New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE
Section 11:4-16.8 - Required disclosure provisions

1. Each individual policy of health insurance shall include a renewal, continuation, or nonrenewal provision. The language or specifications of such provision must be consistent with the type of contract issued. Such 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.

2. Except for riders or endorsements by which the insurer effectuates a request made in writing by the policyholder, exercises a specifically reserved right under the policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a policy after the date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the insured. After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term, shall be agreed to in a written instrument signed by the insured, except if the increased benefits or coverage is required by law.

3. Where riders or endorsements which reduce or eliminate coverage are attached to the policy at issue, the policy shall contain on the first page or specification page either a prominent warning or the full text of the rider or endorsement.

4. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy.

5. The words "guaranteed renewable" shall not be used in a policy unless the insurer's right to change premium rates is clearly stated in the caption of the renewal provision or in the brief description of the policy.

6. In a policy which provides for payment of benefits based on standards specified as "usual, customary and reasonable", such standards shall be defined in the policy and explained in the outline of coverage. Such standards shall not be more restrictive than:

7. A policy which provides for the payment of benefits based on standards described as "usual and customary", "reasonable and customary", or other words of similar import shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.

8. If a policy contains any limitations with respect to preexisting conditions, such limitations must appear as a separate paragraph in the policy and shall be labelled as "Pre-existing Condition Limitation".

9. If age is to be used as a determining factor for reducing the benefits available in the policy as originally issued, such fact must be prominently set forth in the policy and in the outline of coverage.

10. All policies, except short-term nonrenewable policies, Medicare supplement policies and as otherwise provided in this paragraph, shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder shall have the right to return the policy within 10 days of its delivery and to have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason. With respect to Medicare supplement policies and policies issued pursuant to a direct response solicitation, the policy shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder shall have the right to return the policy within 30 days of its delivery and to have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason.

11. An accident only policy shall contain a prominent statement on the first page of the policy or attached thereto in either contrasting color or in boldface type at least equal to the size of type used for policy captions as follows: "This is an accident only policy. It does not pay benefits for loss from sickness."

12. If a policy contains a conversion privilege, 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. Where a policy provides a benefit that is payable while the insured is participating in a rehabilitation program the policy shall specify the type of rehabilitation program allowed and any limitations or restrictions on the program.

14. An informational brochure entitled "Guide to Health Insurance for People with Medicare", hereinafter referred to as "the Guide", for persons eligible for Medicare, is intended to improve the buyer's understanding of Medicare and ability to select the most appropriate coverage. The Guide shall be furnished by each insurer to each such Medicare eligible person in connection with the purchase of health insurance policy, other than a short-term nonrenewal policy, regardless of whether the policy purchased is advertised, solicited or issued as a Medicare supplement policy meeting the requirements of N.J.A.C. 11:4-23.

15. To ensure uniformity in content, form and printing, the Guide has been made available through the Publications Department of the National Association of Insurance Commissioners, Kansas City, MO.

16. Delivery of the Guide shall be made at the time of application except in the case of direct response solicitations where the Guide shall be delivered with the policy. Acknowledgment of receipt of the Guide shall be obtained by all insurers.

1. No individual health insurance policy that is not a health benefits plan shall be delivered or issued for delivery in this State unless the appropriate outline of coverage in (c) through (n) below is completed as to such policy and:

2. If an outline of coverage was delivered at the time of application and the policy is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy must accompany the policy when it is delivered and contain the following statement, in no less than 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 and the coverage originally applied for has not been issued."

3. Completed copies of all original and corrected outlines of coverage shall be retained by the insurer.

4. The appropriate outline of coverage for policies providing coverage which only meets the standards of N.J.A.C. 11:4-16.6(d) shall be that statement contained in N.J.A.C. 11:4-16.9(c). The appropriate outline of coverage for policies providing coverage which meets the standards of both N.J.A.C. 11:4-16.6(d) and (e) shall be the statement contained in N.J.A.C. 11:4-16.8(g). The appropriate outline of coverage for policies providing coverage which meets the standards of both N.J.A.C. 11:4-16.6(d), (e) or (f) shall be the statement contained in N.J.A.C. 11:4-16.8(f). The appropriate outline of coverage for policies providing coverage which meets the standards of N.J.A.C. 11:4-16.6(h), (i) or (k) when sold to Medicare eligible persons shall be the statement contained in N.J.A.C. 11:4-16.8(i), (k) or (n) respectively.

5. In any case where the prescribed outline of coverage is inappropriate for the coverage provided by the policy, an alternate outline of coverage shall be submitted to the Commissioner for prior approval.

6. The outline of coverage shall be printed in a style of general use. The size of type for statements contained in N.J.A.C. 11:4-16.8(c), (d), (e), (f), (g), (h), (j) and (m) shall not be less than 10 point, and for statements contained in N.J.A.C. 11:4-16.8(i), (k), (l) and (n) shall not be less than 12 point.

7. The outline of coverage shall specify a method for an applicant or insured to telephone a representative of the insurer other than the licensee to obtain information about policy benefits and claims. The method shall not require additional expense for the applicant or insured.

8. Parentheses in the outline of coverage indicate instructions or variable wording. Wording appropriate to the type of benefits should be used.

9. For the outline of coverage prescribed by N.J.A.C. 11:4-16.8(i), (k) and (n), the following instructions apply:

1. Disability Income Protection Coverage--This type of policy is designed to cover you for disabilities resulting from a covered accident or sickness. Benefits may be subject to any limitations set forth in the policy. Coverage is not provided for basic hospital, medical and surgical, or major medical expenses.

2. Read Your Policy Carefully--This outline of coverage briefly describes the important features of your policy. This is not the insurance contract. Only 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. REMEMBER, if you are not satisfied with your policy, you have (10-30) days to return it to the company and get your money back.

3. Annual Premium $ ..... You Pay $ ..... per .....

(A brief specific description of the benefits contained in the policy.)

4. (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in 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. The following statement shall be included in policies which provide the benefit set forth in N.J.A.C. 11:4-16.6(g)2.

Information Statement

Each annual premium of $ ..... for this policy includes a $ ..... charge for the (Cash Value Provision). In the event of nonpayment of premium, death, or written request to surrender this policy before it has been in force for at least ..... years, the (cash value) payable will be less than the sum of the extra charges you have paid for the (Cash Value Provision). Therefore, you are cautioned that this policy should not be purchased unless you plan to continue it in force for ..... years or longer. You should also be aware that if the policy is maintained in force beyond ..... years, the time at which the potential (cash value) exceeds the charges for the (Cash Value Provision), the actual amount payable upon lapse, surrender, or death may be less than the charges for the (Cash Value Provision) if claim payments have been made under the policy.)

FOR ADDITIONAL INFORMATION ABOUT POLICY BENEFITS OR CLAIMS, TELEPHONE (COLLECT) (TOLL FREE) (LOCAL NUMBER) ......

1. Hospital Confinement Indemnity Coverage--This type of policy is designed to pay you a fixed dollar amount each day that you are in the hospital as a result of a covered accident or sickness. (Certain other benefits are also provided.) Benefits may be subject to any limitations set forth in the policy. Coverage is not provided for basic hospital, basic medical and surgical, or major medical expenses.

2. Read Your Policy Carefully--This outline of coverage briefly describes the important features of your policy. This is not the insurance contract. Only 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. REMEMBER, if you are not satisfied with your policy you have (10-30) days to return it to the company and get your money back.

3. Annual Premium $ ..... You Pay $ ..... per .....

4. (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in 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.)

FOR ADDITIONAL INFORMATION ABOUT POLICY BENEFITS OR CLAIMS, TELEPHONE (COLLECT) (TOLL FREE) (LOCAL NUMBER) ......

1. Hospital Confinement Indemnity Coverage--This type of policy is designed to pay you a fixed dollar amount each day that you are in the hospital as a result of a covered accident or sickness. (Certain other benefits are also provided.) The policy is not designed to provide hospital and medical coverage for the costs not paid by Medicare.

2. Read Your Policy Carefully--This outline a coverage briefly describes the important features of your policy. (Your agent, broker or other company representative will explain each item to you so that you fully understand what you are buying.) For more information about the costs not paid by Medicare and what to look for in policy provisions, read the (Shopper's Guide) that was given to you with this form.

This form is not the insurance contract. Only the policy itself spells out the rights and obligations of both you and your insurance company. It is important that you READ YOUR POLICY CAREFULLY. REMEMBER, if you are not satisfied with your policy, you have (10-30) days to return it to the company and get your money back.

3. Annual Premium $ ..... You Pay $ ..... per .....

(After you have been in the hospital for ..... days), this policy will pay you $ ..... per day (up to ..... days).

(List other benefits).

4. This policy does not pay you benefits for:

5. (A description of any policy provisions which will exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in 3 above.)

6. (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

FOR ADDITIONAL INFORMATION ABOUT POLICY BENEFITS OR CLAIMS, TELEPHONE (COLLECT) (TOLL FREE) (LOCAL NUMBER) ......

1. Accident Only Coverage--This type of policy does not pay you benefits if you get sick. It covers you for certain losses resulting from a covered accident ONLY. Limitations on benefits may apply. Basic hospital, basic medical and surgical, or major medical coverage is not provided.

2. Read Your Policy Carefully--This outline of coverage briefly describes the important features of your policy. This is not the insurance contract. Only the policy itself sets forth the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY. REMEMBER, if you are not satisfied with your policy you have (10-30) days to return it to the company and get your money back.

3. Annual Premium $ ..... You Pay $ ..... per .....

(A brief specific description of the benefits contained in this policy. Note: This 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. In addition, if benefits vary according to accidental cause in accordance with N.J.A.C. 11:4-16.5(b), proper disclosure of the varying benefits shall be made.)

4. (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of benefits described in 3 above. If benefits vary according to the type of accidental cause, describe prominently the circumstances under which benefits are payable which are lesser than the maximum amount payable under the policy.)

5. (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

FOR ADDITIONAL INFORMATION ABOUT POLICY BENEFITS OR CLAIMS, TELEPHONE (COLLECT) (TOLL FREE) (LOCAL NUMBER) ......

1. Accident Only Coverage--This type of policy does not pay you benefits if you get sick. It covers you for certain losses due to a covered accident ONLY. Limitations on benefits may apply. The policy does not provide hospital and medical coverage for the costs not paid by Medicare.

2. Read Your Policy Carefully--This outline of coverage briefly describes the important features of your policy. (Your agent, broker or other company representative will explain each item to you so that you fully understand what you are buying.) For more information about costs not paid by Medicare and what to look for in policy provisions, read the (Shopper's Guide) that was given to you with this form.)

This form is not the insurance contract. Only the policy itself spells out the rights and obligations of both you and your insurance company. It is important that you READ YOUR POLICY CAREFULLY. REMEMBER, if you are not satisfied with your policy, you have (10-30) days to return it to the company and get your money back.

3. Annual Premium $ ..... You Pay $ ..... per .....

(A brief specific description of the benefits contained in this policy. Note: The above 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. In addition, if benefits vary according to accidental cause in accordance with N.J.A.C. 11:4-16.5(b), proper disclosure of the varying benefits shall be made.)

4. (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of benefits described in 3 above. If benefits vary according to the type of accidental cause, describe prominently the circumstances under which benefits are payable which are lesser than the maximum amount payable under the policy.)

5. (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

FOR ADDITIONAL INFORMATION ABOUT POLICY BENEFITS OR CLAIMS, TELEPHONE (COLLECT) (TOLL FREE) (LOCAL NUMBER) ......

1. Limited Benefit Health Coverage--This type of policy will provide you with limited or supplemental benefits only. It is not designed to provide you with basic hospital, basic medical and surgical or major medical coverage.

2. Read Your Policy Carefully--This outline of coverage briefly describes the important features of your policy. This is not the insurance contract. Only 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. REMEMBER, if you are not satisfied with your policy, you have (10-30) days to return it to the company and get your money back.

3. Annual Premium $ ..... You Pay $ ..... per .....

(A brief specific description of the benefits, including dollar amounts, contained in this policy. Note: The above 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.)

4. (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in 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.)

FOR ADDITIONAL INFORMATION ABOUT POLICY BENEFITS OR CLAIMS, TELEPHONE (COLLECT) (TOLL FREE) (LOCAL NUMBER) ......

1. Limited Benefit Health Coverage--This type of policy will provide you with limited benefits only. It is not designed to provide hospital and medical coverage for the costs not paid by Medicare.

2. Read Your Policy Carefully--This outline of coverage briefly describes the important features of your policy. (Your agent, broker and other company representatives will explain each item to you so that you fully understand what you are buying.) For more information about the costs not paid by Medicare and what to look for in policy provisions, read the (Shopper's Guide) that was given to you with this form.

This form is not the insurance contract. Only the policy itself spells out rights and obligations of both you and your insurance company. It is important that you READ YOUR POLICY CAREFULLY. REMEMBER, if you are not satisfied with your policy, you have (10-30) days to return it to the company and get your money back.

3. Annual Premium $ ..... You Pay $ ..... per .....

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4. (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay or in any other manner operate to qualify payment of the benefits described in 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.)

FOR ADDITIONAL INFORMATION ABOUT POLICY BENEFITS OR CLAIMS, TELEPHONE (COLLECT) (TOLL-FREE) (LOCAL NUMBER) ......

1. For policies sold to Medicare eligible persons which do not meet the minimum standards for coverage set forth in N.J.A.C. 11:4-16.6(j) but which do provide coverage for confinement or care in a skilled nursing facility:

"ATTENTION POLICYHOLDER: THE PROVISIONS OF THIS POLICY DO NOT RELATE IN ANY WAY TO MEDICARE. THIS POLICY DOES NOT COVER CUSTODIAL CARE (HELP IN MEETING YOUR PERSONAL NEEDS) OR REST HOME CARE."

2. For accident only policies sold to Medicare eligible persons:

"ATTENTION POLICYHOLDER: THIS IS AN ACCIDENT ONLY POLICY. IT DOES NOT PAY YOU BENEFITS IF YOU GET SICK. THIS POLICY DOES NOT PROVIDE HOSPITAL AND MEDICAL COVERAGE FOR THE COSTS NOT PAID BY MEDICARE."

3. For limited benefit health insurance policies sold to Medicare eligible persons:

"ATTENTION POLICYHOLDER: THIS POLICY PROVIDES LIMITED BENEFITS ONLY. IT DOES NOT PROVIDE HOSPITAL AND MEDICAL COVERAGE FOR THE COSTS NOT PAID BY MEDICARE."