Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This rule specifies the criteria that must
be found in policies of accident and health insurance before the director will
approve these policies for use in this state. This rule is adopted pursuant to
the provisions of section
374.045,
RSMo and implements and defines sections
375.936,
376.405,
376.775
and 376.777, RSMo.
(1)
Application. From the effective date of this rule, application forms, policies,
riders and endorsements to policies of health and accident insurance will not
be approved for use in this state unless they conform to the criteria stated.
This disapproval shall meet the statutory procedural requirements of sections
376.405
and
376.777,
RSMo.
(2) Definitions in Policy
Submittals.
(A) Alcoholism treatment facility
shall be substantially defined in policies as a residential or nonresidential
facility certified by the Department of Mental Health for treatment of
alcoholism.
(B) Hospital shall be
substantially defined in policies as a legally constituted institution (or an
institution which operates pursuant to law) having organized facilities for the
care and treatment of sick and injured persons on a resident or inpatient
basis, including facilities for diagnosis and surgery under the supervision of
a staff of one (1) or more licensed physicians and which provides twenty-four
(24)-hour nursing service by registered nurses on duty or call. It does not
mean convalescent, nursing, rest or extended care facilities or facilities
operated exclusively for treatment of the aged, drug addict or alcoholic, even
though the facilities are operated as a separate institution by a hospital.
Notwithstanding any other language in this rule, the definition of hospital
contained in this rule shall not apply to Medicare supplement
policies.
(C) Intensive care unit
shall be substantially defined in policies as that part of a hospital service
specifically designed as an intensive care unit permanently equipped and
staffed to provide more extensive care for critically ill or injured patients
than available in other hospital rooms or wards, the care to include close
observation by trained and qualified personnel whose duties are primarily
confined to the part of the hospital for which an additional charge is
made.
(3) Elements of
Coverage Required.
(A) If individual benefits
are not actually provided for those insured who have joined the military, the
contract must contain a phrase or wording advising same and substantially
indicating that-"Upon notice to the company of entry into such service, the
pro rata unearned premiums shall be refunded." Companies, as
an optional provision, may utilize a military suspension clause permitting the
insured to reinstate his/her policy after discharge from the military without
showing evidence of insurability.
(B) If benefits under any individual contract
of accident or sickness are reduced or reducible because of the insured's age,
the policy must so state in conspicuous print in a conspicuous location in the
policy.
(C) No application form
will be approved containing such statements as "No information acquired by any
representative of the company shall be binding upon the company unless written
herein." The company may specifically disclaim any insurance producer's
authority to waive a complete answer to any question in the application, pass
on insurability, make or alter any contract or waive any of the company's other
rights or requirements.
(D) No
hospital reimbursement policy may exclude payment for services rendered in a
government or state hospital if the insured is legally required to pay for the
services or charges in the absence of insurance. Any exclusion subsequently
approved must therefore state "unless the insured is legally required to pay in
the absence of insurance." This provision does not apply to hospital or cash
indemnity contracts subject to
20
CSR 400-2.020.
(E) In calculating benefits payable, the
policy or certificate deductible first shall be applied to the allowable
expenses covered by the policy or certificate prior to applying any applicable
coinsurance factor.
(F) Any policy
or certificate of accident or health insurance or any accidental death or
dismemberment benefit provided in or supplemental to a policy or certificate of
accident or health insurance shall not include any language which requires that
accidental bodily injury be effected solely through external, violent and
accidental means. Any policy or certificate of accident or health insurance, or
any benefit for accidental death or dismemberment provided in or supplemental
to, a policy or certificate of accident or health insurance shall not exclude
payment of benefits for any covered loss, as provided in the contract, due to
suicide or any attempt at suicide while insane; unintentional or nonvoluntary
inhalation of gas or taking of poisons; pyogenic infections which result from
an accidental bodily injury; bacterial infections which result from the
accidental ingestion of contaminated substances; or the insured's being under
the influence of drugs if these drugs were taken as prescribed by a
physician.
(G) All group health
insurance policies providing coverage on an expense-incurred basis, all group
service or indemnity contracts issued by a not-for-profit health service
corporation, all self-insured group health benefit plans, of any type or
description and all these health plans or policies that are individually
underwritten or provide for coverage for specific individuals and the members
of their families as nongroup policies, which provide for hospital treatment,
shall provide coverage while confined in a hospital or alcoholism treatment
facility, for the treatment of alcoholism on the same basis as coverage for any
other illness, except that coverage may be limited to thirty (30) days in any
policy or contract benefit period.
(4) Essential Conditions to be Contained.
(A) If a certificate or coverage booklet used
in lieu of a certificate is to be delivered to a member of a group insured
under a master contract, the certificate or coverage booklet must be submitted
for approval with the master contract. This also shall apply to blanket
policies.
(B) Provisions in master
contracts for group plans which are necessarily unique to each particular group
policyholder, such as eligibility requirements, benefit amounts and time or
waiting periods, may be filed as being variable with appropriate examples. This
must be accompanied by a statement describing the nature and scope of the
variations. Other less variable language, such as inclusion or exclusion of
certain clauses, must be submitted with all variations.
(C) The definition of total disability may be
no more restrictive than the following: Total disability means the insured's
inability, because of sickness or injury, to perform the material and
substantial duties of the insured's occupation for a period of at least twelve
(12) months, unless the total benefit period is less than twelve (12) months.
After the initial benefit period, total disability shall mean the insured's
inability to perform the material and substantial duties of any occupation for
which the insured is qualified by education, training or experience. In a
policy that also provides benefits for residual disability, however, the
definition of total disability may require that the insured not be gainfully
employed in any occupation.
(D)
Residual disability shall be defined in relation to the insured's reduction in
earnings and may be related either to the insured's inability to perform some
part of the material and substantial duties of employment or to perform all
usual business duties for as much time as is usually required. A policy which
provides residual disability benefits may require a qualification period,
during which the insured must be continuously, totally disabled before residual
disability benefits are payable. The qualification period for residual benefits
may be longer than the elimination period for total disability. In lieu of the
term residual disability, an insurer may use proportionate disability or other
term of similar import which in the opinion of the director adequately and
fairly describes the benefit.
(E)
Each company, within sixty (60) days of home office receipt of the application
for an individually underwritten health or accident insurance contract, shall
notify a prospective insured as to whether or not the application has been
accepted or else give the prospective insured the reason for any further
delay.
(F) No policy may exclude
coverage for self-inflicted injuries resulting from attempted suicide while
insane. Exclusions or exemptions which presently exclude coverage for death or
injury arising out of a suicide or any attempt suicide while sane or insane or
which exclude coverage for intentionally self-inflicted injuries shall delete
the words . . . or insane and provide for payment for self-inflicted injuries
while insane. A policy may exclude coverage for intentionally self-inflicted
injury obviously not an attempted suicide.
(G) Policy language intended to exclude
coverage for occupational injuries or illnesses may exclude injuries or
illnesses arising out of or in the course of employment or an occupation for
wage, profit or gain. More restrictive provisions which exclude coverage for
duties performed on an occasional or sporadic basis will not be
permitted.
(5) Benefit
Reduction Clauses.
(A) No disability
insurance policy forms may provide for reduction in the amount of benefits
payable to the insured under the insurance policy due to eligibility for
disability or retirement benefits under the Social Security program or any
partially or wholly employer-funded plans unless-
1. The policy provides a minimum amount
payable regardless of the reduction of fifteen percent (15%) of the benefits
specified in the contract or fifty dollars ($50) per month, whichever is
greater;
2. The amount of the
reduction is not increased with any increase in the level of Social Security
benefits payable which becomes effective after the first day for which the
insurance disability benefits become payable; and
3. In no event shall a reduction in the
benefits be made due to eligibility or receipt of retirement benefits resulting
from employment other than employment through which the disability insurance
benefits were made available.
(B) All group disability income policies
delivered or issued for delivery after June 15, 1982 shall comply with its
provisions upon delivery or issue. All existing group policies shall be amended
to comply on the next renewal anniversary date following June 15,
1982.
(6) Ambulatory
Surgical Centers.
(A) No individual or group
accident and sickness insurance policy will be approved by the director which
does not provide coverage for all services performed at a duly licensed
ambulatory surgical center which are covered as a hospital inpatient benefit,
are within the scope of the license of the ambulatory surgical center and would
normally require hospital rather than office or clinic care. In keeping with
the essential purpose of ambulatory surgical centers, this rule in no way shall
be construed to require the same level or dollar amount of benefits to be paid
for services performed in an ambulatory surgical center as is paid to a
hospital or on account of inpatient hospital treatment.
(B) Any policy not in compliance with this
rule shall be deemed to provide equal benefits in scope and amount for
ambulatory surgical center services as for inpatient hospital care until
amended or replaced by an approved policy form.
(7) Variable Deductible.
(A) The variable deductible provision may be
stated in substance as to basic deductible (a stated dollar amount) or the
other coverage deductible (stated as the amount of benefits payable under other
valid coverage for the same loss) whichever is greater. A variable deductible
may not be stated as the aggregate of the basic deductible plus the other
coverage deductible.
(B) All
policies forms utilizing a variable deductible shall contain a prominent notice
(printed, stamped or attached to their policy face page or schedule page)
stating that the actual deductible amount for each claim may vary depending on
other medical expense insurance the insured may have.
(C) Other valid coverage shall include only
benefits actually provided for the same loss by medical expense coverage by any
other group or individual hospital, surgical or medical insurance policy or
medical practice or other prepayment plan or any other plan or program whether
insured or uninsured or by reason of state or federal law. Other valid coverage
may also include automobile medical payment coverage provided that this
inclusion is clearly disclosed in the policy.
(D) If at the time a claim arises the
variable deductible results in the imposition of a deductible amount greater
than the stated basic deductible, the disposition of the claim shall include a
clear written statement to the insured explaining how benefits were calculated
and the effect of the variable deductible. This written notice shall advise the
insured, as follows:
1. To review his/her
insurance needs because of other coverage;
2. S/he may request an increased basic
deductible if the present basic deductible is not the highest available through
the insurer, at an appropriate reduction in premium rate in accordance with the
applicable rates on file by the insurer; and
3. If appropriate, any subsequent request to
decrease the basic deductible will require evidence of insurability acceptable
to the insurer.
(E)
Variable deductible may be contained only in insurance policies or certificates
which are individually underwritten.
(F) If more than one (1) policy containing a
variable deductible provides benefits for medical expenses incurred due to a
loss by one (1) individual, the amount of benefits payable by each company
shall be determined as follows:
1. After
applying benefits payable under any plan(s) not containing variable
deductibles, each variable deductible plan shall share remaining expenses on a
pro rata basis; and
2. Each variable deductible plan's
pro rata share of expenses shall be that portion of the total
remaining expenses as each plan's benefits bears to the total benefits payable
under all variable deductible plans.
*Original authority: 374.045, RSMo 1967, amended 1993,
1995; 375.936, RSMo 1959, amended 1967, 1969, 1971, 1976, 1978, 1983, 1991;
376.405, RSMo 1959, amended 1984; 376.775, RSMo 1959; and 376.777, RSMo 1959,
amended 1984.