct response insurance product,
unless such is the fact, and is clearly substantiated in such marketing
method.
(j) It shall be considered
misleading, and therefore prohibited, for a marketing method to use
photographs, illustrations, depictions or fictionalized accounts of illness or
illness-related subjects, or overemphasis of exceptional or catastrophic risk,
or exaggeration of potential out-of-pocket costs of health care, or any other
marketing method in such a way as to invite the purchase of an insured health
plan for emotional rather than functional reasons.
(2) Exceptions, Reductions and Limitations.
(a) When a
marketing method refers to either a dollar amount or a period of time for which
any benefit is payable, or the cost of the policy, or specific policy benefit,
or the loss for which such benefit is payable, it shall be considered
misleading, and therefore prohibited, unless it also discloses those
exceptions, reductions and limitations affecting the basic provisions of the
policy without which the marketing method would have the capacity or tendency
to mislead or deceive.
(b) When a
policy contains a waiting, elimination, probationary or similar time period
between the effective date of the policy and the effective date of coverage
under the policy or a time period between the date benefits begin to accrue for
such loss, a marketing method which is subject to the requirements of the
preceding paragraph shall disclose the existence of such periods or be
considered misleading and therefore prohibited.
(c) A marketing method shall not use the
words "only"; "just"; "merely"; "minimum"; or similar words or phrases to
describe the applicability to any exceptions and reductions such as: "This
policy is subject to the following minimum exceptions and reductions" or it
shall be considered to be misleading, and therefore prohibited.
(3) Pre-Existing Conditions.
(a) A marketing
method shall, in negative terms, disclose the extent to which any loss is not
covered if the cause of such loss is traceable to a condition existing prior to
the effective date of the policy or it shall be considered misleading and
therefore prohibited. The use of the term "pre-existing condition" without an
appropriate definition or description shall not be used or it shall be
considered misleading, and therefore prohibited.
(b) When a policy does not cover losses
resulting from pre-existing conditions, no marketing of the policy shall state
or imply that the applicant's physical condition or medical history will not
affect the issuance of the policy or payment of a claim thereunder or it shall
be considered misleading and therefore prohibited. 211 CMR 40.07(3)(b)
prohibits the use of the phrase "no medical examination required" and phrases
of similar import, but does not prohibit explaining "guaranteed issue." If a
carrier requires a medical examination for a specified policy, the marketing
material shall disclose that a medical examination is required or it shall be
considered misleading, and therefore prohibited.
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