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 11:4-42.4 - General standards

Universal Citation: NJ Admin Code 11:4-42.4

Current through Register Vol. 56, No. 24, December 18, 2024

(a) The face page of every certificate issued under a blanket insurance policy or a group policy providing health insurance or life insurance delivered or issued for delivery in New Jersey shall state that it is subject to the laws of the State of New Jersey.

(b) Group policies and certificates providing health or blanket insurance that include convalescent or extended care benefits following hospitalization shall not condition such benefits upon admission to the convalescent or extended care facility within a period of less than 14 days after discharge from the hospital.

(c) Group policies and certificates that provide disability benefits shall provide that a period of disability begins on the date that disability commences.

1. A period of disability shall not be based on the date of first medical treatment.

(d) Group policies and certificates providing health or blanket insurance that contain provisions relating to recurrent disabilities shall not specify that a recurrent disability be separated by a period greater than six months.

1. A subsequent disability resulting from an unrelated cause shall not be a recurrent disability.

(e) Group policies and certificates providing accidental death and dismemberment benefits shall provide that such benefits shall be payable if the loss occurs within a period no less than 90 days from the date of the accident.

1. There shall be no requirement that the covered person be disabled at the time of loss.

2. The form shall state, in effect, that neither termination of the group policy nor termination of the covered person's coverage under the group policy shall prejudice the settlement of any claim for loss where the accident precipitating the loss occurred on or before the date of termination.

(f) Group policies and certificates providing life insurance shall not limit or exclude benefits for a loss resulting from the suicide of the covered person if the suicide occurs more than 24 months following the effective date of the covered person's coverage under the policy.

1. No limitation or exclusion shall apply to any increase in benefits under a group policy or certificate which became effective 24 or more months prior to the death of the covered person, notwithstanding that the loss results from the suicide of the covered person.

(g) The signature block for all group life, group health and blanket insurance application and evidence of insurability forms shall contain a statement of certification that all statements made by an applicant are to be true and complete to the best of the applicant's knowledge and belief.

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