New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS
Section 11:4-42.2 - Definitions

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:

"Blanket insurance" means a policy or contract of insurance against death or injury resulting from an accident or from accidental means otherwise in compliance with the requirements of 17B:27-32.

"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.

"Covered person" means any person for whom an insurer has promised to provide a benefit of pecuniary value in accordance with the terms of a contract or policy for group life, group health or blanket insurance.

"Department" means the New Jersey Department of Banking and Insurance.

"Federal plan" means a plan for benefits established in accordance with the Federal Social Security Act (OASDI), the Railroad Retirement Act, the Jones Act, or the Canada Pension Plan, the Quebec Pension Plan, or any similar plan or act.

"Group health benefits plan" means a hospital and medical expense insurance policy or certificate, health service corporation contract or certificate, hospital service corporation contract or certificate, medical service corporation contract or certificate, health maintenance organization subscriber contract or certificate, or other plan for medical care delivered or issued for delivery in this State to a small employer group pursuant to N.J.S.A. 17B:27A-19, or a large employer, or any other similar contract, policy, or plan issued to an employer not explicitly excluded from the definition of health benefits plan at N.J.S.A. 17B:27A-2, and rules promulgated pursuant thereto at N.J.A.C. 11:20. For purposes of this subchapter, group health benefits plan shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; stop loss or excess risk insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in Federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Group health benefits plan shall not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan; limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in Federal regulations. Group health benefits plans shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor, and those benefits are paid with respect to such an event under any group health plan maintained by the same plan sponsor. Group health benefits plan shall not include the following if it is offered as a separate policy, certificate, or contract of insurance: Medicare supplemental health insurance as defined under Section 1882(g)(1) of the Federal Social Security Act ( 42 U.S.C. § 1395ss(g)(1) ); and coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code ( 10 U.S.C. §§ 1071 et seq.); and similar supplemental coverage provided to coverage under a group health plan.

"Group life insurance" means a policy or contract which covers more than one person as part of a group that satisfies the specifications of 17B:27-2 through 17B:27-8, under which an insurer is obligated to pay or allow a benefit of pecuniary value with respect to the cessation of human life. The term "group life insurance" also includes the granting of endowment benefits and optional modes of settlement of proceeds of group life insurance, as well as provisions in a group policy for: additional benefits in the event of death by accident or accidental means or in the event of dismemberment or loss of sight; or safeguarding such insurance against lapse or giving a special surrender value, or special benefit or annuity in the event that the insured shall become totally and permanently disabled, whether such provisions are incorporated in a policy or contract or supplemental thereto. The term "group life insurance" does not include worker's compensation coverages.

"Insurer" means any person transacting or authorized to transact the business of life and/or health insurance in the State of New Jersey, including insurance companies operating pursuant to 17:17-1 et seq., or 17B:17-1 et seq.; fraternal benefit societies operating pursuant to N.J.S.A. 17:44-1et seq.; hospital service corporations operating pursuant to 17:48-1 et seq.; medical service corporations operating pursuant to 17:48A-1 et seq.; health service corporations operating pursuant to 17:48E-1 et seq.; and any insurer operating pursuant to P.L. 1995, c.196.

"Other income," when used in relation to offsets against group disability income benefits, means and may be defined no more restrictively by an insurer than:

1. That portion of retirement benefits and/or disability benefits provided under the employer's plan attributable to the group policyholders or sponsoring employer's contributions;

2. Benefits paid by Federal plans to the covered person and to those family members receiving supplementary Federal benefits as a result of the covered person's disability where the family members reside with the covered person or the covered person has a legal obligation to provide their financial support;

3. Compensation from secondary employment obtained after the date of disability or from all secondary employment where the group policy providing disability income benefits insures employment income from all sources;

4. Expected retirement benefits and expected benefits payable by Federal plans, pursuant to the limitations set forth at 11:4-42.7(b);

5. Expected retirement benefits where the covered person is eligible for full retirement benefits under either the policyholder or sponsoring employer's retirement plan at the later of age 62 or the plan's normal retirement age, but only to the extent of expected benefits attributable to the policyholder or sponsoring employer's contributions;

6. Expected disability benefits provided under the policyholder's or sponsoring employer's retirement plan where acceptance of such benefits would not result in a reduction of the covered person's ultimate retirement benefits at the retirement plan's normal age, but, to the extent the covered person accepts such disability benefits, only that proportion of the disability benefits attributable to the policyholder's or sponsoring employer's contribution; and

7. The amount the covered person receives or is entitled to receive as disability income payments under any state compulsory benefit law.

The term "other income" does not include:

1. Cost of living increases in benefits (including cost of living increases in benefits which qualify as other income);

2. Disability income benefits provided by no-fault motor vehicle insurance;

3. Worker's compensation benefits if the group disability income policy excludes benefits for occupational injuries or illnesses;

4. Military and veteran's benefits where such benefits are paid for illnesses and injuries that were incurred prior to the date of disability or where the group disability policy excludes or limits benefits for illness or injury due to war or military activity;

5. Disability or retirement benefits provided by sources other than the group policyholder or sponsoring employer;

6. Disability or retirement benefits or other income benefits not paid in the same month as the policy's disability benefit, except as noted at 11:4-42.5;

7. Social security retirement benefits received by the covered person or members of his family which are not the direct result of the covered person's disability; and

8. Anticipated or expected benefits obtained or obtainable through legal doctrine, third party liability, subrogation, or other arrangement.

"Pre-authorization" means the processes by which insurers determine the medical necessity and/or medical appropriateness of otherwise covered treatments and procedures prior to the rendering of such treatments and procedures, including, but not limited to, pre-admission review, pre-treatment review, utilization review and case management.

"Sponsoring employer" means the employer sponsoring the retirement and/or disability plan and includes employers participating in a group insurance trust.