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 11:4-42.9 - Provisions for pre-existing condition exclusions and limitations
Universal Citation: NJ Admin Code 11:4-42.9
Current through Register Vol. 56, No. 6, March 18, 2024
(a) Blanket and group policies and certificates providing life insurance or accidental death and dismemberment insurance benefits shall not subject such benefits to pre-existing condition exclusions and limitations.
(b) Group policies and certificates providing health insurance benefits, other than accidental death and dismemberment and group health benefits plans, may include pre-existing condition exclusions and limitations subject to the following:
1. A
pre-existing condition may be defined no more restrictively than as an illness
or injury for which the insured received treatment or advice from a physician
or used prescription drugs within no more than a two year period prior to the
effective date of coverage.
2. No
policy, other than a policy providing group disability income insurance shall
exclude coverage for a loss due to a pre-existing condition for a period
greater than 24 months following the effective date of coverage, nor shall any
policy provide any exclusion or limitation applicable to new losses due to a
pre-existing condition after the 24-month (or lesser) period. Policies
providing group disability income insurance may exclude coverage for losses
beginning during the first 24 months after the effective date of coverage due
to disabilities and recurrent disabilities which result from a pre-existing
condition.
3. A succeeding insurer,
in applying a pre-existing condition waiting period in its policy shall credit
the covered person for satisfaction of the pre-existing condition waiting
period under a prior policy or contract, or any portion thereof if the prior
waiting period has not been satisfied in full.
4. No policy shall limit benefits to
illnesses or injuries which first manifest themselves while the covered person
is covered under the policy.
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